Barriers and facilitators of implementing escape room in nursing education: a mixed-method systematic review protocol using an implementation framework

Abstract

Introduction

Escape room (ER) methodology is recognised as an innovative pedagogical tool in nursing education, fostering an interactive environment that transforms students from passive observers into active participants. Current research on ER in educational contexts primarily emphasises their effectiveness and learner experiences, while neglecting the specific facilitators and barriers relevant to nursing education. This gap leads to a lack of essential frameworks for course design. Understanding these barriers and facilitators is crucial for the effective application of ERs in educational settings. Consequently, this review aims to identify factors associated with the implementation of ER in nursing education, using the Consolidated Framework for Implementation Research as a guiding framework.

Methods and analysis

The search will encompass six English databases and three Chinese databases from their inception to 1 October 2025: CINAHL, Embase, Education Resources Information Center, Scopus, Web of Science and MEDLINE, Wang Fang, China National Knowledge Infrastructure and the Chinese Biomedical Literature Database. Studies with qualitative, quantitative or mixed-methods designs will be included. Publications in English or Chinese will be considered from database inception. Two independent researchers will conduct screening and data extraction according to predefined criteria. A convergent integrated approach, including the transformation of quantitative results, will be employed, followed by thematic synthesis to analyse the findings. Discrepancies will be resolved through discussions with a third reviewer.

Ethics and dissemination

The ethical approval for this review is unnecessary due to the utilisation of secondary data. The outcomes are scheduled for publication in a peer-reviewed journal, with the aim of elucidating the facilitators and barriers linked to the integration of ER in nursing education.

PROSPERO registration number

CRD42024605953.

Strengths and limitations of this study.

• This protocol is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines.

• The Consolidated Framework for Implementation Research will guide our analysis to systematically identify and synthesise multilevel barriers and facilitators affecting the implementation of escape rooms in nursing education.

• This research protocol may be subject to linguistic bias due to the restriction of inclusion criteria to English and Chinese publications.

Introduction

An escape room (ER) is an interactive group activity in which participants collaborate to discover clues, solve puzzles and overcome challenges within a limited space to achieve a specific goal, often centred around escaping the room within a designated timeframe.¹ The majority of ERs were originally designed for recreational purposes. Owing to the interactive and engaging characteristics inherent to recreational ER, the fundamental concept has been integrated into educational settings.^{2 3} As educational methods continue to evolve, ER is increasingly being adopted as a teaching strategy in classroom, clinical and simulation scenarios across various fields, including medicine,4,6 pharmacy,⁷ chemical engineering,⁸ maths,⁹ Science, Technology, Engineering, and Mathematics (STEM) subjects¹⁰ and physics.¹¹ The specially designed educational ER is structured to facilitate collaborative problem-solving among a specific group of learners, aimed at achieving well-defined learning objectives.¹² This teaching method merges simulation with gamified approaches, enabling students to enhance their clinical resilience, teamwork skills, interprofessional abilities, critical thinking and other essential competencies.13,15 The effectiveness of ER in medical education has also been confirmed in a systematic review and meta-analysis.¹⁶

In the realm of nursing education, educators have integrated the ER structure with simulation exercises to create a secure and immersive environment that fosters the development of practical skills.¹⁷ The implementation of ER methodology has proven beneficial, transforming students from traditional passive bystanders into active participants within an innovative educational framework.¹⁸ This shift enhances the learning experience by promoting collaboration, fostering engagement, developing teamwork skills, optimising resource utilisation and improving communication and critical thinking skills.¹⁸ A randomised controlled trial found that nursing students in the ER group outperformed the control group in post-test knowledge and skills related to drug administration, and they also rated the ER education positively.¹⁹ Furthermore, a study indicated that participation in the ER significantly reduced stigmatising attitudes, underscoring its effectiveness as a training tool for future nursing professionals in mental health.²⁰ The COVID-19 pandemic has accelerated the adoption of virtual learning and digital educational tools worldwide.²¹ In response, many education programmes have integrated online or hybrid ERs as innovative pedagogical strategies to engage students remotely while maintaining interactivity and collaboration.^{20 22}

Current systematic reviews of ER have predominantly focused on their effectiveness and learners’ experiences.^{3 23} For example, a recent systematic review summarises the use of ERs in nursing education, including educational settings, delivered topics, delivery modes and methods, and learners’ experiences, but did not address factors influencing their application.¹² Only one integrative review identified three barriers (time required for preparation and delivery, cost considerations and participant stress), without mapping them to a comprehensive implementation framework or identifying facilitators.²⁴ This gap results in a lack of essential practical guidelines for nursing educators in designing and implementing ER in relevant courses. Given the growing number of empirical studies on ER implementation in educational contexts, there is an urgent need for a systematic synthesis of the barriers and facilitators influencing their adoption.²³ Effective implementation of innovative pedagogical tools requires knowledge of the barriers and facilitators that influence their implementation. When implementation interventions are designed to overcome identified barriers, the utilisation of ER in educational environments increases.²⁵

Study aims and research questions

The implementation framework-driven systematic review aims to assess the current status of educational ER for nursing students and to explore the barriers and facilitators encountered in executing this educational initiative. This review seeks to provide valuable empirical evidence for nursing and healthcare educators, promoting the effective and widespread adoption of ER in nursing education, ultimately enhancing educational outcomes and students’ clinical competencies. This review aims to explore the following research questions:

1. What is the present situation of educational ER for nursing students?

2. What are the facilitators and barriers of implementing ER in educational settings?

3. What strategies or recommendations have been proposed in the literature to address these barriers and enhance the effective integration of ER into nursing education?

Methods and analysis

Protocol and registration

The systematic review protocol has been registered in the PROSPERO and has been developed in accordance with the guideline set forth by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement^{26 27} (online supplemental additional file 1). The forthcoming systematic review will be conducted in adherence to the PRISMA statement.²⁸

Theoretical framework

The Consolidated Framework for Implementation Research (CFIR), a pivotal meta-theoretical framework, plays a crucial role in understanding the facilitators and barriers of implementation research as outlined by established theories and models.^{29 30} It comprises 39 constructs distributed across five domains: intervention characteristics, outer setting, inner setting, characteristics of individuals and process.³¹ Each of these five major domains is further subdivided into subcategories, or constructs, associated with effective implementation. Additional insights and comprehensive explanations for each domain can be found in the provided resources (https://cfirguide.org/constructs-old/). This review will employ the CFIR framework to evaluate the implementation barriers and facilitators of ER in nursing education. Given the expansive scope of this framework, CFIR may serve as a valuable tool for facilitating comprehension and integration of implementation factors identified in the literature. The use of this framework allows studies conducted in varied environments to synthesise factors impacting the execution of interventions at multiple levels. Furthermore, it will inform the identification of articles reporting factors of interest, support theme generation during data extraction and analysis and enhance the interpretation of results.

Inclusion and/or exclusion criteria

The PICOS framework (population, intervention, comparison, outcome and study design) was used to establish eligibility criteria for this systematic review. Articles published in both English and Chinese will be considered.

Population

This study will include nursing students currently enrolled in a nursing school or structured nursing education programme. Participants may pursue any nursing degree or certification and engage in coursework, clinical training or related educational activities. No restrictions will be imposed based on sex/gender, race/ethnicity, course level, programme duration or academic year. Additionally, individuals involved in implementing ER activities in nursing education, such as teachers, task publishers, organisers, planners and designers will also be included.

Intervention

Eligible studies will involve ER interventions specifically designed to teach various nursing-related subjects (eg, acute ischaemic stroke and soft skills). This includes any types of ER (eg, physical, virtual and hybrid) implemented in both clinical and non-clinical settings, such as theory classes, clinical practices, laboratory environments and internships. As these modalities differ in their design and delivery, we will take ER type into account during the analysis phase.

Comparator/control

Relevant studies that do not have a control group, do not use a before and after design, or have a control group that receives alternative forms of traditional educational methods (eg, regular classroom instruction) or no intervention will be considered.

Outcomes

The outcomes will be the associated barriers and facilitators to implementing ER in nursing education. The CFIR framework will guide the identification of these factors.³² For this review, factors may include (a) the intervention characteristics dimension: critical attributes that impact the effectiveness of implementation, such as team size, timeframe, type of games, puzzle pathways and their structure; (b) the inner setting dimension: features of the implementing organisation, including its structural characteristics (eg, availability of physical spaces or digital infrastructure for ERs), networks and communication among educators, culture (eg, organisational culture towards innovation and active learning) and preparedness for the implementation (eg, staff training and resource allocation); (c) the outer setting dimension: economic conditions (eg, funding availability, technology costs), political influences (eg, policies promoting innovative education) and social contexts (eg, acceptance of game-based learning among students, educators and society); (d) the characteristics of individuals dimension: individual stages of change, intervention-related knowledge and beliefs, self-efficacy and other personal features (sex, age, interest, leadership) and (e) the implementation process dimension: strategies for engaging, executing, planning, reflecting and evaluating (pre-briefing and de-briefing).

This data will be obtained in the form of student or teacher feedback through qualitative methods such as interviews, as well as quantitative approaches including surveys or assessments of factors like motivation, study results where success rates are linked to certain variables (eg, motivation) and any available process evaluation data (eg, program-specific evaluations and their relationship to success) collected during the study will form the basis of the data analysis.

Study design

Original studies with qualitative, quantitative and mixed-method design will be included. Case studies, reviews, protocols, conference proceedings, editorials and letters will be excluded, but the references of reviews will be checked for further eligible studies.

Patient and public involvement

No patient or public will be involved.

Information sources and search strategy

The proposed timeline for the systematic review is from October 2025 to October 2026. We will search for eligible studies using six English databases (CINAHL, Embase, Education Resources Information Centre, Scopus, Web of Science and MEDLINE) and three Chinese databases (Wang Fang, China National Knowledge Infrastructure and the Chinese Biomedical Literature Database). Google Scholar will be used to find grey literature. Publications in English or Chinese will be considered from database inception. Initially, an exhaustive search strategy was developed collaboratively by FC and XT, with assistance from a librarian. This strategy was based on the PICOS framework and employed to capture a broad range of studies.

The search will include variations and synonyms for ‘escape room’ and ‘nursing students’ using Medical Subject Headings, keywords, Boolean operators and wildcards as appropriate for each specific database. Additionally, systematic reviews and keywords from relevant literature on ER and nursing education were incorporated into the strategy. The draft search was performed in MEDLINE on 16 October 2024. Draft search strategy in MEDLINE is shown in table 1. The search strategies for the other databases can be found in online supplemental additional file 2. Two reviewers (XT and FC) will randomly select 50 results each to evaluate them against the established eligibility criteria. We will also review these results for any additional relevant search terms and subsequently update the search strategy as necessary.

Table 1. Search strategy in MEDLINE.

Number	Search terms
#1	exp Education, Nursing/
#2	Nursing Education*.mp.(mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word)
#3	exp Students, Nursing/
#4	exp Education, Nursing, Baccalaureate/
#5	exp Education, Nursing, Graduate/
#6	(Nursing Student* or Nurse, Pupil or Pupil Nurse* or Student Nurse* or Nursing Undergraduate* or Nursing Graduate* or Nursing Postgraduate*).mp.(mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word)
#7	1 or 2 or 3 or 4 or 5 or 6
#8	(escape room* or escape game* or escape box* or escape activit* or escape lab* or escape pod* or breakout room* or breakout game* or breakout box* or exit game* or puzzle room* or mystery room*).mp.(mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word)
#9	7 and 8
#10	limit 9 to (english language and (chinese or english))

Screening for articles

Articles will be retrieved from online databases by a single reviewer (XT) and managed using EndNote (https://endnote.com/). After removing duplicates, the results will be transferred to Covidence (https://www.covidence.org/) for screening and data extraction. The second reviewer (FC), in collaboration with the main reviewer, will perform title and abstract screening and full-text review. Both reviewers will conduct a thorough independent screening based on the established eligibility criteria. Any discrepancies in the screening process will be resolved through discussion with a third reviewer (MS) to reach a final consensus. Only articles that meet the inclusion criteria will be retained for data extraction.

Data extraction

A data extraction form will be developed by the research team. To test the usability of the form, we will conduct a pilot test of the form with five randomly selected studies. Data extraction will be carried out in duplicate by two reviewers. The extracted information will comprise research characteristics, such as publication details (authors, country, year of publication), primary research objectives, research design, research topic, study participants, sample size and outcomes of interventions (table 2). Furthermore, it will also encompass barriers and facilitators identified within the five major domains of the CFIR.²⁹ Regular meetings will be conducted throughout this phase. Any discrepancies between two reviewers will be resolved through consensus; however, if consensus is not achieved, a third reviewer (MS) will act as an adjudicator to reach a final decision. Furthermore, the data extraction process will be iterative, allowing for the incorporation, modification or exclusion of extraction elements as considered necessary by all team members.

Table 2. Data to be extracted from studies.

Domain	Data
Publication details	Authors
	Year
	Country
Study information	Study design
	Study setting
	Research topic
	Research objectives
	Evaluation tool
Participant characteristics	Age
	Sex
	Sample size
	Course type
Intervention characteristics	Academic year
	Location
	Team size
	Time limit
	Delivery mode
	Puzzle pathway
	Role of facilitator
Outcomes	Barriers and facilitators to implementing ER in nursing education (The data will be obtained by segmenting specific portions to align with the relevant CFIR constructs. If a data segment encompassed various constructs, it will be assigned to each corresponding CFIR construct).

CFIR, Consolidated Framework for Implementation Research; ER, escape room.

Quality assessment

Two researchers (XT and FC) will individually evaluate the quality of each article using the Mixed Methods Appraisal Tool (MMAT).³³ This critical evaluation instrument allows for the assessment of different study types, including qualitative research, randomised controlled trials, non-randomised studies, quantitative descriptive studies and mixed-methods studies. The MMAT includes two initial screening questions and five criteria for each study type, assessed on a categorical scale of ‘yes’, ‘no’ or ‘cannot tell’. Any responses indicating ‘no’ or ‘cannot tell’ to both screening questions will result in exclusion from further analysis. A quality score percentage is derived for each study using the MMAT scoring guide, with the cumulative score determined solely by the number of items marked ‘yes’.³³ Methodological evaluations will be conducted for each study in this review, assigning ratings of high quality (75%–100%), average quality (50%–74%) and low quality (0%–49%) based on the appraisal process. In accordance with best practices, both authors will evaluate each study by thoroughly examining the relevant categories outlined in the MMAT. After individual assessments, the reviewers will convene to discuss their findings and reach a consensus. In cases of disagreement in the final evaluation, a third reviewer (MS) will be consulted for further assessment.

Data transformation and synthesis

In accordance with the methodological recommendations for mixed-methods systematic reviews, we will employ a convergent integrated approach that includes the transformation of quantitative findings.³⁴ The process of qualitising quantitative data is considered suitable for converting the data into a format that is compatible with qualitative data prior to analysis.³⁴ One reviewer (FC) will take responsibility for the quality assurance of data. To verify the accuracy of the data transformation, narrative summaries of the quantitative findings from the original authors will be compared with the qualitised data.

A thematic synthesis approach, as recommended by the Cochrane Handbook, will be used to analyse and synthesise all findings.³⁵ The analysis will begin with line-by-line coding, followed by grouping related codes to establish ‘descriptive’ themes. These themes will represent barriers and facilitators to implementing ER in nursing education and will subsequently be aggregated to form overarching ‘analytical’ themes based on ‘third order interpretation’.³⁶ NVivo V.11 will support data management throughout the thematic synthesis. Thematic synthesis will be conducted by two reviewers (XT and FC) for all included studies. Any differences identified will be discussed to reach an agreement, with disagreements resolved by a third reviewer (MS). Following this, comparative data analysis will be performed to compare barriers and facilitators.³⁴ The barriers and facilitators identified within each main theme will closely reflect the original findings from the included studies and will subsequently be mapped to the five major domains of CFIR. We acknowledge that physical, virtual and hybrid ERs differ substantially in design features, technological requirements and participant experiences.^{37 38} Physical ERs typically involve tangible puzzles and in-person collaboration, whereas virtual ERs rely on digital environments, often with challenges related to technology access, user engagement and cognitive load.^{22 39} Hybrid ERs combine elements of both modalities, while also presenting unique constraints.^{37 39} In line with best practices for systematic reviews,^{40 41} we will synthesise evidence separately by ER type. This approach will ensure that our findings accurately reflect the diversity of ER modalities and avoid misleading generalisations.

Discussion

The implementation of ER in nursing education presents both opportunities and challenges.²⁴ This innovative pedagogical approach enhances active learning and critical skill development, fostering essential competencies such as teamwork and communication in healthcare settings.² Moreover, ER positively impacts student attitudes toward mental health, underscoring their broader societal benefits.²² By improving student engagement and learning outcomes, this method transforms traditional educational practices, stimulates cognitive development and creates a supportive learning environment that mirrors real-world clinical scenarios.^{17 42}

While several systematic reviews have examined the effectiveness of ER in educational contexts, limited attention has been given to the factors influencing their utilisation in nursing education.^{2 3} Currently, the implementation of ERs faces several influencing factors, including time for preparation and conduction, cost consideration, participant stress,²⁴ the level of difficulty,⁴³ irrational clues, technological limitations in virtual ERs,^{12 37} as well as teacher-related factors such as managing activity time, monitoring student performance, providing hints or guidance and offering immediate feedback.⁴³ However, the current evidence remains fragmented and lacks a comprehensive understanding of the full range of facilitators and barriers across different educational and organisational contexts. Therefore, the forthcoming review aims to provide a comprehensive synthesis of qualitative, quantitative and mixed-methods research regarding the barriers and facilitators to the implementation of ERs in nursing education, guided by the CFIR framework. Establishing a robust evidence base will empower nursing educators to advocate for the inclusion of ER in curricula, ultimately enhancing the quality of nursing education and better preparing graduates for the complexities of modern healthcare environments. By leveraging the advantages of ER while addressing associated challenges, nursing education can evolve to more effectively equip students for their future roles in healthcare.

In addition to mapping these factors, the review will identify practical strategies to support ER implementation. These include suggestions on how to integrate ERs into nursing curricula (eg, embedding ER activities within simulation-based learning modules),⁴⁴ design considerations such as aligning ER scenarios with clinical competencies and learning outcomes,²⁴ and implementation strategies including fostering interdisciplinary collaboration,¹³ securing institutional support and allocating adequate time and material resources.²⁴ Preliminary literature indicates that follow-up data on the sustained use of ERs are limited, possibly due to factors such as faculty workload, institutional inertia and resource constraints.45,47 This protocol aims to systematically identify such barriers and facilitators, including those impacting sustainability and long-term evaluation. The findings from the planned systematic review will be used to generate evidence-informed, actionable recommendations for nursing educators and institutions seeking to implement ERs effectively. These recommendations aim to bridge the gap between evidence and practice, promoting wider adoption of ERs as an engaging and competency-based pedagogical approach in nursing education, with considerations for sustainable implementation and ongoing evaluation.

Ethics and dissemination

The ethical approval for this review is unnecessary due to the utilisation of secondary data. The outcomes are scheduled for publication in a peer-reviewed journal, with the aim of elucidating the facilitators and barriers linked to the integration of ERs in nursing education.