Investigation of Nursing Students' Knowledge Levels and Attitudes in Incontinence-Associated Dermatitis Management through Game-Based Learning: A Mixed Methods Study

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Wound Management & Prevention or HMP Global, their employees, and affiliates.

Incontinence-associated dermatitis (IAD) is a condition that results from incontinence in which urine, feces, or both come into prolonged contact with the skin, leading to the formation of an inflammatory response in the affected area.^1-4 This condition also gives rise to complications such as itching, pain, and infection, consequently negatively impacting the quality of life, care, and costs.^5-6 The prevalence and incidence of IAD vary across care settings, ranging from 8.4% to 45.7%.^7-10 Prevention and management of IAD, especially in long-term acute care settings, require the identification of risk factors.¹⁰ To achieve this goal, the recommended approach involves implementing preventive and protective measures and structured care strategies.¹¹ In this context, nurses play a critical role in preventing and managing IAD.^1-12 Despite various studies highlighting the potential of severe complications and emphasizing the preventable nature of IAD,^1-12 it has been demonstrated that nurses possess a low level of knowledge regarding IAD risk factors, classification, prevention, and management.^13-16

It has been emphasized that nurses do not adequately utilize their professional experiences and knowledge in the management of IAD.^1-17 Therefore, IAD prevention, management, and classification should be included in the core nursing education curriculum.¹⁸ On the other hand, the younger generations (Generations Y and Z) prefer practical, individualized, engaging, technologically advanced, and visually based learning approaches.^19,21 In the literature, the significance of utilizing active learning modalities for easier comprehension of complex cases in chronic wound management by students is underscored.²¹ In this context, various learning modalities—such as interactive educational materials, clinical simulations, and problem-solving-focused activities—provide students with opportunities to translate theoretical knowledge into practical application and foster a more profound understanding.²¹ Moreover, group collaborations and case analyses that actively engage students stimulate interactive and realistic learning, assisting students in delving deeper into the subject matter.²¹ The incorporation of these approaches in chronic wound management education allows students to build a robust foundation in both theoretical knowledge and practical skills.²¹ Despite the effectiveness, efficiency, and enjoyment of skill training through active learning approaches like gamification for both participants and educators, there is a lack of studies in the literature that have utilized a game-based educational method to enhance nursing students' knowledge and attitudes towards IAD.

Purpose and design of the study

This study aimed to explore nursing students' level of knowledge and attitudes toward the etiology, risk factors, and preventive measures of IAD through game-based instruction. The study was designed as a mixed-methods research, incorporating both quantitative (pre-post test quasi-experimental design) and qualitative data.

Research questions. What was the students' focus while playing the game during the learning of IAD? What were the benefits/advantages of teamwork in managing IAD during the game? How did the game contribute to students' better understanding and classification of IAD?

Setting and participants. The research population consisted of 59 third- and fourth-year students who enrolled in the Chronic Wound Management elective course conducted within a bachelor's degree program during the spring semester of the 2022-2023 academic year at Koç University's School of Nursing. However, considering that students enrolled in this course could have potentially been biased or already had an increased interest in learning, participants in the study were categorized into the following 4 groups:

• Students enrolled in the course interested in both theory and escape room game,
• Students enrolled in the course interested only in theory,
• Students not enrolled in the course interested in both theory and escape room game,
• Students not enrolled in the course interested only in theory.

Therefore, the participants selected for the study using purposive sampling met the following criteria: (1) Enrolled in the elective Chronic Wound course, (2) Interested in both theory and escape room game, (3) Lacked prior knowledge of and experience in escape room game and voluntarily willing to participate in the research. In line with these criteria, the sample group was comprised of a total of 35 students, and 24 students were excluded who qualified to participate in the study. Three invited students declined to participate in the study. Consequently, the qualitative and quantitative phases of the research were completed with a total of 32 students, and 8 students participated in each discussion group.

Data collection and instruments

Quantitative phase of the study. For obtaining descriptive and quantitative data in the study, a demographic identification form containing information about students' age, gender, and year of study, the "Knowledge, Attitude and Practice of Nurses in Managing Incontinence-Associated Dermatitis Questionnaire (KAP-IAD-Q)," and integrated puzzles within an escape room game were employed.

KAP-IAD-Q: The scale was developed by Cheryl Tay and colleagues²² in 2020 and was adapted to Turkish validity and reliability by Sönmez et al²³ in 2022. It consists of 4 subscales (etiology and diagnosis knowledge, 5 items; risk factors knowledge, 6 items; attitudes, 3 items, practices, 6 items) and 20 total items. The 4 subscales are evaluated independently. Possible scores from the scale range from 5 to 25 points for subscale 1, 6 to 30 points for subscale 2, 3 to 15 points for subscale 3, and 6 to 30 points for subscale 4. The total questionnaire scoring ranged from 20 to 100 points. Each item is rated on a 5-point Likert scale where 1 means "not agreeable" and 5 means "highly agreeable." The questionnaire's Cronbach's alpha coefficient is 0.92.^23. Within the scope of the present study, Cronbach's alpha value was determined as 0.826 in the pre-test and 0.872 in the post-test.

Theoretical knowledge questions: The questions were designed to enhance both knowledge and attitude levels regarding IAD etiology, classification, risk factors, preventive measures, and care interventions. The questions had yes-no, short, and clear answers. In this study, the Davis technique was employed to enhance the content validity of the questionnaire. Within this framework, collaboration was established with 5 experts in the field to develop 10 questions. The content validity index of the questionnaire was calculated and was found to be 0.90, indicating that the questions reflect the relevance to the subject and the ability to measure the intended learning areas.²⁴ This value demonstrates the reliability and validity of the content. This question form was used as an element of escape room game–based learning.

Visual pictorial puzzles: In this study, a total of 12 IAD images—comprising 1a, 1b, 2a, and 2b classifications—were designed as puzzles to enable accurate classification of IAD. The IAD images used in the puzzles were reviewed by 3 certified wound and ostomy nurses (CWONs) for appropriateness, and consensus was reached on their suitability and relevance for IAD classification. The Ghent Global IAD Classification Tool (GLOBIAD) was employed for the classification. The design and international validation of GLOBIAD were conducted in 30 countries, including Turkey.²⁵ This puzzle was one of the tools of Game-Based Learning.

Qualitative phase of the study. For the qualitative data of the research, semi-structured questions and focus group discussions (FGDs) were conducted by one of the researchers, a CWON, using a phenomenology methodological approach. Before the start of the study, this CWON did not engage with students. The students had not been informed about the interviewer before. In line with the literature,²¹ researchers prepared FGD questions for post-game interaction to comprehensively determine students' emotions and thoughts during the game interaction (Figure 1). Five FGDs were conducted with a total of 32 students. Each FGD consisted of 6 or 7 participants. The students were assigned to the focus groups in a randomized manner using https://www.randomizer.org. In the literature, it is recommended that focus groups should ideally consist of a minimum of 6 and a maximum of 11 individuals to achieve a sufficient sample size.²⁶

Intervention of the study

Preparation and application of escape room game. Before providing students with theoretical education on IAD, the KAP-IAD-Q questionnaire was administered as a pre-test. The theoretical course, which covered the definition, classification, prevention, and care practices of IAD, comprised a 6-hour segment of the students' chronic wound care education. After completing the theoretical lessons, 2 weeks elapsed, during which students were randomly assigned to 6 different groups for the game with the assistance of department faculty members. Students and instructors were directed to their respective classrooms, and the doors were closed. All groups were simultaneously guided into their designated rooms, and the game commenced.

Each group was presented with 10 theoretical knowledge questions regarding IAD in the form of puzzles. These questions were designed to be drawn at random from a box in written form, ensuring an element of chance. Within their respective groups, students discussed the questions and continued until they arrived at the correct answer. Upon finding the correct answer, they earned the right to proceed to the next question. Once all questions were completed, they moved on to the puzzle images prepared for IAD classification.

They worked on classifying 12 IAD visuals until they correctly classified all of them. The group that completed the puzzle pieces correctly in the shortest time received the key to the room, signaling their success in escaping. After all the games concluded, students were subjected to the post-test using the KAP-IAD-Q questionnaire. Following the post-test, students were invited to participate in FGDs.

Preparation and application of FGDs. Invitations to participate in FGDs were sent to the students 2 weeks after completing the escape room game. Students who agreed to participate in the discussions were informed about the following before FGDs began: the meetings' purpose, points of attention, recording methods (audio recording and note-taking), the observer's role, the assurance that their statements would be used solely for the study and would not impact their academic performance, and the confidentiality of their identities. A total of 5 FGDs were conducted and concluded when data saturation was achieved. Audio recordings were made using recording devices during the meetings, and the observer maintained written records. An experienced observer in qualitative research attended the FGDs with the interviewer and recorded the students' main points and emotional expressions during the sessions.

Study's trustworthiness and consistency

The validity and reliability of the study adhered to all criteria specified in the literature.^27-29 To ensure sufficient interaction, each interview with the students lasted between 30 and 40 minutes. All interviews were supplemented by written notes from students and the recordings captured by the observer during each FGD. Questions seeking more detailed explanations were directed to students during the interviews to confirm their statements. The same questions were posed to every group during the FGDs to maintain consistency in the study. Data analysis was independently conducted by the researchers. After data analysis, the information was categorized into themes and subthemes, with researchers reaching a consensus after reviewing the data.

Data analysis

IBM SPSS Statistics Version 28.0.0.0 (190) was utilized for data analysis. A nonparametric dependent samples t-test (Wilcoxon signed-rank test) was employed to compare the pre-training and post-training score averages obtained from KAP-IAD-Q. Significance was assessed at the P < .05 level. The thematic analysis method was used to analyze qualitative data obtained from FGDs.³⁰ The study report was prepared following the Consolidated Criteria for Reporting Qualitative Research checklist.³¹ Audio recordings were transcribed verbatim by the researcher, and each FGD transcript was transferred as a separate Word file with no additional comments. FGDs were compared with the observer's notes after each session. To ensure student confidentiality, each student was coded by gender, age, and class (eg: F, A21, 3rd/4th). The researchers reviewed the students' responses and categorized them according to the study's purpose and structure. The collected data were synthesized, leading to interconnected categories, themes, and subthemes.³² Where relevant, student quotations were used to support the data.

Ethical considerations

Before commencing the research endeavor, requisite written endorsements were acquired from the University Ethics Committee, identified as (No: 2023.192.IRB3.088). To ensure the voluntary engagement of participating students in the study, comprehensive elucidation concerning the study's objectives and methodological framework was provided and written informed consent was secured.

Quantitative findings

The average age of the participants was 22.63 + 0.90 (21-25); 87.5% of them were female (n = 28) and 12.5% male (n = 4); 50% were juniors (n = 16) and 50% seniors (n = 16) (Table 1).

There were significant differences between the post-test scores and pre-test scores of factors 1, 2, 3, and 4; sequentially, factor 1 (Z = ˗2.173, P = .030), factor 2 (Z = ˗3.932, P < .001), Factor 3 (Z = ˗3.756, P < .001), and factor 4 (Z = ˗3.530, P < .001) (Table 2). Additionally, there was a significant difference between the scale's total post-test and pre-test scores (Z = ˗4.392, P < .001).

Qualitative findings

The authors evaluated the data from the students participating in the FGDs according to 3 categories. The primary focus of participation in the IAD-themed escape room game was the advantages and disadvantages of teamwork in IAD management and how the game contributed to a better understanding and classification of IAD. Concepts representing themes and subthemes for all categories are shown in Table 3.

Category 1: While engaging in the IAD-themed escape room gaming, your primary focus was...

Theme 1: Realizing how they learned: As students participated in the IAD-themed escape room game, they focused on recognizing the topics they had learned. Subthemes emerged within this overarching theme, such as increased knowledge about IAD, more effective implementation of game-based learning, and the enjoyable nature of the game. The interactive nature of the escape room game facilitated students' acquisition of more information about IAD and created a dynamic learning environment that combined education and entertainment. Below are some student statements that contribute to these findings:

"… Compared to my other theoretical courses, I can definitely say that I learned the subject much faster." (F9, A22, 3rd)

"For skills-based and complex topics, traditional methods should not be used." (F7, A23, 4th)

"… I had a lot of fun during the game. At the same time, I believe that learning through games is much more enjoyable and much more effective than theoretical learning." (F6, A21, 4th)

Category 2: Advantages/disadvantages of teamwork for IAD management

Theme 2: Positive feelings & challenging feelings: When examining the advantages and disadvantages of teamwork in IAD management, significant findings emerged under positive and challenging emotions. Factors such as collaboration and intra-team harmony reflected the positive effects of teamwork in IAD management. Coming together as a team to share knowledge and experiences provided a more comprehensive perspective.

However, elements such as collaborative decision-making processes and ensuring equitable participation occasionally evoked challenging emotions. Students' expressions highlighted aspects that require balance, particularly the designation of a team leader and the management of intra-team dynamics. These findings emphasize the need for careful planning and management of teamwork for effective IAD management.

"…In the game, we reached the correct answers by collaborating among team members and synchronizing to fill in the missing information." (F2, A21, 3rd)

"...Equal contributions from team members allowed us to answer the questions more quickly." (F8, A23, 4th)

"…It was really challenging to determine the leader within the team, but it was necessary." (F11, A23, 4th)

Category 3: How the game contributed to your understanding and classification of IAD

Theme 3: Realizing what they learned: The analysis regarding the impact of game-based education on understanding IAD management and making accurate classifications yielded significant findings related to students' awareness of what they had learned. An important outcome derived from the game was enhancing the ability to classify IAD cases accurately. Similarly, the capacity for making quicker decisions emerged due to this learning experience. Moreover, students recognized the development of critical thinking skills and how these skills contributed to understanding and classifying IAD cases. These achievements through the escape room game underscore its effectiveness in enhancing knowledge and skills in IAD management.

"… I believe I can definitely distinguish IAD from other wounds." (F10, A22, 3rd)

"We made quick and accurate decisions together as a team." (F1, A21, 3rd)

"… Within the game, we managed to accurately stage IAD using the puzzle images within a specific time." (F5, A21, 4th)

"… While solving the game's questions, I realized I learned a lot. The variety of question examples contributed to an increase in my knowledge level." (F4, A22, 3rd)

This study demonstrated a strong and consistent relationship between quantitative and qualitative data. First, when evaluating the quantitative outcomes of the study in general, it was observed that the total scores obtained from KAP-IAD-Q by all students in the game-based education were significantly high (88.06 ± 7.00) (P < .001). Students obtained the highest scores from the dimensions of KAP-IAD-Q, particularly those related to risk factor knowledge and preventive measures (P < .001). The lowest score was obtained from the attitude subdimension of KAP-IAD-Q (9.0 ± 3.16), and a significant difference in the post-education scores was found (P < .001). Attitude is a learnable concept and is influenced by an individual's level of knowledge on the subject, interest in the topic, and experiences.³³ The low score in this subdimension could be attributed to the fact that students had not yet experienced the management of patients with IAD in clinical settings. However, numerous studies indicate^12-16 that nurses have low knowledge about IAD, highlighting the need for comprehensive education in diagnosing, preventing, and managing IAD. Although the students had prior experience in regular patient care, they did not have specific theoretical knowledge regarding IAD care before the elective course and the escape room game. This is because managing patients with IAD requires classification, considering risk factors, and applying theoretical and advanced care practices. Multiple studies emphasize the importance of integrating evidence-based nursing education into fundamental nursing curricula and strengthening these educational programs.^15-16

The primary findings obtained from the present study revealed that students' knowledge levels about IAD significantly increased after the education and, most importantly, that students were aware of this improvement. Students found using visual puzzle images integrated into the escape room game more effective than traditional lecture techniques. They indicated that the lesson was designed around entertainment, leading to quicker learning. This finding aligns with numerous studies emphasizing the significance of innovative approaches in nursing education.^21-34-35

The secondary outcomes of the present study demonstrate that students experienced a range of advantages and disadvantages of teamwork in IAD management. Firstly, under the subtheme of "Collaboration," it was observed that working together allowed students to combine knowledge and skills from different perspectives to generate more comprehensive solutions. This result could facilitate the development of more effective strategies in IAD management by enabling a deeper understanding. Additionally, the "Time Management" and "Team Cohesion" subthemes helped students enhance their abilities to use time efficiently and create a harmonious working environment within the team. Thus, these games can aid students in developing collaboration and leadership skills for their future professional lives. However, challenges in time management and achieving team cohesion were also observed among some students. Numerous studies emphasize the prevention, application of protective measures, and management of IAD as collaborative efforts.^1-22-23 Therefore, in all health care settings, the role of nurses who work to maintain and protect patients' skin integrity is of significant importance.^{1-22-23,36-37} The findings of the present study, aligned with the literature, highlight the importance of nurses functioning cohesively within a team to have a stronger impact on patient care outcomes and the significance of acquiring such experiences before nurses graduate.

The use of escape room gaming in the present study provided students with an opportunity to enhance their coping abilities with both positive and challenging emotions. Under the theme of "Positive Emotions," it was observed that students had a positive working experience, along with factors such as equal participation and team leadership. On the other hand, under the theme of "Challenging Emotions," students' strategies for dealing with challenges and utilizing problem-solving skills were observed. This experience could contribute to students' ability to enhance their stress management and flexibility in facing various challenges.

The present study's findings indicated that the education provided through the game allowed students to enhance their clinical assessment abilities by correctly classifying IAD and improving their practical skills. The management of IAD, including risk factors and classification, involves complex skills such as preventive interventions.^15-38 Therefore, accurate classification of IAD is crucial as it can be confused with other wounds, which may lead to incorrect treatment application and the inability to integrate current evidence into care. Additionally, analyzing puzzles and clues within the game contributed to developing critical-thinking skills. The results obtained from the present study instill the hope that nursing students can enhance their ability to make more precise and accurate diagnoses in future clinical practices. Furthermore, within a specific timeframe, they can elevate their effectiveness in making correct and prompt decisions, thus enhancing their professional lives.

This study has certain limitations. One of these limitations is the restricted number of students and the fact that the education was conducted solely in a single university. Additionally, the game's scope was focused only on IAD. The lack of similar studies specifically addressing the use of game techniques in teaching complex skills also made it difficult to compare this study's results with those of the existing literature. On the other hand, the limited number of students made it possible to monitor and manage the learning experience of this study closely. Teaching the game to all groups simultaneously in an interactive educational environment positively influenced the learning experience. However, challenges may arise in future studies involving broader student participation, especially with escape room games. Managing such interactive games and ensuring equal participation from every student could become more complex. Furthermore, organizing games at different time intervals within the same class may lead to certain disadvantages. For instance, sharing test questions among students could negatively impact test results. Therefore, careful attention is required in the timing and management of games.

From the students' perspective, game-based learning was found to support rapid and effective learning in complex skill areas like IAD, enhance knowledge levels, and emphasize the significance of teamwork in IAD. Furthermore, students suggested that active learning methods should be favored over traditional ones, potentially making skill training more effective through these models. From the viewpoint of nurse educators, the most significant finding of this study was that nursing students struggle with correctly diagnosing IAD and differentiating it from other wounds. The authors believe a similar situation could apply to all nurses working in health care settings, where their knowledge about IAD might not yet have reached the desired level.

Acknowledgments: The authors thank the students who took part in the study.

Authors: Tuba Sengul, RN, CWON, PhD, Assoc Prof.¹; Nurten Kaya, RN, PhD, Prof.²; Holly Kirkland-Kyhn, PhD, FNP-c, GNP-c, CWCN³; Dilek Yilmaz Akyaz, RN, Msc, WOCN⁴; Tuğba Cevizci, RN, WOCN⁴; Tuğçe Oldaç, RN¹; and Hamza Can Koyun, RN¹

Affiliations: ¹Koç University School of Nursing, İstanbul, Turkey; ² Istanbul University-Cerrahpasa, Health Sciences Faculty, Department of Midwifery, İstanbul, Turkey; ³UC Davis, Betty Irene School of Nursing Sacramento; California,⁴ Koç University Hospital

Correspondence: Assoc Prof. Tuba Sengul, RN, CWON, PhD; Koc University, Koç University School of Nursing, Davutpaşa Caddesi No:4, 34010 Topkapı, İstanbul, Türkiye; tsengul@ku.edu.tr

Ethics Committee Approval: Written permission was obtained from the School of Nursing where the study was conducted and the Koç University Ethics Committee before the data collection process (2023.192.IRB3.088).

Financial Disclosure: This project has been awarded Teaching Improvement grants by Koç University's Office of Learning and Teaching (KOLT; https://kolt.ku.edu.tr/projects/), with the received support, necessary equipment, and materials for the game having been prepared. The authors declare that there are no competing interests.

ORCID: Sengul, 0000-0002-6253-2016; Kaya, 0000-0003-0414-3589; Akyaz, 0000-0001-7991-3176; Cevizci, 0009-0001-1609-0528; Oldaç, 0009-0002-0333-7250; Koyun,0000-0002-4769-6047

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