Escape Room Learning Helps Nursing Students With ADHD but Hurts Those With Language Difficulties

A virtual escape room designed to teach nursing theory turned out to be a strikingly uneven educational tool, according to a quasi-experimental cohort study published in Nursing Open. The intervention, introduced into a mandatory undergraduate nursing course at a single Israeli institution, appeared to boost recognition-based test performance among students with ADHD or learning difficulties, yet was associated with markedly lower scores for students struggling with the language of instruction. The findings challenge one of the most widely repeated assumptions in modern educational innovation: that gamification benefits everyone.

The study, conducted across the 2023 to 2025 academic years, compared 150 students who received traditional instruction with 276 students who completed a digital escape room built on the Genially platform. The activity lasted between 30 and 60 minutes and comprised eight tasks, including classifying nursing theories, matching concepts with definitions, identifying theorists from clues, interpreting images, drag-and-drop exercises and multiple-choice questions. Students worked individually at their own pace, with unlimited attempts and access to course materials, and completion was monitored through platform logs as part of exam preparation. The control group received the same course instruction without the escape room, and both groups sat the same final examination.

In total, 426 students aged between 18 and about 55 were analysed, with a mean age of 25.31 years. Roughly 80 percent were women and nearly half identified as belonging to Arab society, for whom Hebrew, the language of instruction, was frequently a second language. Crucially, learner classifications were not based on self-report: students were categorised through formal institutional records held by the student support services office, reflecting documented diagnoses or recognised accommodations. Of the sample, 153 students had language difficulties, 32 had learning difficulties including ADHD, and 241 had no recorded difficulties. Students in the supported categories were eligible for 30 minutes of additional examination time.

At first glance, the escape room looked like a modest failure. Students in the intervention group scored significantly lower on constructed-response questions, the section requiring organised written answers, with a small effect size, while multiple-choice and total scores showed no significant differences. But the aggregate picture concealed what happened when the researchers split the data by learner status. Using two-way analyses of covariance that controlled for age and gender, the team found statistically significant interactions between instructional format and learner category for all three outcomes: constructed-response scores, multiple-choice scores and total exam scores.

The pattern for students with ADHD or learning difficulties was the most eye-catching, though it comes with an important caveat: the subgroup contained only 32 students, 21 in the escape room group and 11 receiving traditional instruction, so the results are exploratory. Within that small group, escape room learners scored dramatically higher on multiple-choice questions, averaging 93.33 percent versus 70.00 percent for traditionally taught peers, a large effect. A formal contrast against the reference group of traditionally taught students without difficulties showed a mean advantage of 14.60 percentage points. No differences emerged on constructed-response or total scores, suggesting the benefit was specific to recognition and rapid decision-making rather than to sustained written expression.

The results for students with language difficulties point in the opposite direction. These 153 students scored significantly worse under escape room instruction on constructed-response questions, averaging 54.20 percent compared with 71.00 percent under traditional teaching, and on total scores, 61.68 versus 72.70 percent. The roughly 11-point gap in total scores is substantial enough to affect academic standing. Notably, the disadvantage persisted despite the extra examination time these students were entitled to, which the authors interpret as evidence that the problem extends beyond simple time pressure. Holm-corrected post hoc comparisons confirmed that the escape room disadvantage was concentrated in this subgroup rather than spread across the cohort.

Why would a game-like format hurt students who are already managing a second language? The researchers offer several hypotheses, emphasising that none were directly measured. Escape rooms typically demand rapid information processing, which may disproportionately burden students already working to decode language. Multi-layered puzzle instructions often require high-level language processing, particularly when medical terminology is embedded in narrative contexts. The gamified wrapper may also add extraneous cognitive load, siphoning resources away from the already demanding task of reading in a non-native language. Even though the activity was completed individually, its text-heavy puzzle design may have disadvantaged students less comfortable interpreting complex written instructions.

The analysis by cognitive level, using Bloom’s revised taxonomy, added another layer of nuance. Escape room students performed significantly worse on lower-level constructed-response questions, those targeting remembering and understanding, while no differences appeared on higher-level constructed-response items or on multiple-choice questions at any level. The authors caution that this classification was performed by the study authors without formal inter-rater reliability testing, and that only cognitive levels one to three were represented in the exam, so these conclusions remain tentative.

The study’s limitations are considerable and the authors are candid about them. Because allocation was determined by academic year rather than randomisation, cohort effects cannot be excluded, and baseline equivalence was not established for prior academic performance, motivation or digital literacy. The exams differed across years in the proportions and weighting of multiple-choice and constructed-response items, meaning some observed differences could reflect assessment design rather than teaching method. Intervention fidelity and engagement data, such as time on task, were not captured, the study took place at a single institution with one instructor, and 12.3 percent of participants lacked demographic data due to institutional retention policies. The authors explicitly state that the associations should not be read as causal effects of the escape room intervention.

Nevertheless, the implications for educational equity are hard to ignore. The findings align with Universal Design for Learning principles, which call for multiple means of representation, engagement and expression to accommodate diverse learners. The authors suggest that escape rooms may work best as a complementary tool rather than a wholesale replacement for traditional teaching, and that future designs could incorporate vocabulary support, multimodal materials, flexible pacing, multilingual resources and structured debriefing sessions. For students with ADHD, escape-room-style instruction may be worth investigating further where learning objectives emphasise quick recognition and decision-making. The broader lesson, the researchers argue, is that the prevailing narrative of gamification’s universal benefit deserves scrutiny: before adopting any engaging new format, educators should ask not only whether it works, but for whom.

Subject of Research: Differential effects of gamified virtual escape room instruction on academic performance of nursing students with ADHD and language difficulties

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

Article References: Weil‐Lotan, D., Harari, R., Tannenbaum‐Baruchi, C., & Theilla, M. (2026). One Size Does not Fit All: Gamified Escape Room Learning for Students With ADHD and Language Difficulties in a Quasi‐Experimental Cohort Study. Nursing Open, 13(10), Article e70882. https://doi.org/10.1002/nop2.70882

Image Credits: AI Generated

DOI: 10.1002/nop2.70882

Keywords: nursing education, gamification, escape room, ADHD, language difficulties, quasi-experimental study, Bloom's taxonomy, Universal Design for Learning, educational equity, cognitive load, assessment, higher education