Effect of Repeated Crossword Puzzles Experience on The Motivation, Cognitive Load and Intramuscular Injection Skill Learning of Nursing Students

Nursing students must learn a variety of concepts and professional skills during their education. This learning process can be challenging, and reinforcement is often necessary. To support students and enhance their interest, it is recommended to implement active learning strategies. One effective strategy is the use of puzzles. The purpose of this study was to examine the effect of puzzles on nursing students' learning concepts and skills related to administering medication via intramuscular injection.

Study Overview

• Status: Completed
• Conditions: Learning Concepts and Skills
• Intervention / Treatment: Other: Crossword Puzzles; Other: Control group

Detailed Description

This study were conducted a randomized controlled experimental design incorporating pre-test and post-test follow-ups. The study sample consisted of volunteer nursing students at the nursing department of a university in western Turkey. In this department, an internship program is offered and the Fundamentals of Nursing course. Drug Administration Unit is designed to provide 15 hours of theoretical instruction and 40 hours of practical training during the spring semester in Fundamentals of Nursing course. For the IM application, 5 hours of theory and 16 hours of practice were used from the 15 hours of theoretical lectures and 40 hours of practical training.

Students were informed of the purpose of the study and their consent was obtained. Students who gave their consent were asked to choose a code name to protect both the security of duplicated data and student privacy, and the Student Information Form, pre-tests the Motivation Strategies for Learning Questionnaire (MSLQ) and the Cognitive Load Scale (CLS) were administered. For three weeks (15 hours), the "Drug Administration" unit was presented to both the experimental and control groups via PowerPoint presentations. This unit was divided into three main topics: "Oral and local drug administration," "Parenteral drug administration," and "Complications of intravenous fluid therapy." These sections also included information on the importance of intramuscular (IM) administration, points to consider during and after administration, administration steps, and potential complications. Following the presentations, students reinforced their knowledge about Drug Administration" unit through question-and-answer sessions and discussions. Following the standard lesson, students in both the experimental and control groups were taken to the vocational skills lab. A video of the IM skill application was projected once, and then an instructor explained the IM application again using a skill mannequin. Students in the experimental group were presented with two puzzles before the first skill application on the mannequin: one focusing on the concepts related to the skill and the other on the steps of skill application, and were asked to solve them. After solving the puzzles, students submitted them to their instructors. In the two weeks following this training, students first solved the same puzzle, researcher collected the crossword puzzles, and then students performed the IM skill application on a skill mannequin. After solving the puzzle and performing the skill application a total of three times, students took post test the CLS and MSLQ and a skills exam four weeks later.

During the application process, the control group of students received standard training and then students took post test the Cognitive Load Scale and Motivation Scale and a skills exam four weeks later. After the skills exam, all students were given the puzzle to help consolidate their learning. This skills test did not affect the students' academic averages.

For the sample size calculation of the study, since there is insufficient data in the literature on the effect of Motivation Strategies for Learning Questionnaire, cognitive load, and intramuscular skills of nursing students, it was calculated that 64 students from each group (experimental=64, control=64) should be included in the study with a 5% margin of error and 80% power value to test the moderate effect size (d=0.5) prediction of the puzzle intervention. Given the potential losses during the research process, 70 students will be included in each group.

Turkish version of Motivated Strategies for Learning Questionnaire and Cognitive Load Scale, and skill exams specific to M skill application were used for data collection.

• Study Type: Interventional
• Enrollment (Actual): 140
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Edirne
    • Edirne, Edirne, Turkey (Türkiye), 22030
      • Trakya University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Be over 18 years of age,
• To volunteer,
• Taking the Fundamentals of Nursing course for the first time,
• Absence of any psychiatric disorder that will reduce the ability to comprehend and understand,

Exclusion Criteria:

• Being under 18 years of age,
• Not being a volunteer,
• Having previously taken the Fundamentals of Nursing course,

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: The crossword puzzle group; The "Drug Administration" unit was presented via PowerPoint presentations. Following the standard lesson, students in both the experimental group were taken to the vocational skills lab. A video of the IM skill application was projected once, and then an instructor explained the IM application again using a skill mannequin. Students in the experimental group were presented with two puzzles before the first skill application on the mannequin: one focusing on the concepts related to the skill and the other on the steps of skill application, and were asked to solve them.	Other: Crossword Puzzles; Students in the experimental group were presented with two puzzles before the first skill application on the mannequin: one focusing on the concepts related to the skill and the other on the steps of skill application, , and were asked to solve them. After solving the puzzles, students submitted them to their instructors. In the two weeks following this training, students first solved the same puzzle, researcher collected the crossword puzzles, and then students performed the IM skill application on a skill mannequin. After solving the puzzle and performing the skill application a total of three times, students took post test the CLS and MSLQ and a skills exam four weeks later.
Other: The control group; During the application process, the control group of students received standard training (explanation with ppt presentation) .	Other: Control group; During the application process, the control group of students received standard training.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cognitive Load Scale	The 9-point rating scale developed by Paas and Van Merrienboer (1993) and adapted into Turkish by Kılıç and Karadeniz (2004) was used to calculate students' cognitive load scores. The scale consists of a single item and measures the effort students expend while performing a task, and this effort is taken as an indicator of cognitive load. The lowest score on the scale is 1 and the highest is 9, and the higher the score, the higher the level of cognitive load.	Before courses begin and 4 weeks after the courses concluded, an average of 3 months
The Motivated Strategies for Learning Questionnaire (MSLQ)	The questionnaire was developed by Pintrich et al. in 1991.24 It was adapted to Turkish language by by Büyüköztürk et al. in 2004. This scale allowing students to indicate how well the items describe their personal situation. This scale consists of two main section, learning strategies and motivation, and 15 sub-dimensions. Responses are provided on a 7-point Likert scale, ranging from "not at all true of me" to "very true of me". In this study, the motivation section with its 6 sub-dimensions were applied to the students. Each sub-dimension is scored separately, and increasing scores indicate increased student motivation.	Before courses begin and 4 weeks after the courses concluded, an average of 3 months
Checklist of Intramuscular Injection Skills	To measure nursing skills, the researchers converted items from the intramuscular injection skills test into a checklist format.The checklist, which consisted of 29 steps to perform intramuscular injection skills in the ventrogluteal region, was created based on the literature, and each step of the checklist was scored. Scores of the checklist were generated based on a100 point scale. The higher score students get from the checklist, higher their intramuscular injection skill performance.	4 weeks after the courses concluded, an average of 3 months

Collaborators and Investigators

• Sponsor: Trakya University
• Investigators: Principal Investigator: Berna AKSOY KAHRAMAN, PhD, Trakya University

Publications and helpful links

General Publications

• Büyüköztürk, Ş., Akgün, Ö. E., Kahveci, Ö., & Demirel, F. (2004). Güdülenme ve öğrenme stratejileri ölçeğinin Türkçe formunun geçerlik ve güvenirlik çalışması. Kuram ve Uygulamada Eğitim Bilimleri, 4(2), 207-239.
• Kaynak, S., Ergün, S., & Karadaş, A. (2023). The effect of crossword puzzle activity used in distance education on nursing students' problem-solving and clinical decision-making skills: A comparative study. Nurse Education in Practice, 69, 103618.
• Hdaib, M. T., Al-Momany, S. M., & Najjar, Y. W. (2015). Knowledge level assessment and change among nursing students regarding administering intra-muscular injection at Al-Balqa'a Applied University: an interventional study. Nurse education today, 35(7), e18-e22.
• Karaman, D. (2015). Using ventrogluteal site in intramuscular injections is a priority or an alternative. International Journal of Caring Sciences, 8(2), 507.
• Kılıç, A. G. E., & Karadeniz, Ö. G. Ş. (2004). Hiper ortamlarda öğrencilerin bilişsel yüklenme ve kaybolma düzeylerinin belirlenmesi. Kuram ve Uygulamada Eğitim Yönetimi, 40(40), 562-579.
• Kalkan, N., Demir, S., Ezer, Z. G., & Dalgıç, C. (2025). The effect of using puzzles as a teaching method on the study process and motivation of students taking the operating room nursing course. Global Nursing Insights, 12(2), 197-204.
• Barış Eren, N., & Çiftçi, B. (2025). The Use of Puzzles as a Teaching Technique in Nursing Education: A Randomized Controlled Study. Journal of Evaluation in Clinical Practice, 31(4), e70118.
• Kalkan, N., Güler, S., Bulut, H., & Ay, A. (2022). Views of students on the use of crossword and word search puzzle as a teaching technique in nursing education: A mixed-method study. Nurse education today, 119, 105542.
• Acun, A. (2025). The effect of puzzles on nursing students' learning concepts related to vital signs: A randomized controlled study. Journal of Nursing Education, 64(8), e98-e102.
• Tosunöz, İ. K., & Doğan, S. D. (2023). The effect of crossword puzzles on nursing students' learning of concepts related to pain management course: A randomized controlled trial. Nurse education in practice, 71, 103740.

Study record dates

Study Major Dates

• Study Start (Actual): February 9, 2025
• Primary Completion (Actual): June 2, 2025
• Study Completion (Actual): February 9, 2026

Study Registration Dates

• First Submitted: March 19, 2026
• First Submitted That Met QC Criteria: March 19, 2026
• First Posted (Actual): March 25, 2026

Study Record Updates

• Last Update Posted (Actual): May 8, 2026
• Last Update Submitted That Met QC Criteria: May 4, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: Motivation; Nursing Students; Cognitive Load; Intramuscular Injection; Skill; Puzzles
• Additional Relevant MeSH Terms: Investigative Techniques; Epidemiologic Research Design; Epidemiologic Methods; Research Design; Methods; Control Groups
• Other Study ID Numbers: TÜTF-BAEK 2024/232; 2024/181 (Other Grant/Funding Number: Trakya University)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No