The Effectiveness of the Puzzle Method on Nursing Students' Infection Control Learning Level

The Effectiveness of the Puzzle Method on Nursing Students' Infection Control Learning Level: A Randomized Controlled Trial

This randomized controlled trial aims to evaluate the effect of the puzzle teaching technique on the infection control knowledge levels of first-year nursing students. Infection control and asepsis represent fundamental competencies that are essential for patient safety and quality of care. Despite the recognized importance of these concepts, many undergraduate nursing students struggle to retain theoretical information and apply it effectively in clinical practice when exposed only to traditional, lecture-based instruction.

Active learning approaches have been shown to enhance students' engagement, motivation, and long-term knowledge retention compared to conventional teaching methods. Among these approaches, puzzle-based learning has recently emerged as an innovative, low-cost, and enjoyable educational tool that promotes active participation, problem-solving, and conceptual understanding. By integrating play and cognitive challenge, puzzles help learners reinforce complex theoretical content and recall it more effectively.

In this study, first-year nursing students enrolled in a fundamentals of nursing course will be randomly assigned to either an experimental group or a control group. Both groups will first receive standard theoretical instruction on infection control and asepsis delivered through traditional lectures. Following this, the experimental group will participate in a three-week puzzle-based learning intervention, while the control group will receive no additional activities beyond the standard lecture.

The puzzle intervention will include weekly, instructor-led sessions where students collaboratively complete custom-designed educational puzzles-such as crosswords, matching games, and problem-solving tasks-focused on infection control concepts (hand hygiene, aseptic technique, sterilization, personal protective equipment, and prevention of healthcare-associated infections). Each session will last approximately 45-60 minutes and will emphasize group interaction, peer discussion, and immediate feedback.

Data will be collected using a pre-test/post-test design. All participants will complete a structured infection control knowledge test before the intervention, immediately after the three-week period, and again four weeks later to assess retention. In addition, a short questionnaire will be administered to the experimental group to measure student satisfaction and perceived learning effectiveness associated with the puzzle technique.

The primary outcome is the change in infection control knowledge scores from pre-test to post-test. Secondary outcomes include knowledge retention at four weeks and students' satisfaction with the learning experience. Statistical analyses will compare mean score differences between and within groups using appropriate parametric or non-parametric tests.

This study is grounded in Kolb's experiential learning theory and Bloom's revised taxonomy, both of which support active, student-centered approaches that promote deep learning. Puzzle-based learning is expected to enhance cognitive engagement, encourage self-directed learning, and strengthen understanding of core infection control principles.

By evaluating the effectiveness of this interactive teaching strategy, the study aims to provide empirical evidence supporting the integration of active learning methods into nursing curricula. The findings will contribute to the development of more engaging, effective, and evidence-based instructional strategies in nursing education, particularly for first-year students learning infection control and aseptic techniques. It is anticipated that the puzzle teaching technique will improve students' theoretical knowledge, increase their motivation for learning, and support safer future clinical practice.

Study Overview

• Status: Completed
• Conditions: Nursing Students; Infection Control Training; Puzzle Activity
• Intervention / Treatment: Behavioral: Puzzle Teaching Technique

Detailed Description

Nursing education is a complex, multidimensional process that integrates theoretical knowledge, clinical reasoning, and psychomotor skill development. The primary goal of undergraduate nursing education is to prepare students who are competent, safe, and capable of applying evidence-based practice in real-world healthcare settings (Aksoy & Paslı Gürdoğan, 2022). In their educational journey, nursing students are expected to acquire not only cognitive knowledge but also psychomotor and affective competencies through continuous exposure to theoretical and clinical learning experiences (Moran et al., 2021).

During the first year of nursing education, students are introduced to the foundations of professional practice, including basic nursing skills, anatomy, physiology, and fundamental principles of infection control (Hidalgo-Blanco et al., 2021; Lukić et al., 2023). Among these, infection control is considered a core competency essential to patient safety and the prevention of healthcare-associated infections (HAIs) (Bouchoucha et al., 2021; Chang et al., 2023). The early acquisition of infection prevention behaviors, especially aseptic technique, forms a critical part of the nursing curriculum, ensuring that future nurses understand the importance of sterilization, hygiene, and barrier precautions (Serpici et al., 2023).

Asepsis represents the cornerstone of safe healthcare delivery, reducing the risk of cross-contamination and hospital-acquired infections. Therefore, the theoretical understanding and psychomotor application of aseptic principles should be reinforced throughout the educational process. However, it is well-documented that traditional teaching methods, which predominantly rely on teacher-centered lectures and passive knowledge transfer, often fail to ensure long-term retention and deep understanding of such complex concepts (Den Boer et al., 2018; Gilani et al., 2020; Mshayisa et al., 2020). These methods frequently result in decreased student engagement, limited motivation, and superficial comprehension, particularly in first-year nursing students who are just adapting to the professional discipline (O'Connor, 2023).

Need for Innovative Educational Strategies

Contemporary nursing education increasingly emphasizes active learning, which places students at the center of the learning process. Active learning methods engage learners cognitively and emotionally, stimulating critical thinking, problem-solving, and long-term memory consolidation (Zamani et al., 2021; Chen et al., 2020). Theoretical frameworks such as Kolb's Experiential Learning Theory and Bloom's Taxonomy of Cognitive Learning provide strong pedagogical support for interactive, student-centered teaching techniques (Kolb, 2015; Anderson & Krathwohl, 2001). According to these frameworks, meaningful learning occurs when students are encouraged to connect theoretical content with practical application through experiential and reflective processes.

In line with these approaches, educators are encouraged to implement low-cost, interactive, and engaging methods to improve student motivation and attention to learning content (Zamani et al., 2021; Gilani et al., 2020). One of the most promising active learning tools recently gaining attention in nursing and health sciences education is the puzzle teaching technique (Gupta et al., 2015; Malini et al., 2019). Puzzles, such as crosswords, matching games, and problem-solving exercises, are designed to make learning enjoyable while reinforcing key theoretical concepts through repetition and cognitive engagement.

Puzzle Technique in Nursing Education

Educational puzzles integrate gamification principles with pedagogical intent, transforming traditional instruction into a dynamic and participatory process (Zamani et al., 2021). They promote active recall, conceptual linking, and peer interaction, all of which are essential for consolidating complex information (Gilani et al., 2020). In nursing education, puzzles have been effectively used to teach pharmacology, anatomy, microbiology, and infection control (Gupta et al., 2015; Aşiret et al., 2021).

For instance, Gupta et al. (2015) demonstrated that students who participated in crossword puzzle activities scored significantly higher on post-test knowledge assessments than those who attended lectures alone. Similarly, Malini et al. (2019) found that puzzle-based learning significantly enhanced nursing students' engagement and understanding of infection control concepts. Zamani et al. (2021) reported that puzzle learning improves retention, reinforces key concepts, and enhances problem-solving abilities in health science education.

These findings are consistent with constructivist learning theory, which posits that learners construct knowledge actively through exploration and interaction with learning materials (Piaget, 1973; Vygotsky, 1978). Puzzles, by requiring students to analyze, synthesize, and evaluate content, align closely with higher-order cognitive skills outlined in Bloom's taxonomy (Anderson & Krathwohl, 2001). Moreover, they provide intrinsic motivation, as the challenge and enjoyment inherent in puzzles promote self-directed learning and deeper cognitive processing (Gentry et al., 2022).

Significance of Asepsis and Infection Control Education

Healthcare-associated infections remain a major global concern, affecting millions of patients annually and contributing to increased morbidity, mortality, and healthcare costs (World Health Organization, 2022). Nurses, being at the frontline of patient care, play a pivotal role in infection prevention. Therefore, infection control education that effectively integrates theoretical and practical components is essential for ensuring patient safety (Bouchoucha et al., 2021).

The COVID-19 pandemic further underscored the need for robust infection control education and the ability of healthcare professionals to apply aseptic principles under challenging circumstances (Chang et al., 2023). As a result, many nursing programs worldwide have re-evaluated their curricula, seeking innovative ways to teach infection control more effectively. The integration of game-based learning tools, such as puzzles, provides an engaging and evidence-based approach to address these educational needs.

Purpose and Objectives

This randomized controlled study aims to evaluate the effectiveness of the puzzle teaching technique on infection control knowledge among first-year nursing students. The study is designed to determine whether supplementing traditional lecture-based instruction with puzzle-based active learning activities enhances students' theoretical understanding and retention of infection control and asepsis concepts.

Specifically, the objectives are:

To compare the pre-test and post-test knowledge levels of infection control between experimental and control groups.

To assess the short-term and mid-term retention of infection control knowledge after a 3-week intervention period.

To evaluate student satisfaction and perceived learning effectiveness associated with the puzzle teaching technique.

Study Design and Intervention

The study employs a randomized controlled trial (RCT) design with two groups:

Experimental group: Students receive traditional lectures on infection control followed by puzzle-based learning activities over a period of three consecutive weeks.

Control group: Students receive the same traditional lecture content without the puzzle intervention.

After the standard theoretical lecture on infection control and asepsis, the experimental group will participate in structured puzzle sessions each week. Each session will include:

A short interactive review of previous content,

Distribution of custom-designed puzzles (crossword, matching, fill-in-the-blank) related to aseptic technique, sterilization, hand hygiene, and infection prevention measures,

Group discussions and immediate feedback facilitated by the instructor.

The puzzles are designed to align with learning objectives outlined in infection control modules, ensuring both content validity and pedagogical relevance.

Pre-test assessments will be conducted prior to the intervention to evaluate baseline knowledge levels. Post-test assessments will be performed immediately after the 3-week intervention and again after a 4-week follow-up to evaluate retention.

Expected Outcomes and Hypotheses

It is hypothesized that:

Nursing students who receive the puzzle-based teaching intervention will demonstrate significantly higher post-test knowledge scores compared to those who receive only traditional instruction.

The puzzle group will exhibit better retention of knowledge after four weeks.

Students in the experimental group will report greater engagement, motivation, and satisfaction with the learning process.

The anticipated outcome is that the puzzle teaching technique will serve as an effective, low-cost, and replicable educational strategy for enhancing infection control education among nursing students.

Theoretical Framework

This study is grounded in constructivist learning theory and Kolb's experiential learning model. According to Kolb (2015), effective learning occurs through a cyclic process of concrete experience, reflective observation, abstract conceptualization, and active experimentation. Puzzle-based learning provides opportunities for all these stages by combining problem-solving, reflection, and conceptual reinforcement. Additionally, Bloom's revised taxonomy supports the cognitive progression achieved through puzzles, from remembering and understanding to analyzing and applying knowledge (Anderson & Krathwohl, 2001).

Ethical Considerations and Significance

The study will adhere to the principles of the Declaration of Helsinki and institutional ethical guidelines. Participation will be voluntary, and informed consent will be obtained from all participants. The findings are expected to contribute to the improvement of evidence-based teaching practices in nursing education, offering educators a validated active learning tool to enhance infection control training.

By demonstrating the impact of the puzzle technique on knowledge acquisition, this research may support curriculum reform and the inclusion of active, student-centered teaching strategies in fundamental nursing courses. In the long term, improving infection control competencies at the undergraduate level will contribute to safer healthcare environments and reduced rates of healthcare-associated infections.

Conclusion

In summary, this randomized controlled trial seeks to evaluate the educational effectiveness of the puzzle teaching technique in improving infection control knowledge among first-year nursing students. By combining traditional theoretical instruction with engaging, active learning methods, the study aims to promote deeper understanding, long-term knowledge retention, and increased learner motivation. The findings are expected to advance the pedagogical evidence base for innovative, low-cost, and interactive teaching strategies in nursing education.

• Study Type: Interventional
• Enrollment (Actual): 100
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Samsun
    • Samsun, Samsun, Turkey (Türkiye), 55200
      • Ondokuz Mayıs Universitesi

Participation Criteria

Eligibility Criteria

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

Description

Inclusion Criteria:

1. Volunteering to participate in the study,
2. Taking the Fundamentals of Nursing course for the first time

Exclusion Criteria:

1. Not volunteering to participate in the study.
2. Graduating from a health vocational high school or an associate's degree.
3. Not continuing the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Experimantal: Intervention group; Arm 1 - Experimental: Puzzle Teaching Technique Participants assigned to the experimental group will receive standard theoretical and laboratory instruction on infection control and asepsis, followed by an additional three-week intervention using the puzzle teaching technique. After the conventional lectures, students will attend weekly, instructor-guided puzzle sessions designed to reinforce infection control concepts such as hand hygiene, isolation precautions, aseptic technique, sterilization, waste management, and the chain of infection. Each session will last approximately 45-60 minutes and include: Collaborative puzzle-solving activities (crosswords, matching, fill-in-the-blanks), Immediate feedback and discussion facilitated by the researchers, Projection of completed puzzles for class review and clarification of misconceptions. Students will complete a pre-test, a post-test immediately after the intervention, and a follow-up test four weeks later to assess knowledge retention.	Behavioral: Puzzle Teaching Technique; The puzzles will be developed using https://crosswordlabs.com and aligned with course learning objectives. Students will complete a pre-test, a post-test immediately after the intervention, and a follow-up test four weeks later to assess knowledge retention. Intervention Name: Puzzle Teaching Technique Intervention Type: Behavioral (Active Learning Strategy) Duration: 3 consecutive weeks following theoretical instruction Frequency: 1 session per week (45-60 minutes per session)
No Intervention: Experimantal: Control group; Arm 2 - Control: Traditional Lecture-Based Education Participants in the control group will receive the same standard theoretical and laboratory instruction on infection control and asepsis as the experimental group but will not participate in any puzzle-based activities.The control group will follow the traditional, instructor-centered teaching method that includes didactic lectures and laboratory demonstrations. Students will complete the same pre-test, post-test, and follow-up knowledge assessments as the experimental group but will not receive any additional intervention. After completion of the data collection phase, the educational puzzles used in the experimental group will be shared with the control group as supplementary learning material to ensure equity in educational exposure.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Infection Control Knowledge Scores	Knowledge levels related to infection control and asepsis will be measured using the Infection Control Knowledge Test, a 50-item multiple-choice instrument developed and validated by the researchers. The test evaluates students' understanding of infection prevention concepts, aseptic technique, isolation precautions, sterilization, and waste management. Scores range from 0 to 50, with higher scores indicating greater knowledge. The primary outcome will be the mean change in total knowledge scores between pre-test and post-test measurements, comparing the experimental (puzzle) and control (lecture-only) groups. Statistical Analysis: Between-group comparisons will be conducted using independent-samples t-tests (or Mann-Whitney U tests if data are non-normal). Within-group changes will be evaluated using paired-samples t-tests (or Wilcoxon signed-rank tests). Statistical significance will be set at p < 0.05.	Pre-test (Week 0, before intervention) Post-test 1 (Four weeks after intervention for retention assessment)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Effect Size and Educational Impact	Effect size (Cohen's d) will be calculated to determine the magnitude of the intervention's impact on knowledge acquisition. An effect size ≥ 0.50 will be interpreted as a moderate effect, while ≥ 0.80 will be considered a large educational impact.	Post-test (Week 4)
Knowledge Retention at 4 Weeks	Retention of infection control knowledge will be assessed using the same Infection Control Knowledge Test. The retention score will be calculated as the difference between the post-test 2 (Week 7) and post-test 1 (Week 3) results. A smaller decline in scores or sustained performance in the experimental group compared to the control group will indicate better long-term retention attributed to the puzzle teaching technique.	Four weeks after the completion of the 3-week intervention

Collaborators and Investigators

• Sponsor: Ondokuz Mayıs University

Publications and helpful links

General Publications

• Kaynak S, Ergun S, Karadas A. The effect of crossword puzzle activity used in distance education on nursing students' problem-solving and clinical decision-making skills: A comparative study. Nurse Educ Pract. 2023 May;69:103618. doi: 10.1016/j.nepr.2023.103618. Epub 2023 Mar 24.
• Kose Tosunoz I, Deniz Dogan S. The effect of crossword puzzles on nursing students' learning of concepts related to pain management course: A randomized controlled trial. Nurse Educ Pract. 2023 Aug;71:103740. doi: 10.1016/j.nepr.2023.103740. Epub 2023 Aug 3.
• Kalkan N, Guler S, Bulut H, Ay A. Views of students on the use of crossword and word search puzzle as a teaching technique in nursing education: A mixed-method study. Nurse Educ Today. 2022 Dec;119:105542. doi: 10.1016/j.nedt.2022.105542. Epub 2022 Sep 9.

Study record dates

Study Major Dates

• Study Start (Actual): October 30, 2025
• Primary Completion (Actual): November 1, 2025
• Study Completion (Actual): January 30, 2026

Study Registration Dates

• First Submitted: May 1, 2026
• First Submitted That Met QC Criteria: May 7, 2026
• First Posted (Actual): May 13, 2026

Study Record Updates

• Last Update Posted (Actual): May 13, 2026
• Last Update Submitted That Met QC Criteria: May 7, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Other Study ID Numbers: OMU-SBF-HEM-ESAS-25

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Other researchers may view the study once its is published.

Drug and device information, study documents

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