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

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.