Innovative Game-Based Teaching Methods for Promoting Nursing Students’ Cultural Competence and Attitudes Toward Refugees: An Explanatory Sequential Mixed Study

https://doi.org/10.1177/10436596241297986 Journal of Transcultural Nursing 1 –13 © The Author(s) 2024 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/10436596241297986 journals.sagepub.com/home/tcn Education Introduction Migration is a significant, complex, and growing global phenomenon. Millions of people migrate around the world for a variety of causes, including war, terrorism, displacement, ethnic conflict, environmental crises, economic and political reasons, education, or job opportunities (McAuliffe & Triandafyllidou, 2021). Some of these individuals are refugees, while others are migrants or asylum seekers. These terms are sometimes used interchangeably; however, they have distinct legal meanings. A refugee is someone who has been compelled to flee their home country due to persecution, war, or ethnic, tribal, or religious violence. In most cases, they are unable to return home, as doing so would endanger their lives. Refugees are defined and protected under international law. Asylum seekers, on the contrary, have not yet been legally recognized as refugees and are awaiting a decision on their asylum claim. A migrant is someone who chooses to relocate, not because they face persecution or a threat to their life, but to seek better opportunities, such as employment, education, or family reunification. Migrants retain the protection of their home government and are not protected under international law. Each country accepts migrants according to its immigration laws and processes (UNHCR The UN Refugee Agency, 2022). The increasing number of refugees has greatly impacted countries in terms of political, economic, social, ethnic, religious, and health-related issues (McAuliffe & Triandafyllidou, 2021). Refugees are unable to benefit from health care services sufficiently for such reasons as the language barrier, low health literacy, cultural differences, and the health care staff’s negative attitudes toward refugees (Önal & Keklik, 2016; Schwei et al., 2016). The International Council of 1297986TCNXXX10.1177/10436596241297986Journal of Transcultural NursingBaysal et al. research-article2024 1Manisa Celal Bayar University, Türkiye 2University of Almeria, Spain 3Universitat de València, Spain Corresponding Author: Miguel Rodriguez-Arrastia, Vice Dean and Associate Professor, Department of Nursing Science, Physiotherapy and Medicine, Faculty of Health Sciences, University of Almeria, Carretera Sacramento s/n, Almeria 04120, Spain. Email: [email protected] Innovative Game-Based Teaching Methods for Promoting Nursing Students’ Cultural Competence and Attitudes Toward Refugees: An Explanatory Sequential Mixed Study Ebru Baysal, PhD, RN1, Miguel Rodriguez-Arrastia, PhD, MSc, RN2,3 , and Pablo Roman, PhD, MSc, RN2 Abstract Introduction: Nursing cultural competence is crucial for enhancing the quality of care for refugees. While innovative gamebased teaching methods have been used to foster in a wide range of clinical competences, little is known about its use on refugees’ care. This study aims to evaluate the effect of these methods on nursing students’ cultural competence and attitudes toward refugees. Methodology: An explanatory sequential mixed design was conducted from March to May 2023. Results: One-hundred forty-one nursing students participated. There were no statistically significant differences in total Outgroup Threat Perception Scale and Cultural Competence Assessment Scale scores between the experimental and control groups, preor post-intervention. However, students reported increased awareness and empathy for refugee issues. Discussion: The study showed that innovative game-based teaching methods effectively increased nursing students’ awareness of healthrelated issues faced by refugees. It recommends incorporating transcultural nursing courses into curricula and professional training, with updated content on migration and refugee issues. Keywords cultural competencies, gamification, nursing students, refugees, virtual reality 2Journal of Transcultural Nursing 00(0) Nurses (ICN) indicates that health is a human right and must be made universal and meet the needs of refugees and to provide culturally sensitive care for them (Gunn et al., 2021; H.-L. Lin et al., 2021). As a result of migration, the number of individuals from different cultural backgrounds has increased in societies, which has brought about the issue of health care professionals’ cultural competence. The American Association of Colleges of Nursing (AACN) defines cultural competence as the attitudes, knowledge, and skills necessary for providing quality care to diverse populations in a variety of health care settings (American Association of Colleges of Nursing, 2008). Leininger’s Culture Care Theory suggests that nurses’ knowledge and skills of cultural differences should be improved. The theory also highlights the necessity of being aware of patients’ values, beliefs, and lifestyles (Leininger, 1996). In this sense, nurses may experience problems involving cultural differences, beliefs, communication, and language, as well as a different understanding of health and hygiene while providing care to refugees. Such issues may hurt nurses’ opinions of refugees, leading to xenophobic sentiments and microaggressions in their care (Munyaneza & Mhlongo, 2019). Research results vary regarding nursing students’ cultural competence and attitudes toward refugees. While some studies report that nursing students’ cultural competence is at the desired level (Choi & Kim, 2018; Kohlbry, 2016) and they hold positive attitudes toward refugees (Barutcu & Zengin, 2018; Ugarte-Gurrutxaga et al., 2020), some others show that they have insufficient cultural competence (H.-L. Lin et al., 2021; Preposi-Cruz et al., 2018) and their attitudes toward refugees are negative (Akca & Ayaz-Alkaya, 2023; Alici, 2021). According to studies, a lack of cultural competence relates to health inequities and poor health outcomes (Betancourt et al., 2014). In the Institute of Medicine report, it is stated that nurses’ insufficient cultural competence, awareness, and related training may sometimes cause ethnocentric behaviors and inequity in the delivery of health care services (Betancourt & Maina, 2004). To eliminate these problems, it is recommended that course content addressing cultural differences be included in all health care curricula (Betancourt & Maina, 2004; Liu et al., 2018). According to studies, appropriate and embedded cultural competence education can promote cultural awareness and sensitivity (Kohlbry, 2016; M.-H. Lin et al., 2019). However, some common problems still arise in teaching plans and education in nursing. These include a lack of agreement on what should be taught, related timing, a lack of standard references, and limited and inconsistent formal evaluations of educational interventions (González-Ricoy & Gosseries, 2017). In addition to the traditional teaching methods, various teaching approaches are used in intercultural nursing courses such as reflective reports (Halter et al., 2015), case discussions (Allen et al., 2013), community service programs, and standard patient (Ozkara San, 2019). As well as enhancing students’ cultural competence, such teaching approaches are reported to improve analytical thinking skills, clinical reasoning, decision-making skills, communication skills, team cooperation, self-efficacy, and psychomotor skills (Allen et al., 2013; Halter et al., 2015; Ozkara San, 2019). Having said that, no study result has been found in the literature to use innovative game-based teaching methods like 360-degree videos, serious games (e.g., Refugeoly), and escape rooms to improve students’ cultural competence and attitudes toward refugees. These innovative game-based learning methods offer a myriad of benefits to students, primarily by providing an interactive and personalized learning experience within a safe and controlled environment (Ivanović, 2024; Yang et al., 2024). Research indicates that these methods foster active learning and participation, clinical problem-solving, teamwork, creative thinking, and enhanced satisfaction and motivation (Anguas-Gracia et al., 2021; Gómez-Urquiza et al., 2022; Molina-Torres et al., 2022; Roman et al., 2020). Thus, these innovative teaching approaches aimed to encourage nursing students to reflect deeply on the challenges faced by refugees, to express their emotions, and thereby achieve affective learning. While some of these innovative game-based teaching methods are commonly used to impart professional skills to nursing students or as an assessment resource, this study is the first to use them to evaluate nursing students’ attitudes and cultural competency toward refugees. In this context, the research findings are expected to contribute to the nursing literature by addressing a gap in this area. Method Study Design A sequential explanatory mixed-method study was conducted from March to May 2023. The explanatory sequential design comprised two independent strands applied sequentially: (a) a quantitative strand, which collected and analyzed numerical data and (b) a qualitative strand, which collected and analyzed textual data. The quantitative strand is often prioritized, and the two strands can be connected in various ways during the intermediate stage (Ivankova et al., 2006). In this study, integration occurred during the selection of Phase 2 participants, based on the results of Phase 1. The outcomes of both phases were combined to provide a more comprehensive and meaningful understanding of the impact of innovative game-based teaching methods on nursing students’ cultural competence and attitudes toward refugees (Creswell & Creswell, 2018). All things considered, the research questions were: Research Question 1 (RQ1): What is the impact of innovative game-based learning methods on students’ attitudes toward refugees and cultural competence? Research Question 2 (RQ2): How do nursing students describe their experiences in the use of innovative Baysal et al. 3 game-based methods to fostering attitudes toward refugees and cultural competence? The following mixed methods research question was answered in the interpretation phase of the study, subsequent to an autonomous analysis of the data from each study component: Research Question 3 (RQ3): How do nursing students perceive that these innovative game-based teaching methods affected their attitudes and cultural competence toward refugees? Setting and Participants This study was carried out at the University of Almeria with 141 nursing students in the second semester of the academic year 2022–2023. The selection criteria included those students who were (a) enrolled in the Research Methods module, (b) attended at least 80% of lessons, (c) 18 or older, and (d) willing to provide written informed consent before participating in the study. Procedure The activity was designed to be performed in the final session of the Research Methods module, a mandatory module in the first year of nursing degree that is developed over a 15-week period. In this case, the experimental group received an innovative game-based teaching approach, whereas the control group received a traditional-based teaching approach. The experimental group students were divided into groups of six to eight persons, rotated and watched (a) Clouds over Sidra Documentary with virtual reality (VR) glasses and played the (b) Refugeoly game. A week later, both groups were divided into groups of six to eight persons and participated in an (c) escape room. All programs were scheduled according to students’ availability outside the class hours and were communicated to the students. Clouds Over Sidra Documentary. The students in the experimental group watched the 8-min “Clouds over Sidra” documentary created with 360-degree video technology, wearing VR headsets. The documentary focuses on the Za’atari Refugee Camp in Jordan, which is home to 80,000 Syrians fleeing from violence. Children make up more than half of the population. The documentary tells the story of the 12-year-old Sidra. Viewers can immerse themselves in the film using a VR headset. The users watching the shots made using 360-degree cameras blended into the documentary with their physical reality (Suzuki, 2022). Refugeoly. The students in the experimental participated in a serious game activity based on narrative storytelling scheduled outside of class hours. Refugeoly was designed by Vinny Montag based on the game called “Monopoly” to understand the dramatic journey of refugees trying to find themselves a haven (Montag, 2020). It allows the player to step into the shoes of a refugee and experience the real-life conditions that a refugee must go through on the journey to a safe country. The main principle of the game is to teach and raise awareness. The game consists of cards numbered from 0 to 39. Each of these cards is printed in size A1-A0 and placed to follow one another, creating large square-shaped areas (3 × 3 m). The players are expected to roll the dice and move clockwise along the game area according to the number on the dice. On the subsequent cards, different conditions (adverse weather conditions, disease death, deportation, etc.) encountered by refugees on their journey are presented chronologically. There is a symbol on each box (card) giving information about the situation or event that the player must go through. The meanings of these symbols were read aloud by the researchers, and the students were asked to act according to the instructions (Figure 1). The Escape Room. This activity involved a refugee standard patient who had a language barrier and was unable to communicate effectively. The patient was locked in a room, and the students were told to find two separate codes to unlock the door. The students were informed about the rules and the scenario before the activity. The students were divided into groups of six to eight, each group was further divided into two and was locked in two separate rooms. They were expected to solve the topic-related puzzles and riddles and, ultimately, unlock the padlock in 20 min using their knowledge of the Research Methods module. Meanwhile, the students were in constant communication through a walkie-talkie and found the codes by answering the questions together with team cooperation. To facilitate communication with the patient with a language barrier and to define the patient’s problem correctly, a pictogram was placed in the room where the students were locked, and they were expected to find and use the pictogram. After the students solved all the puzzles and riddles, they unlocked the patient inside the room using the two codes they found. Phase 1. Quantitative Study Quantitative Design and Participants. The quantitative strand followed a comparative cross-sectional design. Participants were asked to fill in the questionnaire, which was comprised of sociodemographic form, Outgroup Threat Perception Scale (OTPS), and Cultural Competence Assessment Scale (CCA-S). Students were assigned to the experimental and control groups using the purposive sampling method based on their “Outgroup Threat Perception Scale-OTPS” scores (Navas-Luque et al., 2012). Students filled out the OTPS and CCA-S scales twice, 3 months apart. The study involved a total of 153 students, including 76 in the experimental group and 77 in the control group. However, because they did not 4Journal of Transcultural Nursing 00(0) participate in all game-based teaching activities, 12 students in the experimental group were eliminated from the study. The study was completed with 141 nursing students meeting the inclusion criteria (Figure 2). Quantitative Data Collection and Measures. The instrument for data collection comprised: (a) a self-administrated questionnaire with sociodemographic data, as well as (b) OPTS and (c) CCA-S scales. The OTPS consists of 13 items (nine realistic threats and four symbolic threats) (Navas-Luque et al., 2012). The scale is a 5-point Likert-type type one (1 = none; 5 = a lot). The participants are asked to indicate “To what extent they feel at risk because of refugees (outgroups)” in terms of educational values, family values, religious beliefs, cultural traditions (symbolic threats), access to employment, health care system, education system, social welfare system, social security, economic stability of the country, health, personal security, public order in the country, and the security of the country (realistic threats). Mean scores vary between 1 and 5. In studies conducted with the Spanish population, Cronbach’s alpha coefficient was found to be between .85 and .94 depending on the refugee group. The Cronbach’s alpha value in the present study was determined as .92. The CCA-S consists of 25 items and two subscales of Cultural Competence Behaviors and Cultural Awareness and Sensitivity (Raigal-Aran et al., 2019; Schim et al., 2003). The 11-item Cultural Awareness and Sensitivity subscale measures cultural awareness and sensitivity. The Cultural Awareness and Sensitivity subscale uses a 7-point Likert-type scale (7 = strongly agree to 1 = strongly disagree) and has a no opinion option. The 14-item Cultural Competence Behaviors subscale measures cultural competence behaviors. The Cultural Competence Behaviors subscale uses a 7-point Likert-type scale (7 = always to 1 = never) and has a not sure option. Higher scores indicate higher levels of knowledge, more positive attitudes, and a greater frequency of competence behaviors. Cronbach’s alpha for CCA-S was .91. Cronbach’s alpha for this study was .91 as well. Quantitative Data Analysis. The quantitative data were analyzed using the SPSS 21.0 (Statistical Package for Social Sciences, IBM Corp., Armonk, New York, USA, ABD) Figure 1. Refugeoly Game Design. Baysal et al. 5 software. Normality was tested using the Shapiro–Wilk normality test. As the data were distributed normally, an independent sample t-test was used to compare the scores of the independent groups, and a paired sample t-test was used to compare the scores before and after the intervention. The statistical significance was set at .05 in the study. Figure 2. Flow Diagram of Study. 6Journal of Transcultural Nursing 00(0) Phase 2. Qualitative Study Qualitative Design and Participants. The qualitative strand followed a descriptive qualitative content analysis (Krippendorff, 2019) after quantitative analysis was completed. The purpose was to understand nursing students’ experiences of the procedure and explore their perceptions of its use for fostering cultural competence and attitudes toward refugees. Qualitative Data Collection. All participants were asked to write a reflection report. Gibb’s model and results from quantitative analysis were used to develop the reflection report form. Gibb’s Reflective Cycle was developed by Graham Gibbs in 1988 to structure learning through experience. The reflection cycle offers a framework for examining experiences and enables you to learn from what works well or does not and to make plans, considering its cyclical nature. The reflection cycle consists of six stages: description of the experience, evaluation of both good and bad experience, feelings and opinions about the experience, analysis of the situation, conclusion on what can be done differently, and an action plan on how to deal with similar situations in the future (The University of Edinburg, 2020). Qualitative Data Analysis. MAXQDA Analytics Pro program 2020 was used to evaluate qualitative data. The written data obtained from the students were analyzed using content analysis. Krippendorff’s (2019) method for qualitative content analysis via “clustering” was used to analyze data. This method allows researchers to make conclusions from interview transcripts by grouping data “based on intuitively meaningful similarities among units of analysis.” Following transcription, an in-depth analysis was performed, and students’ similar expressions were clustered as units. These grouped expressions were used to determine subcategories and then categories. All authors participated in all steps of the analysis process to increase validity. The findings were illustrated with quotes, and each quotation was identified with “student number.” The researchers analyzed the data separately, and categories and meaning units were discussed. Ethical Considerations This study was approved by the Ethics Committee at the University of Almeria (EFM 246/23). Participants were asked to read and accept the informed consent form explaining the aim of the study before starting to answer the questionnaire. The study was conducted in accordance with the ethical standards of the Declaration of Helsinki and subsequent amendments. Written permission was obtained from the scale owners and Vinny Montag, the developer of the game, for the Refugeoly game to be used in research. Validity and Reliability/Rigor Methodological triangulation was the main strategy employed to ensure rigor, accomplished through the deliberate and systematic collection, analysis, and integration of both quantitative and qualitative data. The mixed methods approach facilitated the attainment of more comprehensive and corroborated findings. The narratives provided by nursing students regarding their educational experiences were instrumental in elucidating “how” and “why” they believed the procedure influenced their attitudes toward refugees. Guided by the criteria for high-quality mixed methods studies outlined by Creswell and Plano-Clark (2018), the research team: (a) gathered both quantitative and qualitative data to comprehensively address the overarching research questions; (b) ensured methodological congruence across both evaluation strands; and (c) purposefully integrated the two strands at multiple stages throughout the evaluation process. Prior to the second set of descriptive qualitative content analysis, the quantitative data were analyzed, facilitating the identification of topics for further exploration in the subsequent discussions. The accuracy of the quantitative findings was independently verified by members of the research team (E.B. and P.R.). Furthermore, the trustworthiness of the qualitative findings was bolstered through researcher triangulation during the analysis and interpretation stages (M.R.-A. and P.R.), extended engagement in the field with longitudinal data collection, and reflexivity. Findings Phase 1. Quantitative Findings There were no statistical differences between the experimental and control groups in terms of descriptive characteristics (Table 1). There was no statistically significant difference in the descriptive characteristics of the students based on the mean total OTPS and the mean total CCA-S score (p > .05) (data not shown). The mean total OTPS score of the students was below the average (experimental group: 1.992 ± 0.75, control group: 2.07 ± 0.72), while the total CCA-S scores (experimental group: 126.484 ± 27.08, control group: 122.480 ± 28.47) were above the average. It was determined that the mean total OTPS and total CCA-S scores were not statistically significant differences between the experimental and control groups either before or after the intervention. When the change in the mean total OTPS and total CCA-S scores of the groups before and after the intervention was examined, no significant differences were observed between the changes that occurred in the groups’ scores (Table 2). Phase 2. Qualitative Findings Derived from the content analysis, three major categories emerged from our data: (a) experiences regarding the Baysal et al. 7 360-degree film, with six subcategories; (b) experiences after playing Refugeoly Game, with four subcategories; and (c) experiences related to the Escape Room, with four subcategories. All categories are summarized in Table 3. Experiences Regarding the 360-Degree Film. After watching the film, the students expressed that they felt lucky; they were astonished, desensitized, and felt immersed. They also reported getting more empathetic and developing an increased awareness of the refugee issue. It was determined that the students lacked some knowledge and skills concerning transcultural nursing and that they wanted to address these deficiencies through an empathetic approach, individualized care, active listening, learning different languages, and receiving education. The students feel sadness, anger, and guilt about the refugee issue. Their recommendations for the solution of the refugee issue include helping, raising awareness in society, providing psychological support, and facilitating their integration into society. Experiences After Playing Refugeoly Game. The students found the game design educative, fun, engaging, realistic, and interactive. They stated that they learned about the refugee issue by experiencing, gaining awareness, and developing empathy. They conveyed feelings of sadness, astonishment, anger, and disappointment in response to the challenges faced by refugees during the migration process and expressed that they were grateful for their own circumstances. In addition, they recommended the inclusion of the game into nursing education and the provision of practical training on the refugee issue. Experiences Related to the Escape Room. The students defined the design of the escape room as fun, engaging, educative, and well-organized. However, they recommended that more time and clues should be provided, and technical problems should be anticipated for future implementations of the escape room. They stated that they had the opportunity to put their theoretical knowledge into practice, improve their transcultural nursing skills, team collaboration, and communication skills in the escape room, as well as raise awareness and be more empathetic. Discussion We conducted this study to evaluate the effect of innovative game-based teaching methods on nursing students’ attitudes toward refugees and cultural nursing competencies. In the Table 1. Descriptive Characteristics of the Participants. Characteristics Experimental group (n = 64) Control group (n = 77) Total (n = 141) pn %n%n% Age (M ± SD) 21.734 ± 7.77 21.051 ± 4.67 21.361 ± 6.25 t = 0.643* p = .521 Gender, (%) 52 81.3 58 75.3 110 78.0 χ2 = 0.715** p = .398 Female 12 18.7 19 24.7 31 22.0 Male Having migrant or refugee relatives or friend(s), (%) χ2 = 1.447 p = .229 Yes 7 10.9 14 18.2 21 14.9 No 57 89.1 63 81.8 120 85.1 Having friend(s) from a different culture, (%) χ2 = 0.003 p = .953 Yes 60 93.8 72 93.5 132 93.6 No 4 6.3 5 6.5 9 6.4 Living abroad, (%) χ2 = 0.040 p = .841 Yes 6 9.4 8 10.4 14 9.9 No 58 90.6 69 89.6 127 90.1 Is your family a first-generation immigrant?, (%) χ2 = 0.126 p = .722 Yes 4 6.3 6 7.8 10 7.1 No 60 93.7 71 92.2 131 92.9 Caring refugee patient(s), (%) χ2 = 2.804 p = .094 Yes 38 59.4 56 72.7 94 66.7 No 26 40.6 21 27.3 47 33.3 Feeling competent while caring for refugee patient(s)? (%) χ2 = 0.769 p = .380 Yes 60 93.7 69 89.6 129 91.5 No 4 6.3 8 10.4 12 8.5 *Student’s t-test. **Fisher’s exact test. 8 Table 2. Comparison of the OTPS and CCA-S Scores in Groups Before and After the Intervention (n=141). Variables Times Experimental group (n=64) Control group (n=77) TestM ± SD Mdn (IQR)** 95% CI for mean (lower boundupper bound) M ± SD Mdn (IQR)** 95% CI for mean (Lower BoundUpper bound) Total OTPS score Pre-intervention 1.992 ± 0.75 1.92 (1.32) [1.813, 2.182] 2.07 ± 0.72 2.00 (1.53) [1.897, 2.236] t = −0.646* p= .519 Post-intervention 2.057 ± 0.72 1.92 (1.38) [1.888, 2.245] 2.220 ± 0.77 2.15 (1.61) [2.044, 2.392] t = −1.279* p = .203 aDifference of total OTPS score −0.064 ± 0.802 −0.11 (−0.44) [−0.269, 0.140] −0.146 ± 0.631 −0.15 (−0.61) [−0.278, 0.003] t = 0.678* p = .499 Test t = −0.647*** p = .520 t = −2.041*** p = .05 Total CCA-S score Pre-intervention 126.484 ± 27.08 130.50 (42.75) [119,719, 133,249] 122,480 ± 2,847 126.00 (48.00) [116,016, 128,944] t = 0.850* p = .397 Post-intervention 123.078 ± 28.48 130.00 (39.0) [115.962, 130.193] 126.090 ± 25.33 130.00 (35.0) [120.340, 131.841] t = −0.664* p = .508 bDifference of total CCA-S score 3.406 ± 35.00 7.0 (47.50) [−5.336, 12.149] −3.610 ± 34.08 −3.0 (34.08) [−11.346, 4.125] t = 1.202* p = .231 Test** t = 0.779*** p = .439 t = −0.929*** p = .356 aDifference of total OTPS score: Pre-intervention minus post-intervention. b Difference of total CCA-S score: Pre-intervention minus post-intervention. *Independent sample t-test. **IQR: interquartile range. *** Paired sample t-test. Baysal et al. 9 present study, the above-average cultural competence and below-average external threat perceptions of nursing students were considered positive findings. The literature includes controversial information regarding nursing students’ cultural competence and attitudes toward refugees (Choi & Kim, 2018; Preposi-Cruz et al., 2018; UgarteGurrutxaga et al., 2020). The discrepancy in research findings may have resulted from the cultural characteristics of the countries, differences in their demographic structures, and the teaching methods employed in nursing curricula. The AACN highlights that nurses need cultural understanding and sensitivity to provide safe and high-quality care, suggesting that the increasing globalization requires a focus on diversity and the use of innovative strategies in nursing education (American Association of Colleges of Nursing, 2008). In the literature, it was stated that education interventions can improve health practitioners’ cultural competency in terms of knowledge, attitudes, and abilities, regardless of the duration, design, or contents of the interventions (Alici, 2021; Kohlbry, 2016). A variety of teaching strategies were reported, including traditional lectures, international servicelearning, reflective reports, case discussions, interventions based on the contact hypothesis, community service practices, corporate social responsibility activities, role-play, narrative storytelling, and standard patients (Halter et al., 2015; Kohlbry, 2016; Ozkara San, 2019). Unlike previous educational practices, in the present study, we aimed to evaluate students’ cultural competence and perceptions of out-group threats using methods like 360-degree film viewing with VR headsets and innovative game-based teaching methods like the serious game “Refugeoly” and escape rooms. An increase was expected in the mean total CCA-S and OTPS scores of the students following the implementation of the interventions. However, it was seen that there was no significant difference in both scale scores, and in fact, a slight decrease was discerned in both the experimental and control groups. Similarly, Kohlbry (2016) found that nursing students’ cultural competence levels decreased after a training intervention. This could be explained by participants having a better understanding of the meanings of the associated items after the interventions, allowing them to judge themselves more objectively and therefore lower their scores. This type of experience helps students expand their worldview and forces them to consider if they completely comprehend the requirements of a person from another culture (Liu et al., 2018). Learning through experiences is considered one of the most permanent and effective ways of learning (AnguasGracia et al., 2021). In the present study, in which we employed various teaching methods together, it was aimed to provide students with affective learning in the context of transcultural nursing, migration, and refugee issues. When we evaluated the students’ opinions about the game-based teaching methods, we found that all three of the methods made students contemplate the issue of migration and refugees and gave them some negative feelings about these Table 3. Most Representatives Subcategories, Meaning Units and Quotes of Participants. Categories Subcategories Meaning units Representative quotes Experiences regarding the 360-degree film Emotional effects of the film Desensitization (n = 9) “I feel a little bit empty . . . We have normalized everything so much because of television and media that I believe we have developed immunity to such videos” (D61) Recommendations for the solution of the refugee problem Raising awareness in society (n = 11) “People need to be informed more about the refugee problem. Many people are not even aware of the issue. I think the media should put more effort because they have a great impact on society” (D40) Experiences after playing Refugeoly Game Game Design Interactive (n = 9) “The game was so dynamic . . . It gives information about the difficulties faced by refugees on each box and you learn about the process they go through by playing in order to reach the target” (D37) Learning outcomes Developing empathy (n = 16) “You put yourself into the shoes of these people and try to empathize with them as much as possible because you can’t know what they go through unless you have been there” (D49) Experiences related to the Escape Room What they liked about the game design Educative (n = 37) “The escape room is an engaging and alternative method to evaluate our existing knowledge as well learning new things. We really obtained more information about a culturally different patient in an interesting way” (D45) What they wanted to change in the game design Technical problems should be anticipated (n = 11) “The communication between the two groups was not very good. We had difficulty using the walkie-talkies. Such factors as technology should also be considered. We were racing against time, technical issues caused us to lose time” (K47)