Is it a good thing when students look at the clock? Typically, no. But being cognizant of time is exactly what educators want students to do when participating in interactive competitions such as educational escape rooms. During this immersive gaming experience, a group of students work together, using clues, hints, and strategies, to complete a quest within a certain amount of time. After finishing the skills challenge, the group “escapes” from the game site.
Novel approaches to learning can improve memory and cement knowledge.1, 2 In health sciences, simulation is a well-documented strategy used to improve patient safety and clinical skills by allowing learners to practice high-risk, high-stakes, low-volume scenarios in a safe venue.3 Likewise, game-based instruction can be used effectively to engage learners and develop problem-solving skills. Educators in multiple disciplines, including nursing, medicine, and pharmacy, have developed escape room activities to teach and reinforce knowledge and clinical skills.4-6 By requiring a group of learners to solve a series of skills-related puzzles, educational escape rooms can help to build critical thinking, communication, and cooperative problem-solving skills. Merrill's first principles of instruction provide the foundational framework for using demonstration and application to reinforce didactic content.7
Transforming educational escape room concepts into reality requires careful planning and design. At our school, we developed, piloted, implemented, and evaluated a safe medication administration educational escape room for first-year nursing students. We've found that a well-planned interactive simulation can help to facilitate students' integration of knowledge and skills into clinical practice. From concept to implementation, the process took a year, including the essential steps of piloting the activity and developing a virtual learning environment that ensures students are prepared to participate in the escape room challenge. In this article, we outline the necessary steps for developing an effective escape room learning activity and provide examples and insight from our experience.
DETERMINE THE PROBLEM
When planning an educational escape room, it's important to begin with the end in mind. Such simulations should focus on building the skills needed to address a specific clinical or professional issue. Before designing the game, the planning team should assess the training needs of the institution. What is the overall goal? What should learners gain by participating in this exercise? Do they need to brush up on current evidence-based practice? Gathering objective and subjective data is helpful in determining which educational and training needs are relevant to a specific practice site. Objective data may include hospital patient safety indicators, sentinel events, and quality improvement audits. Patient satisfaction surveys and staff learning needs assessments offer subjective data. This information can then be used to develop the educational game scenario. For example, a sepsis escape room experience might be developed around the need for improved recognition of clinical triggers, such as elevated lactate levels and signs of organ impairment.
In our educational escape room, students use clues to progress through a learning activity focused on the safe administration of medication. The landmark To Err Is Human report from the Institute of Medicine (now called the National Academy of Medicine) identified medication-related errors as a significant cause of morbidity and mortality, and nursing students often report feeling uncertainty regarding safe medication administration.8 Our simulation was created after we noted students' declining safety and medication subscores on the National Council Licensure Examination for Registered Nurses (NCLEX-RN), which occurred after a major curriculum revision in our prelicensure program. In addition, our faculty noted, and students verified, a lack of confidence in medication administration during students' foundational clinical experiences. These objective and subjective data validated the content we chose to reinforce when we began developing our escape room activity.
CREATE THE OBJECTIVES
Much like taking a road trip, it's necessary to know the final destination before setting out on the journey. A clearly defined problem helps to establish the outcome objectives. We wanted first-year students to use teamwork and communication to safely administer medications. To achieve this, we established several learning objectives for our educational escape room. Participants would have to demonstrate (1) the proper techniques to safely administer medication during the simulation, and (2) teamwork and effective communication to complete an assigned task. From a programmatic standpoint, the activity would improve aggregate NCLEX-RN scores in patient safety, communication, and pharmacology.
After the problem has been established and formal or informal objectives developed, the next step is to assess internal strengths and resource gaps.
GATHER THE NECESSARY INFORMATION
Educators planning an escape room activity should assess available resources, including staffing, physical space, and funding. Part of the educational escape room development process is to determine if the institution will support this learning modality. Buy-in is critical. The process of building an escape room activity can be a team-building experience, but planners should recognize that considerable time and energy is needed to design the scenario and simulation. Assembling a supportive and creative team is integral to the development of the puzzles and clues that drive this activity.
In terms of physical resources and logistics, planners must ensure there's adequate space to set up the escape room scenario and funding for the necessary supplies and equipment. Many escape room clues and puzzles can be created at no cost, using available supplies and resources; for example, clues can be hidden within a hollowed-out book. In our escape room activity, which takes place in our school's simulation lab, a headline in a newspaper strategically placed on the “patient's” side table provides one of the clues, and we used the systolic blood pressure number displayed on the patient monitor as the combination for a lockbox. Escape room supplies, such as hidden safes and blacklight pens, are readily available from online retailers at relatively minimal cost. Standard toolboxes, lockboxes, and multiple types of locks, including directional and alphanumeric locks, can be found at most office supply stores.
Before developing this educational game, it may be useful for the planning team to participate in a recreational escape room activity to gain a better understanding of the various types of clues and the way in which this game typically unfolds. A field trip to a local escape room facility was a fun and informative activity for us.
PLAN THE GAME
Planning the game involves setting the scene and developing the clues. An amusing or relevant story line will make the experience more memorable to learners. Our story revolves around our school's retired mascot, Big Blue, who, in our scenario, was admitted to the hospital after celebrating the biggest win in our football team's history. Big Blue was a beloved school mascot, and our school's football team had won an upset victory over a top-ranking school—one of the biggest in football history—earlier in the year we were developing the escape game. We used this real event and pride in our school to build our story. Big Blue, who has a history of diabetes and underlying heart failure, skips his daily medication and spends the day at a tailgate party. After the game, he experiences symptoms associated with high blood pressure, high glucose levels, and heart failure and is taken to the ED. In our escape room simulation, Big Blue is a high-fidelity manikin controlled by a simulation specialist and faculty members. They are located in a control room connected to the simulation lab via a two-way mirror, through which they can view the students' progress throughout the activity, but the students cannot see them. They voice the part of Big Blue and other providers, such as a physician and pharmacist, as needed during the game. They also control the display of blood pressure and vital sign information that appears on the patient monitor.
Students participating in our activity “escape” the room after completing tasks that allow Big Blue to be discharged in time for a victory parade. Personalizing the game in this way enables students to identify with the patient and events leading up to his hospitalization. Game planners should spend some time thinking about local or current events that can have a unifying effect on escape room participants. Additionally, keeping the story line fun and entertaining offsets some of the pressure and anxiety participants might feel about the tasks they have to perform.
Creating the clues and puzzles is a key challenge when planning an educational escape room. It's important to find a balance between providing a fun environment and meeting learning objectives. Clues should be directly related to the skills learners need to demonstrate, with particular consideration of the knowledge and skill level of the targeted learners. For example, because our medication safety escape room activity targets first-year nursing students, navigating the clues and demonstrating the skills needed to successfully escape the room requires only basic knowledge.
In planning an escape room challenge, educators should map out their vision of how learners will move through the scenario and physical space. Each time there's a decision to make or skill to demonstrate, there's an opportunity to build a puzzle that will require learners to solve a problem, gain a clue, and progress through the activity. In our escape room, for instance, we used the score of the football game as the password needed to enter the electronic health record. This was a fun way to support our story line. All clues after that related to clinical concepts—relevant vital signs, lab values, and mathematical calculations for medication administration provided clues to codes for lockboxes. Requiring the use of critical skills to obtain clues means learners have fun while under pressure to demonstrate skill competency within a specified time frame.
Educational escape rooms are best used as a platform for demonstrating synthesized knowledge and skills. As game developers consider the level of baseline knowledge required before learners can participate in the activity, we recommend they prepare an appropriate prelearning activity to ensure students are familiar with the skills they'll need to demonstrate during the escape room scenario. Students should also acquaint themselves with any relevant policies and procedures.
We implemented a content review and knowledge check of safe medication administration procedures prior to students' participation in our activity. Nursing faculty worked with an instructional technology design team to create a computerized module, which we also referred to as the virtual learning environment, that students used to review the rights of safe medication administration. After the content review, students participated in a virtual learning video, in which they directed an avatar through the appropriate steps of safe medication administration. This video includes examples of correct and incorrect decisions and consequences. When students successfully completed this task, they received a computer-generated “admission pass” for the escape room simulation. Our computerized module, the Safe Medication Administration Virtual Learning Environment Simulation, is offered as an open access resource for educators. For more information, see https://odu.co1.qualtrics.com/jfe/form/SV_56GZDxbzFhMOG4R.
MAKE THE ESCAPE
After the clues and pregame education have been developed, the next step is to consider the flow of the escape room activity and rehearse the students' steps through it. The setup of the room depends on the setting and expected outcomes. Our simulation lab is designed like a hospital room, so we only had to add escape room puzzles, lock-boxes, and the countdown clock, among other items, for our learning activity. In a hospital setting, staff educators could use a vacant hospital room for their escape room scenario. A team-building or communications educational escape room, by contrast, could be set up in a conference room or office setting.
Consistent with our program's other simulation labs, the escape room activity begins with a prebriefing. This includes a patient handoff, in which students are informed that interprofessional rounds have just concluded and the provider has ordered three stat medications to be administered to the patient. Their mission is to find clues and solve puzzles that will enable them to access and safely administer the required medications before the countdown clock runs out. The countdown clock was an app we downloaded to a tablet, which was placed on a highly visible table in the simulation lab. Everything in the room is a potential clue that may be immediately or eventually necessary for the students to successfully “escape.”
After the prebriefing, students enter the escape room and perform expected tasks, such as washing their hands and introducing themselves to the patient. Failure to do so results in a hard stop of the simulation. If this occurs, students must exit the room and begin the exercise again.
One of the initial steps when administering medications is accessing the electronic medication administration record. In our escape room scenario, students must quickly find the first clue, which reveals the computer log-in password. The password, “ODU49VT35”—the football game score—is visible in the headline of the newspaper on the patient's bedside table. This password also appears as the medical record number on the patient's armband.
Conversing with the patient, Big Blue, and completing a focused assessment, leads the students to additional clues. For example, they learn from the patient that he has a trip planned this summer to visit his son, who is stationed in the military in Italy. Many of our students are experienced commercial escape room participants and find clues without prompting, but Big Blue also offers them hints. He encourages the students to take a closer look at his book about Rome; inside the book is a hidden lockbox requiring a three-digit code. A written clue reminds students of the importance of monitoring for certain parameters before administering labetalol, one of the required stat medications. The three-digit code needed to open the hidden lockbox is the patient's systolic blood pressure reading, which is visible on the monitor.
Inside the hidden lockbox, students access a worksheet containing calculations for medication administration that they must complete before they can obtain the next clue (see Figure 1). Bolded boxes on the worksheet help students identify the letters and numbers needed to open the combination lock. In our example, “ml312” is the combination code to unlock a toolbox containing all the required medications. Students typically find the locked toolbox early in the scenario; however, they must find the clues and solve all the problems and puzzles to access the combination code. After they've gained access to the toolbox, students have access to all necessary medications and supplies, such as syringes and alcohol swabs. As instructed in the prebriefing, each student in our simulation is required to administer one medication while demonstrating the appropriate steps for safe delivery. Big Blue provides prompts, if needed, to remind students about expectations regarding patient teaching and reassessment.
Game planners must determine the optimum number of participants for their activities. In our scenario, the students' mission was to administer three stat medications, so we selected teams of three, ensuring each student had the opportunity to administer a medication following safety principles. After administering the medications correctly and safely, students are directed by two clues to “escape” the room: one is on the sharps container, which they discover after administering medication to the patient and disposing of the used needles; the other is a verbal clue from a faculty member or simulation technician via the manikin's voice simulator. The escape route and final clue are located on the simulation room door and provide students with the combination of the directional lock to open the remaining lockbox. The lockbox contains notification of the students' successful escape.
To celebrate the completion of the exercise, we created props, including a banner that says, “We Escaped.” Student teams pose for photos, holding any combination of these celebratory props or the countdown clock. With the students' permission, we post these photos on our school's social media sites. Sharing their success in this way creates enthusiasm for the simulation among other students, as well as a spirit of competition, which ensures participants don't share clues that will give a competitive edge to subsequent groups. The social media posts have also attracted attention from our alumni, with many asking for an opportunity to participate.
PILOT THE SIMULATION
We cannot underscore enough the importance of piloting the escape room game before it's implemented. We piloted our activity after it was fully developed but a few months before we planned to use it in class to determine which aspects of the activity needed to be changed or tweaked. We asked all students in the senior nursing class to participate in the pilot program on a voluntary basis, and more than half chose to be involved, which allowed us to run multiple pilot simulations. This helped us to identify unclear clues and problems with our equipment, as well as the ideal length of time and number of participants navigating the escape room. For example, we found that the students didn't realize the patient's medical record number, visible on his armband, was the password for the computer, so we had to make that more obvious during the simulation.
We also elicited students' feedback, asking what they thought worked and didn't work well. We kept notes during each pilot run and made some changes immediately, so these could be piloted with the next group of students. For example, we found we needed to add additional clues for the computer log-in information to ensure students gained access to it earlier in the simulation. Subsequent pilot runs affirmed these changes were helpful.
We used a clock that counted up during the pilot runs to determine a time frame within which each student group had to complete the challenge. Based on this information, students were allowed 25 minutes to complete the activity and could ask for up to two hints from the course coordinator and faculty members inside the control room.
DEBRIEF THE LEARNER
The learning experience doesn't end after the celebration. A planned debriefing or feedback session enriches the experience. Self-evaluation and reflection are important, and learner input is crucial during the debriefing. Feedback should be guided, with participants encouraged to determine if critical actions or performance objectives were achieved.9 During a debriefing, a facilitator should promote collegiality and further team building.
In our facilitated debriefings, which take place as part of all activities in the simulation lab, students critique their individual and team performance and group dynamics, with faculty and students exploring whether the team collaborated to safely administer medications and escape the room. The debriefing session includes a verbal evaluation of the allotted escape time, number of hints given, and safety and communication criteria, as per the Creighton Competency Evaluation Instrument.10
Educators must determine the remediation plan for groups unable to make their escape. Our faculty provided extra prompting and clues during the simulation for student groups that were less comfortable or familiar with the escape room format. However, if basic safety or content remediation is required, we recommend it be provided in a traditional simulation learning setting, not in the gaming scenario. This type of simulation can be stressful for some students, owing to the time structure and competitive nature of the game. Although our educational escape room can help students learn how to work under pressure and as a team, the ultimate objective is to demonstrate the steps of safe medication administration, which can be accomplished in a more standard environment.
Timing is an important consideration when developing a realistic schedule for several groups of students to participate in the escape room game consecutively. Timing the pilot runs allowed our educators to not only set the time frame for students participating in the activity but also help determine how long it would take to reset the clues for the next group of students. In our educational escape room, we reset the clues during the debriefing, because the setting and staffing allow for this. We've allotted 15 minutes to restock the medications and supplies, reset the high-fidelity manikin and countdown clock, return the locks to their original positions, and replenish the math worksheets.
EVALUATE THE IMPACT
As a final step, it's important to evaluate the impact of the learning experience and the skills and knowledge gained. Look back at your objectives—were they met? Evaluation data in the clinical setting might include improved quality improvement measures and patient safety indicators. In the academic setting, examination scores and clinical performance appraisal can be evaluated.
Educators should elicit feedback from participants about the educational experience. Our faculty developed surveys to gauge students' reactions. Students evaluate the efficacy of the computerized module and escape room as they relate to learning, collaboration, communication, teamwork, and competency. They are asked to complete the surveys within 48 hours of the simulation, and most of their feedback has been positive. Eighty-eight percent of students have said the escape room simulation was an effective way to practice skills related to safe medication administration. In addition, they said they found the escape room to be a fun and interactive way to collaborate on tasks while improving team building and communication skills. Students have told us they “loved working as a group to figure out the puzzles” and that “being able to work as a team” was “the most valuable aspect” of the exercise.
Students have noted that using a familiar story line made the activity fun and searching for clues decreased the stress associated with medication administration. To date, all students have completed the task within the time allotted and reported that the escape room improved their confidence and medication administration skills. Although NCLEX-RN scores for the participants are not yet available, we expect the escape room experience to translate into safe medication administration practices, as well as improved test results upon graduation.
Our medication administration escape room was spotlighted at a recent nursing conference, in which more than 200 nurses and nurse educators participated in the simulation. Nurses told us they valued the opportunity to practice their skills in a nontraditional setting. Nurse educators affirmed the value of using this teaching strategy, and clinical nurse educators identified the applicability of such a model in reinforcing hospital medication administration policies during orientation programs for newly graduated nurses and new hires. Researchers have found that students believe an escape room is a useful and enjoyable learning tool for attaining clinical skills and knowledge.11
There are some drawbacks to using these gaming experiences in education. As previously mentioned, designing escape room scenarios and clues requires considerable time and energy. However, Gómez-Urquiza and colleagues note that this instructional model can be reused in future semesters.11 Because the learning experience is limited to a few participants, adequate faculty and staff are needed to run the escape room simulation multiple times. Optimally, two faculty or staff run each simulation. We use one faculty member and one simulation technician. The faculty member communicates with the students during the prebriefing, simulation, and debriefing, and the simulation technician resets all clues and equipment during the debriefing. Our escape room simulation can be run with one faculty member, but then additional turnover time between groups of students is needed. These staffing challenges, which are common to all small group simulation scenarios, should be weighed when considering this educational modality. Educators should also be aware and sensitive to the potential negative aspects of game-based learning. For example, we fully recognize that safe medication administration is not a game and have taken extra steps to ensure students are serious in their approach to the simulation and demonstrate best practices in performing all aspects of patient care required for this scenario. We also anticipated that the competitive nature of the game would potentially make some students anxious and uncomfortable. We assure students that the learning objective is not to escape the game but to practice and demonstrate the skills associated with safe medication administration.
Morrell and Ball have reported an overall positive experience for students who participated in their educational escape room, but they noted students were confused and frustrated when attempting to navigate and solve some of the clues.6 They found it necessary to simplify and reduce the number of clues and puzzles in their initial design. These findings highlight the importance of piloting an escape room game before its implementation. By piloting our simulation with senior-level students and making necessary adjustments before the simulation went live, we were able to avert some of the challenges cited by Morrell and Ball.
Escape room activities allow for interactive, immersive learning that can be applied to a variety of clinical scenarios. We are currently developing an interprofessional escape room exercise with physical therapy students, for instance. In this scenario, team members will collaborate to assist a patient who has been admitted with an exacerbation of chronic obstructive pulmonary disease. The team's goal is to help the patient “escape” from the ED to an inpatient unit and, ultimately, telehealth-assisted home care. Such a multiunit scenario could be adapted to a new employee orientation simulation, helping to foster understanding about different departments and services in the hospital and facilitate interprofessional collaboration.