Simulation & Gaming

Escape rooms have been adapted from a range of educational purposes across disciplines, including healthcare simulation. The use of this technique has become increasingly popular among industry and faculty members. We sought to clarify the characteristics of healthcare simulation escape rooms in order to work toward a shared mental model and definition.

A scoping review of the literature with an environmental scan of websites and other public information was performed to identify concepts which describe educational and healthcare simulation escape rooms to differentiate between and determine key features and scope of this clinical education tool to provide an interprofessional definition. Twenty-three references were used.

Healthcare simulation escape rooms share many of the characteristics of those being used for education and may be utilized for teaching a variety of skills. These may be conducted either within a simulation scenario, within the simulation/simulated environment, and/or with associated equipment. It is essential that the development and implementation of these escape rooms follow design standards of best practice for healthcare simulation for optimal learning. Only one definition of simulation escape rooms was found.

While similar to escape rooms utilized in other forms of education, there are principal differences between those escape rooms and ones used in healthcare simulation. Key features include utilization of core healthcare simulation principles, including providing a safe and realistic learning environment.

Escape rooms may be used to engage learners in a simulation experience. It is important to differentiate between true simulation escape rooms and escape rooms that do not reflect healthcare simulation-based learning experiences. An expanded definition is provided, as reflected by the literature review, to provide a clearer understanding of the term as applied to healthcare simulation and enhance repeatable studies to advance the science of healthcare simulation.

The implementation of educational escape rooms has shown great value in learner outcomes. The design of such simulations requires a thoughtful, well-defined process.

The purpose of this article is to encourage educational escape room designers to use a thoughtful, methodical, iterative process to ensure quality, educational capacity, and a positive learner experience.

When designing an educational escape room, designers should consider implementing a cyclic design process: design, pilot, evaluate, redesign, re-evaluate, and repeat.

A methodological process for educational escape room design can promote deep learning and positive student perceptions.

Turnover rate for new graduate nurses at a midwestern community hospital was 30% for the first two years. Central clinical orientation for new hire registered nurses and care assistants was heavily executed via didactic format. Feedback from instructors suggested boredom and disengagement of learners during these sessions. Post central orientation evaluations resulted in 49% of attendees feeling not “very confident” to apply skills in clinical practice.

Clinical educators created an escape room to improve learner satisfaction, interprofessional communication, and confidence in applying skills in practice. A convenience sample of twenty-three (23) registered nurses and care assistants participated in an escape room, Contagion Crisis, covering basic knowledge of infection control, emergency response, restraints, and drug calculation.

Average Likert scores on the post survey for satisfaction and communication were 4.67 and 4.0 respectively. Confidence in applying skills to practice averaged 4.72. Subjective feedback from participants included enjoyment of a fun, non-pressure environment.

Multiple clinical disciplines can use this escape room, as it covers topics from central hospital orientation. Learners preferred the escape room format versus a high-fidelity simulation, due to it being less “high stakes” and not a judgement of individual performance.

Escape rooms have been utilized to incorporate teamwork, communication, policy, and procedures reinforcement, as well as clinical care. Often themed, escape rooms challenge a team of players to discover clues and sequentially solve puzzles with the ultimate task of accomplishing a specific goal in a limited time frame, fostering critical thinking.

This learning activity incorporates legal implications for prelicensure nursing students in a pediatric community summer camp/after school care environment. Care and legal implications for a minor experiencing respiratory distress was the premise of this escape room.

While this was not a research study, surveys were distributed for quality improvement and a deeper needs assessment related to the content and delivery of an escape room. Learners discussed the positive aspects of this activity through journal entries and a survey, noting the need for increased content related to legal implications for the medical team. This room engaged the learner in the forward-thinking that is needed related to emergency care, Good Samaritan Act, liability for cost, and permission to treat in a time-pressured environment.

Testing the knowledge pre-post survey related to legal implications with implied care will be explored.

Nurse educators are challenged to develop simulation activities that will engage interest and help baccalaureate nursing students administer medications safely. Students must be able to recognize and report medication errors and effectively collaborate with their patient care team to provide safe and competent care to patients across the healthcare spectrum. Escape rooms are an innovative learning platform where students can work as a team to build these skills.

We report on the strategies and resources used to create and implement an escape room simulation for a problem-based learning activity to practice medication safety behaviors, using critical thinking, communication and team building skills.

Using Kolb’s Learning Cycle and the International Association for Clinical Simulation in Learning (INACSL) Standards of Best Practice^SM, we developed a team-based, four-hour escape room simulation activity around detecting and reporting medication errors in the hospital setting.

The result was a hybrid escape room simulation that mimics a situation nursing students might face in the hospital setting where they have to work as a team to assess a new patient, reconcile medications, perform medication calculations, problem solve intravenous infusion set ups, and communicate medication errors. Data collected for quality purposes indicated a positive student response.

The escape room platform served as a foundation for incorporating other simulation modalities and provided a stimulating learning activity. The next step is to conduct a multi-site study with pre-test and post-test data collected from students to gauge learning and behavior change.

Commercial escape room simulation-based educational experiences were piloted on a cohort of ten RN-BSN students to determine the effect on mastery of communication, leadership, and teamwork skills.

Pre-test/post-test research design and qualitative questions were used to measure the impact of an escape room simulation activity on teamwork, communication, and leadership skills. The Team Strategies and Tools to Enhance Performance and Patient Safety^® Teamwork Attitudes Questionnaire, and self reported levels of confidence and competence questionnaire were administered pre/post escape room simulation to measure communication, team structure and leadership skills. The University of Miami-Crisis Resource Management tool was utilized to measure observed teamwork. Additionally, four open-ended qualitative self-reflective questions were asked following the escape room.

Data from the analysis of the pre and post observations of simulation encounters found statistically significant time dependent differences noting improvements in observed teamwork and leadership, p <.001, pre-mean 18.5, post-mean 35.0. Qualitative data revealed the participants found the escape room simulation to be an engaging teaching method to master teamwork and leadership skills.

This pilot study sets the foundation for future use and exploration of escape room experiences to teach teamwork, communication, leadership and situational awareness. Following the escape room simulation, observed improvements in teamwork and leadership were found. Participants found the escape room activity to be an engaging experiential teaching method to promote attainment of critical skills needed to work as an effective member of a team. Study findings suggest that the use of an escape room can impart experiential learning with critical skills needed to work as an effective member of a team. As a result of this pilot study, nursing faculty developed an escape room simulation experience that was initiated the following semester.

Healthcare simulations are used at most academic facilities to improve knowledge and performance on critical and key concepts and can also be used to enhance competency and teamwork. Group simulation scenarios often have individual team leaders, but these scenarios require a team to work together to efficiently care for the patient. Escape rooms can be utilized in healthcare as a fun educational activity to encourage teams to work together and think creatively to solve puzzles and challenges. One advantage of this type of activity in a healthcare setting is to dissolve any hierarchy amongst the team and build the confidence of novice or more passive participants. Escape rooms in a healthcare setting do not have to be medically themed to be effective, and rooms can be set up with minimal equipment.

This article addresses the detailed steps required to set up a healthcare themed escape room that has been shown to work well. It is applicable to healthcare professionals and can be adapted for non-healthcare workers.

Based on the Escape Room video games and social activity phenomenon, teams compete to solve content-specific challenges to attain pieces of the final puzzle set forth by the instructors. Traditional quiz-type exercises, pictograms, and procedural based activities comprise the puzzles of the game. The first team to obtain all pieces of the final clue and put them together in the correct order in the shortest amount of time is deemed the winner. Gameplay is designed to conclude in approximately 20 minutes.

This game mimics interdisciplinary teamwork environments. Participating in interactive collaborative learning environments enhances the overall learning experience, allowing learners to apply knowledge.

Cardiovascular content is challenging for students to master in the undergraduate nursing curriculum. Educational escape rooms have been shown to be useful in increasing student knowledge, immersing students in the learning process, and facilitating the growth of soft skills among learners.

This article details a cardiovascular educational escape room in an undergraduate nursing course, including educational objectives, design considerations, and all materials for seamless transferability into other curricula.

Faculty designed, implemented, evaluated, and revised a nursing cardiovascular escape room over three years. In this sequential-style escape room, junior-level students worked together in groups to complete nine puzzles and activities. The student teams solved puzzles during the allotted 60 minutes to save a fictional patient at risk for further clinical deterioration related to cardiogenic shock. Participants complete activities including drug dosage calculations, rebus puzzles, multiple choice items, and clinical reasoning activities based around course and licensing objectives for the content area in nursing education. Upon game conclusion, faculty lead a guided debriefing to close the loop of learning. The escape room has been implemented for groups ranging from 31 to 68 students in each cohort.

Previously published results on this topic indicate that student content knowledge improved after the event. Students also reflected growth in confidence, critical thinking, and teamwork and also appreciated the real-life nature of the activity. The educational game can be adapted and transferred to other schools of nursing or clinical sites.

Clinical learning activities in a pre-licensure nursing program are challenging to rapidly convert to an online format due to their objectives to provide hands-on practice. Previously, students spent their final day of pharmacology participating in low-fidelity lab-based, simulated pharmacology activities. Due to a public health crisis, the instructional team had to quickly change course to create an equally engaging virtual activity that provided opportunities for clinical judgment.

In this article, we discuss a virtual pharmacology escape room created using Google forms for pre-licensure nursing students prior to their final pharmacology course exam. The learning objectives were to review difficult course concepts by making clinical decisions and to practice using medication protocols.

The design and evaluation of a virtual pharmacology escape room are presented to reflect a learner centered approach. Key considerations when designing the escape room were to best use the students’ time, to focus on content frequently missed on exams by the student cohort, and to include medication protocols commonly encountered during the clinical part of their program.

Surveys provided positive feedback from learners along with suggestions for strengthening future escape room activities. Most students reported the activity provided opportunities for clinical judgment and was helpful for learning.

Benefits of virtual escape rooms are they can be created at no cost to educators of learners and easily accessed using personal electronic devices. Future applications include designing additional escape rooms to aid student learning in challenging nursing coursework, such as pharmacology and clinical courses.

Perioperative nursing is expected to see a 20% reduction in the workforce due to retirement within five (5) years. To recruit and retain nurses within this specialty, the Association of Operating Room Nurses (AORN) Periop 101: Core Curriculum™ OR was added to an existing nurse residency program. Periop 101 is an online learning program providing evidence-based guidelines for practice and requires the learner to pass a final exam with a score of 80% or higher. Following a didactic final exam review session, most nurse residents at a midwestern community hospital failed to pass the final exam on their first attempt.

To address this knowledge gap, the clinical educators decided to create a more interactive review session by creating an escape room. Current literature supports the use of escape rooms to increase knowledge and learner engagement.

Nurse residents participate in Operation Outbreak during the exam review session. A convenience sample of twenty-two (22) registered nurses were included in the quality improvement project. Group one consisted of 18 participants who received only the didactic review session. Group two had four participants who participated in the didactic review session as well as the Operation Outbreak escape room.

Overall, there was improvement in the average final exam scores and average percentage of residents to pass the exam on the first attempt after the addition of the escape room. Statistical analysis was not performed due to sample limitations.

Due to advanced maternal age, obesity, drug use, and other comorbidities, the frequency of maternal cardiac arrest continues to rise nationally and in our Midwestern community hospital. While still a relatively rare occurrence, the national rise in maternal mortality rates has created a need for population-specific resuscitation education for caregivers of obstetric patients. Educators are challenged with creating engaging, meaningful education that is inexpensive and effective. Educational escape rooms challenge participants to discover clues, solve puzzles, progress through the game and ultimately escape the room. The format offers team problem-solving and experiential learning with immediate feedback in an enjoyable atmosphere.

In order to provide an interprofessional and economical educational intervention for labor and delivery teams, the authors created an escape room focused on principles of effective maternal resuscitation.

Participants completed an evaluation tool measuring perceptions of content clarity and confidence, and an author created pre-test and post-test to measure knowledge of cardiopulmonary resuscitation medications and interventions for the obstetric patient.

Comparison of aggregated pre- and post-test showed an 11% increase in knowledge scores. All participants self-evaluation showed improved clarity and confidence and described the activity as a fun way to learn and reinforce knowledge.