We were at a loss. Previous attempts to use games, such as Jeopardy and Family Feud, with nursing-themed questions in a fundamentals course rarely required more than student comprehension of material. Only a few students actively participated, and they quickly became bored. Inspired to create a game of intrigue and inquiry, we adapted the escape room concept to two undergraduate content areas in the baccalaureate nursing program at a midsized Midwestern university.

BACKGROUND

Escape rooms are a form of live-action gaming in which teams solve clues to successfully unlock a locked room or solve a puzzle (Nicholson, 2015). Games may include puzzles, tasks, locks, and hints (Nicholson, 2015). The estimated 1,950 commercial escape room locations now operating across the United States (Spira, 2017) bring together mystery, teamwork, communication, and lateral and critical thinking (Nicholson, 2015).

Gaming promotes active learning, reinforces knowledge, and engages and motivates learners (Aburahma & Mohamed, 2015; Phillips, 2016). More specifically, escape room gaming for educational, rather than purely entertainment purposes, has been used for primary and secondary education. Various online resources guide primary and secondary teachers on how to incorporate escape room technologies into their classrooms (Breakout EDU, n.d.). Reade (2017) used a narrative puzzle game, much like an escape room, to orient college students to the library and its resources. The University of Ottawa implemented an escape room for medical students studying vascular surgery to promote active learning, practical use of knowledge and skills, and student preparation (Kinio, Brandys, & Jetty, 2017). We found no mention of escape rooms in the nursing literature.

THEORETICAL BASIS

Escape rooms build on the theories of constructivism and adult learning theory. Constructivism asserts that learners build on knowledge as they make sense of new experiences. Furthermore, social interactions foster learning (Candela, 2016). Adult learning theory says that adults build upon life experiences and individual learning styles (Merriam & Bierema, 2014). They prefer to take an active role in learning and, impacted by the social context of learning, enjoy the connection and support of other learners. The escape room allows students to construct meaning with sequential tasks and instantaneous feedback and meets the needs of adult learners, actively engaging them and promoting interaction.

ESCAPE ROOM PREPARATION

A week before the escape room event, the authors created a short, suspenseful video trailer with the use of a free movie creation application. The video provided clues about the upcoming game without divulging its nature. After the video was shown, students each picked a woven bamboo finger trap from a bucket; a letter printed on the toy was used to divide students into teams. The movie trailer and team assignments excited students and created a competitive team spirit.

On the day of the event, students waited outside the room, listening to spooky music and wondering what would happen. Faculty, dressed in all black, led students through doors marked with "caution" tape to their "locked" classrooms. This added to the theme as well as students' anticipation and interest. As the event began, an instructional video, complete with a scary-sounding voice, provided team instructions, including the goal of the game, the use of up to three clues per team during the event, and the requirement for team collaboration through each task.

LEARNING ACTIVITIES

The escape room teaching strategy has been implemented twice in the nursing program. The six tasks for the first event in a fundamentals course included a crossword, an interactive case study, and a drug dosage calculation worksheet. In another task, students had to determine the acid-base imbalance present based on a case study and correctly match related clinical manifestations. Yet another task required students to induce a patient's diagnosis based on prescribed medications and lab and diagnostic results. Students completed multiple-choice questions related to course content as their final task.

Likewise, the second escape room event, this time for cardiovascular content in a critical care course, entailed six tasks. Students first completed a crossword puzzle related to cardiovascular diseases and medications. They also interpreted electrocardiogram rhythms, induced the cardiovascular condition present based on physician orders, and determined the type of shock present based on clues. One activity required them to illustrate hemodynamic changes expected for a given condition with props, pictures, and/or drawings. Related multiple-choice questions concluded this event.

Each activity provided clues to help students proceed to subsequent tasks. Some activities included certain numbers that, when combined, created a code to open a locked box that contained directions for the next task. Some answers started with a letter that, when combined, spelled out information about where to locate the next clue. For some tasks, faculty verified the answers and indicated how to continue. For the final tasks, smaller groups merged into two larger groups. Each team opened a box containing threaded letter beads, which spelled out a few words. When combined with the clues of other teams, these words spelled out a sentence, revealing the location of a metal key.

The metal key opened a lock box that contained a password-protected cell phone and pens with invisible ink and a small black light on the end. Instructions attached to the black light indicated that students had to complete a page of NCLEX(R)-style multiple-choice questions to enlighten the code to unlock the phone. Faculty had previously circled four of the multiple-choice questions with the black light pen. Students used the black light to discover the four circled items. Correctly answering these four questions provided a passcode to unlock the phone. Students used the quick response application on the phone to scan a quick response code on the door of the room. When scanned, the phone displayed the message, "Congratulations, you have successfully escaped the room!" When this task was done, students were able to open the door to escape the room.

OUTCOMES

Although this learning activity was not part of a research study, students and the authors noted benefits of the escape room events. First, the authors were able to conduct formative assessments, noting particular areas of weakness that could be improved on before the students' examinations. The authors anticipated students would easily solve the puzzles as the activities were designed as a review of course content, rather than new material. Students were able to reflect on their successes and challenges during the escape room event and believed the activity helped them to identify areas of content for which additional time and attention were needed. Next, students were active and engaged in learning and became excited and competitive. The students collaborated as teams to answer questions and discussed how the activities were fun, collaborative, and tested their knowledge. Finally, each activity was unique and aimed at different learning styles.

The authors recommend the following steps to educators who plan to implement this strategy:

* Allow sufficient time to plan all of the activities, at least six weeks for the first event. Creation of a second event requires a fraction of the time.

* Test out locks and clues for accuracy.

* Start the event with a simple task to ease students into the game. Because the initial crossword tasks frustrated students with the number and specificity of the clues, the authors replaced this with a simpler task for subsequent events.

* Allot enough time for the event. Setup on the day of the event took at least 30 minutes, and the game itself required approximately two hours. However, faculty can limit the number and type of activities based on the time available.

The authors plan to continue the escape room activities in the future. A prequiz and postquiz would determine improvement in learning before and after the game. Although group games are aimed at collaboration, a few students appeared confused and frustrated. The faculty have since condensed activities and set a time limit for the escape room to ensure sufficient debriefing time to reinforce content and address students' questions and concerns. The overall response to the implementation of escape rooms as an alternative learning strategy has been overwhelmingly positive. Now that the authors have piloted this strategy, the focus will turn to research on students' experiences of the event as well as developing preevent and postevent measurement strategies.

REFERENCES