Nurse educators seek innovative teaching strategies to develop clinical reasoning and judgment in nursing students.1 Active learning using an escape room is an innovative way to build thinking skills through peer collaboration.2 Teams are involved in a live-action game to solve puzzles. Use of gamification strategies such as an escape room offers a fun entertainment venue, mystery, and excitement to active learning. The competitive physical adventure of an escape room requires participants' active learning to think critically and creatively.1
Overview of Escape Rooms
Escape rooms, also referred to as escape games, are versatile and can vary by format or setting. Escape games can take place in a room designated as an escape room, around a table, or even virtually on a computer.3 Settings for games can be set in various locations (eg, hospitals, prisons, haunted houses) based on learning objectives. Rules and guidelines are provided by a moderator. A time limit is given for how quickly players must discover and answer clues. The goal is to have a group of players work together to solve puzzles, find hidden clues, and ultimately escape to win the game. If all clues are not solved in the time allotted, the players do not escape or win the game. This idea of working together translates well to nursing education. Gamification can reinforce the importance of coordinating efforts and recognizing tasks that need to be done, including delegating to other players, similar to nursing.
Nurse educators can search Google or Pinterest for escape room clue ideas and for guidance on types of clues to use. For instance, pens with invisible ink and a black light, or a decoder wheel with letters and numbers can be used to decipher a clue. Consider how simple or complex you want your room to be. There are multiple options for puzzles. Blank jigsaw puzzles with varying amounts of pieces can be purchased online or at craft supply stores. Picture puzzles can be used with types of dressings, blood loss amounts, or supplies needed for an intravenous start or other nursing skills. All it takes is imagination to come up with a fun way for students to remember nursing care principles while thinking critically as they progress in the escape room.
Planning an Escape Room Learning Activity
Development of an active learning activity using an escape room format necessitates consideration of 4 key areas: (1) topic, (2) setting, (3) clues, and (4) activity debriefing (Supplemental Digital Content, http://links.lww.com/NE/A901, Figure). In-depth planning by faculty includes securing a defined space and obtaining resources for activities within the space.4 Once learning objectives are identified, the clues to be used are identified. Assigned roles are not necessary as all team members work together toward a common goal. Finally, opportunity to debrief with students allows for synthesis of the patient case and review of important learnings.
Exemplar of Planning an Escape Room: Postpartum Hemorrhage
An escape room was developed focusing on postpartum hemorrhage. The learning goal was to use an active learning strategy to facilitate students' understanding of previous learning about obstetrics nursing. The concept of postpartum hemorrhage was selected because it provided opportunity to address multiple learning objectives related to patient assessments, diagnostic evaluation, and nursing interventions. Variations in diagnostic test results and vital signs, as well as nursing assessment and interventions, were incorporated into the escape room clues. Planning for the escape evolved from the learning objectives. The Supplemental Digital Content, http://links.lww.com/NE/A902, Table, provides the specific learning objectives used for this exemplar.
Preparation of Clinical Scenario and Launching the Escape Room
The escape room learning activity started by using a patient scenario taking place in a patient room in the simulation laboratory. The patient scenario was provided to the students using a laminated card placed at the patient's bedside table in the simulation laboratory. This scenario included a Situation, Background, Assessment, and Recommendation report of the assigned patient. When the student group entered the room, they immediately read the patient scenario and began exploring for their first clue.
Escape Room Team and Timing
A group of 4 to 5 nursing students comprised the team entering the patient room. Once the student team entered the room, the 45-minute time countdown for the activity was initiated by the instructor. The time countdown was displayed on a laptop in the patient room for reference by the student team during the activity. Resources for countdown timers are available for use on websites such as YouTube. Timing for this escape room was guided by previous reports of nurse educators that 1 hour was too lengthy.3 Therefore, the time allotted for this escape room was determined by having faculty walk through the process of finding all clues and opening all lock boxes; a 45-minute period provided adequate time for completion of the activity.
Escape Room Clues
Once students read the scenario, the students realized that puzzle pieces were scattered around the room. All puzzle pieces were purposefully in plain sight, to minimize the time searching or looking for puzzle pieces (eg, such as opening drawers to find puzzle pieces). In this escape room scenario, there were a total of 12 puzzle pieces. Clues were hidden in various locked devices placed throughout the patient room. The Supplemental Digital Content, http://links.lww.com/NE/A902, Table, details examples of clues used to generate codes to open locks placed on items such as a community health bag, makeup bag, tackle box, and dictionary safe.
During the escape room experience, students were able to ask for up to 3 clues from the instructor. If more than 3 clues were needed, the student team was penalized with 1 minute added to their final time for each additional clue requested. The overall 45-minute timer did not stop when students requested a clue.
Planning Considerations
The goal of the student group size was determined to allow opportunities for each student's active participation. Another consideration for this escape room was the use of 2 groups simultaneously competing in parallel escape rooms. This plan allowed more students to be accommodated in each 45-minute time. The competition element of 2 groups participating concurrently added to the enthusiasm and engagement during the learning activity. All escape times and results were recorded and displayed with their team names and pictures on television and interactive monitors on campus. The escape times ranged from 18 to 37 minutes; all groups successfully escaped. Immediately after the escape room experience, students gathered for a 15-minute debriefing to review and synthesize the case scenario of postpartum hemorrhage and key learning concepts.
Student User Experience
After all groups had participated in the escape room experience, an anonymous survey was sent for the students to express their user experience. Thirty of 78 students (38.4%) responded. The user experience survey consisted of 4 questions using a 5-point Likert scale with responses of "strongly agree" (5) to "strongly disagree" (1). The mean scores were 4.33 and higher.
One takeaway or lesson learned from developing this escape room was that this teaching strategy was not costly to develop and implement. Most of the materials needed to plan and implement this escape room were everyday materials easily accessed and/or available on campus. Ultimately, these low-cost options were easier to conceal in the escape room because they were not obvious lock boxes.
Summary
Escape rooms are a fun and exciting way to actively engage students and reinforce knowledge of key nursing concepts. Allowing students to think critically in a safe learning environment encourages confidence and teamwork. Students naturally take on leadership roles when working together toward a common goal.
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