Effective teaching is not a one-size-fits-all approach. Freeman and colleagues1 conducted a meta-analysis with findings that indicate the importance of active learning strategies for improved learning outcomes. As educators strive to engage learners in didactic classrooms, care must be taken to ensure that teaching strategies are not only varied to meet the preferences of individual learning styles but are also effective. Gamification is often used to increase active learning, and one method that has been gaining support in both traditional and virtual nursing classrooms is the use of escape rooms.2-4 An escape room is a team activity in which participants complete puzzles and uncover clues in a race against time to "escape" a simulated scenario. Available studies on escape rooms attempt to answer questions related to both student perceptions and attainment of knowledge.4 However, a gap in the literature exists when comparing the effectiveness of the delivery methods. The purpose of this quasi-experimental study was to verify whether an escape room was an effective strategy by measuring knowledge gained, to assess student perceptions, and to determine whether a significant difference exists if completed online or in person.

Methods

A 35-minute escape room activity was conducted both virtually and in person for 83 students enrolled in a 200-level baccalaureate nursing fundamentals course in the fall and spring semesters of 2022-2023. Course objectives related to patient safety and teamwork were addressed in the activity. A case study was developed, which included the history and physical of a fictional hospitalized patient. Students were asked to identify or manage concerns regarding interpretation of medication orders, isolation precautions, fire safety, restraints, fall risk, and high-alert medications.

Institutional review board approval was obtained. This was a required, ungraded activity. Students were given a pre- and posttest on course content related to safety and completed a survey after the activity. All scores and comments were downloaded into the Excel spreadsheet software and numbered anonymously without any identifying information.

In-person students met in their regular classroom. They received instructions, completed the pretest, and were placed in groups of 4 to 5 students. Each group received a locked tackle box and a history and physical. Teams solved a puzzle to unlock the box and reveal the next clue. Items inside the box included medications with written orders, personal protective equipment, and an additional locked container with several hospital policies, case study progression, and clues. Eventually, students unlocked each layer, navigated to a simulated electronic chart, and completed the final steps to "escape."

Virtual students met online via videoconference. After receiving instructions, students completed the pretest and were placed in breakout rooms in groups of 3, and 1 participant shared their screen. Participants were provided with a link to a Google slide designed to look like a hospital room. Students worked together as they uncovered clues by clicking on items in the room, which required correct answers to questions to receive the codes needed to eventually "escape." Regardless of which setting students were in, students utilized the same case scenario, and had access to the same policies. Posttests and surveys were completed immediately following the activity.

Data Collection and Analysis

The 5-question, researcher-generated, multiple-choice, pre- and posttests were completed independently, immediately before and after the activity through the learning management system. In addition to the posttest, students completed a survey using a Likert scale to indicate their perceptions regarding communication, teamwork, and critical thinking. They were given an opportunity to provide narrative comments. Common themes embedded in the narrative comments emerged as each researcher analyzed the responses using a general inductive approach.

Results

Demographics

A total of 83 students participated in escape rooms. The virtual escape room consisted of 41 students, 2 males and 39 females. The in-person escape room consisted of 42 students, 5 males and 37 females. The average participant was White and 19 years old.

Knowledge Gained: Pre- and Posttests

Dependent t tests were used to compare pre- and posttests for students in both groups. The results from the virtual pretest (mean = 2.8, SD = 0.15) and posttest (mean = 3.4, SD = 0.13) indicated that the escape room had a significant positive effect in earning higher test scores (t₍₃₉₎ =-4.02, P < .001) with a medium effect size (d = 0.5 95% CI). The results from the in-person pretest (mean = 2.9, SD = 0.18) and posttest (mean = 3.8, SD = 0.15) also indicated that the escape room had a significant positive effect in earning higher test scores (t₍₄₀₎ =-4.1, P < .001) with a medium effect size (d = 0.5 95% CI). The results from the 2-sample t test used to compare the differences from pre- to posttest results in virtual students (mean = 0.6, SD = 0.14) compared with in-person students (mean = 0.8, SD = 0.20) indicated that there was no significant difference between delivery methods (t₍₇₉₎ = 1.02, P = .30).

Participant Perception

Narrative comments and survey questions were analyzed to determine participant perception of taking part in the escape room. Over 93% of participants from both instructional methods reported they either completely or somewhat agreed that they felt like they were an integral member of the team, and over 83% of participants enjoyed working in a team environment. One participant stated, "This activity was a good way to collaborate with people that we may have never worked with before. It helped us practice teamwork skills."

Another theme that emerged from participants in person (83%) and virtual (73%) was that the activity challenged critical thinking and provided a unique method for reviewing and learning new material. A participant stated, "It helped me think critically and carefully about keeping patients safe." These comments further support participants from both groups reporting their team had effective communication (88% either completely or somewhat agreed) and that team members equally contributed to the activity (73%). The last theme that surfaced was that the activity was "fun" and engaging, with one participant stating, "I am more of a hands-on person, and this is my preferred learning method, it also gives me the opportunity to learn from others as well."

Discussion and Conclusion

There is an increased need for the ability to engage students in both face-to-face and online environments. Literature supports the use of escape rooms in the classroom, showing them to be an effective strategy for applying nursing knowledge, and fostering teamwork and communication while challenging critical thinking.3 Our study is among the first to reveal that an escape room can improve student academic performance regardless of virtual or in-person delivery. By incorporating an activity that stimulated multiple domains of learning, we were better able to meet the diverse educational needs of students. This activity promoted the acquisition of practice skills including communication, teamwork, and problem-solving, and was well received by students.

References