Open lock and key sitting next to it on wooden table
HealthSeptember 14, 2020

Enter if you dare! Lessons learned from the Orvis School of Nursing

By: Carrie D. Hintz, DNP, RN, CEN
Welcome to the nursing escape room. These types of activities aim to promote teamwork, engagement, critical thinking, assessment skills and leadership. After months of exams, textbooks, and clinical rotations, students…and faculty…need a little fun.

Escape rooms sprang to international fanfare in the early 2000s. These activities are based upon the principles of team dynamics as teams work to solve puzzles, accomplish tasks, and discover clues…seeking to escape their circumstances, save the day and beat the clock (Nicholson, 2015). These types of “live-action” activities have been integrated into nursing schools, professional nursing conferences, and nursing work environments in recent years.

Nurse educators at Penn Presbyterian Medical Center in Philadelphia used the concepts of an “escape room” to improve nursing and other healthcare professionals’ knowledge about sepsis. Approximately 270,000 patients die every year as a result of sepsis, and the nursing educators used the escape room to highlight sepsis care from an interdisciplinary perspective for World Sepsis Day in 2017 (Clark, 2019).

Sigma Theta Tau International also recently hosted two escape rooms during their biennium convention in Washington D.C. in the fall of 2019. These two escape rooms were sponsored by Old Dominion University School of Nursing and the Epsilon Chi Chapter. These escape rooms were interactive, bringing together chapter members from all over the world. Participants worked to beat a “techno-virus,” which threatened all electronic medical records. Sigma reported over 130 nursing participants in their escape rooms (Sigma, 2019)…which I am sorry to say that my team did not escape from!

Instructions

You and your peers have been tasked with saving Thelma. This is going to require teamwork and good communication. You will work through the nursing process while solving puzzles and riddles. Feel free to look around the room, but you must stay within the boundaries of your room until you save Thelma, or run out of time! Please do not use any force with the equipment, locks, boxes, or Thelma. You will be successful in your “Escape from nursing school” when all ordered medications have been safely administered. You are racing the clock! Use the buzzer on top of the IV pump to indicate successful completion. Good luck! May the care be ever in your favor!

Oh, the days of nursing school and being locked in a safe place. However, now is the time you must work to escape! You have 30 minutes to save the patient, or you will be trapped in nursing school forever!

SBAR report

Situation: Your patient is Thelma Bogtrotter, a 78-year-old female who arrived in the ED 30 minutes ago via a local ambulance service. The patient’s daughter reported finding Thelma confused and disoriented, with a fever of 102 F. She notes that her mother was combative and refusing assistance so, she decided to call 9-1-1. In route, the paramedics started two 20g IVs, and administered a 500cc bolus of normal saline.

Thelma’s EMS vital signs:
BP – 72/18
HR – 118
R – 22
T – 102 F
SpO2 – 93% RA

Upon arrival, her BP was assessed to be 62/40, with a HR 120. The ER physician has seen the patient and placed orders.

Background: 78-year-old female patient with a history of diabetes, hyperlipidemia, hypertension, and major depression. She was discharged from a skilled nursing facility one week ago, where she had been for rehabilitation following a right great toe amputation due to a diabetic foot ulcer. She recently finished a 14-day course of Augmentin.

Home medications:
Metformin 850 mg BID
Lisinopril 20 mg daily
Metoprolol 10 mg daily
Simvastatin 40 mg nightly
Zoloft 50 mg daily
Ambien 10 mg nightly prn sleep

Allergies – No known allergies
Code status – Full Code

Escape rooms and evidence-based learning

Nadelson and Nadelson (2020) highlight the use of escape rooms as an innovative strategy to promote evidence-based learning. The educational benefit of escape rooms is correlated to the positive application of critical thinking and problem-solving skills while supporting decision-making skills and team dynamics.

These types of gaming learning strategies augment traditional assessment of skills and knowledge, by allowing students to apply their clinical knowledge in actual case scenario situations that promote critical thinking and reasoning. By deploying a variety of teaching strategies, faculty can engage a diverse group of learners, lending to each team member’s individual clinical strengths. Unlike traditional simulations, escape rooms offer students an unsolved mystery along with the air of mystique that promotes out-of-the-box thinking. Escape rooms and the gamification of education can offer something for everyone.

Gamification of education is intended to “engage and motivate” students to improve their skills and application of knowledge (Palomino, Toda, Oliveria, Cristea, & Isotani, 2020). Hallifax, Serna, Marty, & Lavoue (2019) believe that the application of game-like elements to non-game scenarios helps to improve student motivation, engagement, and performance. While Garcia-Viola et al. (2019) report that the application of gamification to nursing education improves student satisfaction, creative thinking, and control, while subsequently improving student decision-making. By generating new experiences to actively participate to improve their learning, educators can promote elements of leadership, teamwork and autonomy in a safe and realistic setting.

The Orvis School of Nursing Escape Room Experience… i.e., Mrs. Thelma Bogtrotter

Building the escape room took three days, and many, many tacos. Two of the level faculty created a core set of activity objectives. These were based upon the student learning outcomes or course objectives from the level practicum experience for pre-licensure nursing students entering their last semester of nursing school. As educators, we attempted to balance the level of difficulty for each of the tasks based upon didactic information presented in their core courses. We also attempted to balance the difficulty of the puzzles by integrating brainteasers into a simulated patient care scenario. All aspects of the escape room, including activities, games and puzzles were relevant to the care needing to be delivered to the patient.

Our patient presented with a complex set of problems, similar to real-life ED patient scenarios. Our escape room scenario also supported patient assessment, room assessment, safety practices, isolation necessities, medication administration, medication math, SBAR reporting and documentation requirements. The escape room did have an associated point value for the activity, but these points were associated with the quality of the SBAR report and documentation generated secondary to the escape room experience.

Enter if you dare…

In the creation of the experience, we decided to run two “escape rooms” simultaneously and side-by-side. This really appeared to up the ante and the competitive nature of the teams, since they were able to see and hear each other throughout the experience. The escape rooms were set-up in our skills labs, which were reflective of an acute care patient room. The escape rooms were also “taped off” to ensure that the students not only had access to all of their clues in one location but to promote more engagement in the activity.

We used our pre-established clinical groups with eight to ten students in each group for our escape room teams. The teams were randomized for the schedule, and all teams were prepped ahead of time as to the potential for other groups to overhear and oversee their work. This not only helped the groups to function with effective purpose and dialog but allowed them to discuss their potential team roles prior to entering the escape room. The teams were all involved in a pre-briefing, which included escape room rules, simulation expectations, student learning outcomes, documentation and reporting requirements, as well as identified opportunities for them to seek help in the event that they needed it. The pre-brief last for ten minutes.

The escape room was trialed by willing faculty members to ensure that the clues, riddles and processes made sense and were appropriate to the patient’s care prior to the student participation. No tacos were hurt in the practice attempt.

The Escape room

The escape room ultimately had a total of eight puzzles, riddles, instructions and medications to complete and administer. The students were required to use data from the puzzles and riddles to successfully “unlock” storage boxes that contained their medications, equipment supplies, and physician orders. Both escape rooms were created with less than $80 in supplies obtained from the local hardware store and the skills lab repository. The purchased supplies included a variety of locks, storage boxes, and painters tape. We also incorporated the use of drug guides, nursing diagnosis books, IV tubing, needles, syringes, vials of simulated medications, bags of saline, isolation gowns and gloves and IV pumps. We also utilized several NCLEX pearls, along with an article on nursing and sepsis care, and a sepsis screening tool to generate a real-life application scenario.

The information, puzzles, pieces of the SBAR report form and documentation requirements were provided to the students as they entered the escape room. This information was placed into eight manila folders, and one envelope was given to each student on the team. This helped to ensure that all members of the team were given a task that they could own. Students ultimately worked on the puzzles together, but by providing each student with a task, we tried to ensure that all students had the opportunity to engage in the great escape. As instructors, we also prepped them in the pre-brief that their “piece of the puzzle” also correlated to giving reports and completing the documentation. These tasks were non-transferrable, so whoever received the report envelope had to give a report. For the most part, this was effective in ensuring that all team members actively participated, and were able to use their “nursing voice” to contribute to the care of the patient.

The students were given 30 minutes to properly medicate their patients, and escape nursing school. The patient care scenario was situated on the basis that the patient had C-Diff, and was septic. We did not alter the vital signs throughout the course of the scenario. However, the students had to medicate their patient with medications that corresponded to the patient’s presentation. The students also had to initiate contact precautions due to the C-Diff diagnosis. The following clue was taped to the hand sanitizer, which students would have found when they “foamed in” to their escape room.

Riddle me this…

Your patient has had four “code browns.”
This change will quickly turn your smiles into frowns.
The classic odor and mucus will make you want to brace…
The lab has been sent, and now isolation precautions must be put in place.

Upon donning isolation gowns, the students would find another clue that supported continued care or assessment needs. It’s important to note that although some groups successfully found all the clues hidden throughout the room, some did not, which meant that all of the care items were not successfully implemented. This provided great discussion content for their post-escape room debrief.

One puzzle example…

The students were required to complete the following crossword puzzle as one of their tasks. The answers to the crossword puzzle were associated with a cipher that helped the students identify a keyword associated with a lock on one of the storage boxes. The locked box held their medication, but no supplies. In order to successfully medicate their patient, they had to address all of the locked boxes.

These types of puzzles also had hints, or ways for the students to seek additional information relevant to their locked boxes. For example, the physician order form also provided a myriad of lab orders, so if the students found that clue (which was hidden in the room), they could use that information to fill in the crossword puzzle. Students could also “phone an instructor” for help, but before help was provided, all team members had to complete a medication math question.

After the great escape

Of the seven teams and 63 students who participated in the escape room activity, four groups successfully assessed, medicated and provided report on the activity. Had the escape room been five minutes longer, two additional groups would have finished as well.

Post escape room debriefing was built into the exercise. This 20-minute debriefing opportunity allowed the individual groups to talk about their experience, reflect upon each other’s contributions and deliver an SBAR report on their patient care. The debriefing also allowed the faculty to tailor the debriefing to identify the individual group dynamics and teamwork elements that supported the team performance in the escape room, while also talking about the patient’s presentation, assessment finding, and medication needs.

To escape or not…

Ironically, while we ran simultaneous escape rooms, we had the opportunity to see a textbook version of good and bad team dynamics in one of the scheduled pairs. These contrasting views and approaches to “escaping” the room really demonstrated how important group work is for laying the foundation for interdisciplinary team practices in their future nursing careers. We did not instruct the students to select a team leader in the pre-brief, but six of the seven groups elected to do that upon entering the room based upon the information provided in their manila envelope.

During the textbook version of good and bad team dynamics, one group demonstrated strong communication and delineated the tasks based upon group member strengths. Their selected team leader ensured that everyone was engaged, included and supported throughout the process. However, the second group was divisive right from the beginning. They opted to not select a “team leader,” and within five minutes of starting had formed “cliques.” This group refused to share information with team members, which ultimately limited their ability to move forward due to the stepped and connected nature of the puzzles. Group members resulted in yelling and sniping at one another. It was a classic depiction of a dysfunctional team, who failed to identify the underlying patient problem. Consequently, this group did not make the great escape!

Conclusion

The use of the escape room was well received by our students. We received positive feedback and were afforded the opportunity to really connect with our students about proper patient care. This exercise also instilled courage and pride in our students. Many students commented that their escape room experience helped them to realize that they know more than they sometimes give themselves credit for. It also provided us a way to break down traditional nursing school stereotypes, and come to mutual respect and understanding among the student peers. Students who are not normally verbose, found themselves directing the pack. Students who maybe did not feel confident giving report found their nursing voice. It was a proud moment for students, faculty, and Mrs. Thelma Bogtrotter.

Carrie D. Hintz, DNP, RN, CEN
Assistant Professor, Post Masters Doctorate of Nursing Program Coordinator, Orvis School of Nursing

References

Clark, M. (2019). Nurses create escape room to increase sepsis awareness. HealthLeaders. Retrieved from https://www.healthleadersmedia.com/nursing/nurses-create-escape-room-increase-sepsis-awareness

Garcia-Viola, A., Garrido-Molina, J. M., Marquez-Hernandez, V., Granados-Gamez, G., Aguilera-Manrique G., & Gutierrez-Puertas, L. (2019). The influence of gamification on decision making in nursing students. Journal of Nursing Education, 58(12), 718-722. https://doi.org/10.3928/01484834-20191120-07

Hallifax, S., Serna, A., Marty, J.C., & Lavoue, E. (2019). Adaptive gamification in education: A literature review of current trends and developments. European Conference on Technology Enhanced Learning. https://doi.org/10.1007/978-3-030-29736-7_22

Nadelson, S., & Nadelson, L. (2020). Bringing a mystery to the evidence-based practice: Using escape rooms to enhance learning. Worldviews on Evidence-Based Nursing, 1(3). https://doi.org/10.1111/wvn.12461

Nicholson, S. (2015). Peeking behind the locked door: A survey of escape room facilities. Retrieved from http://scottnicholson.com/pubs/erfacwhite.pdf

Palomino, P., Toda, A., Oliveria, W., Cristea, A., & Isotani, S. (2020). Narrative for gamification in education: Why should you care? 2019 IEEE 19th International Conference on Advanced Learning Technologies (ICALT). doi: 10.1109/ICALT.2019.00035.

Sigma. (2019). Convention highlights. Retrieved from https://www.sigmanursing.org/connect-engage/meetings-events/convention/highlights

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