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

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

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.

References

1. 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
2. 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
3. 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
4. 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
5. Nicholson, S. (2015). Peeking behind the locked door: A survey of escape room facilities. Retrieved from http://scottnicholson.com/pubs/erfacwhite.pdf
6. 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.
7. https://www.merriam-webster.com/dictionary/escape%20room