Finding unique ways to engage nursing staff in ongoing continuing education can be challenging. Staff in any given unit are often multigenerational, ranging from Millennials to Generation X to Baby Boomers to Traditionalists. Challenges to nurse educators include the diversity of learners based on attributes such as age, developmental levels, learning styles, and experience in their profession with interprofessional collaboration. An escape room is a “live-action team-based game in which players discover clues, solve puzzles, and accomplish tasks in one or more ‘rooms’ or locations, in order to accomplish a specific goal within a limited amount of time. Successful team actions and decisions during the interactive game result in escaping from the room before time expires” (Nicholson, 2015, p. 1).
Designing an escape room lesson can be time consuming and expensive depending on the resources available to nurse educators. Space to design an escape room can also be challenging. A popular new concept to control cost and space issues is to design a portable escape box (Boysen-Osbourne et al., 2018). An escape box can be any box that contains clues and can be locked. Instead of solving clues to escape an actual room, participants used an escape box to solve clues and progress to the next box or level in a scenario. A resource to facilitate this lesson development is the immersive game room platform known as Breakout Edu ( http://www.Breakoutedu.com), which offers portable escape boxes as a way to incorporate the escape room method in small spaces.
The purpose of this article is to describe the implementation of an escape box as an escape room lesson and a teaching method during an inpatient nursing skills day with a multidisciplinary team. This learning activity was deemed to be a quality improvement education project and did not require institutional review board approval at either the academic or the practice institution. Participants included nurses, respiratory therapists, and advanced practice nurses (APRNs) working in a pediatric cardiothoracic intensive care unit (CTICU) setting. Learning goals included the promotion of knowledge, teamwork, and collaboration to develop a teamwork approach to an emergency situation. Learning goals and feedback were evaluated using standardized hospital nursing education evaluation forms. These forms were updated to include feedback specific to an escape box activity and were later classified by the student educator and preceptor into domains of learning and outcome themes were identified.
Escape Room Use in Health Care and Domains of Learning
Learner engagement has become increasingly important in the current learning climate and requires educators to rethink how we teach. This includes the concept that learners must be active partners and change agents when contributing to their own learning, all of which can be accomplished through an escape room strategy (Docherty et al., 2018; Hudson & Carrasco, 2015).
Efficacy about escape room lessons has been demonstrated in nursing, pharmacy, and medical educational activities as an effective way of engaging and activating students to achieve optimal learning outcomes (Adams et al., 2018; Hermanns et al., 2017; Zhang et al., 2018). For example, Boysen-Osbourne et al. (2018) demonstrated a toxicology escape room and a scavenger hunt for fourth-year medical students. This project included 25 medical students split into five teams of five who progressed through 10 different stations of toxicology content. The material was linked to learning objectives and used a locked box concept (escape box) to represent the escape room and scavenger hunt. This demonstrates the use of an escape box as an escape room concept that will be discussed throughout this article. Students assigned a high value to the activity as a learning methodology and teamwork activity, and they expressed a desire to repeat the activity in the future. Hermanns et al. (2017) and Adams et al. (2018) demonstrated improvement in the student experience through positive qualitative comments from participants about engagement in the lesson and a desire for more active learning opportunities.
Literature related to escape rooms or escape boxes often focuses on the academic setting with undergraduate nursing students (Gómez-Urquiza et al., 2019). One study examined the successful use of an escape room lesson for continuing nursing education where learners were participants in a nurse residency program rather than performers in the clinical environment (Adams et al., 2018). Despite the growing body of evidence around escape rooms and escape boxes, a gap exists in the literature related to their use for multidisciplinary team building.
Escape room lessons encourage participants to actively communicate, collaborate, and work as a team to achieve a common goal of escaping the room or activity. Health care educators can implement the escape room lesson with unfolding case studies, which promote critical thinking and time-sensitive problem solving. The team-oriented and goal-focused approach to a patient case can be an effective method of incorporating the affective, cognitive, and psychomotor domains of learning of Bloom's taxonomy (Anderson & Krathwohl, 2001; Bloom, 1956). Psychomotor skills related to basic assessment skills such as auscultation and identification of a murmur. Cognitive learning focused on the pathophysiology associated with cardiac lesions and the Blalock-Taussig-Thomas (BTT) shunt. The affective domain of learning focused on support of parents during their child's health crisis and the end-of-life issues associated.
Setting, Participants, and Identification of Learning Needs
The CTICU is a 20-bed intensive care unit that cares for critically ill medical and surgical pediatric cardiac patients. The project was designed and conducted in collaboration with unit nurse educators, who served as preceptors, and course faculty at the university. Learners included nurses and respiratory therapists in a CTICU in a large, academically affiliated pediatric institution. APRNs are part of the multidisciplinary team and were invited as voluntary participants in the escape room lesson as schedules allowed.
Many new staff members are added to the CTICU setting on a quarterly basis. A need was identified by the simulation team to enhance simulation sessions with additional engagement activities. The activities focused on the emergent issue of BTT shunt thrombosis, a rare but serious emergency in the CTICU. This clinical event is a rotating topic every 2 years in the simulation curriculum due to its rare but serious nature. Maintaining competency during infrequent and critical events such as BTT thrombosis is challenging but essential for the CTICU team. Nurses and respiratory therapists regularly participate in quarterly education days as part of their core curriculum for continuing education. Routine mock simulations for deteriorating patient conditions are performed each education day; however, an escape room format for learning had not yet been introduced. As a result, an escape box lesson was developed in place of an escape room as an unfolding case study to address the learning needs and knowledge deficits of staff. The case details, integrated as clues in the escape box, included vital signs, test results, parental feedback, and patient history. Staff who participated in the escape box lesson ranged from less than 1 year of experience to more than 20 years of experience, with the majority falling into the 1 to 5 year range of experience. A total of 64 nurses and 11 respiratory therapists participated in the escape room experience as part of their regularly scheduled and mandatory education day.
Escape Room Design: Preparation
This project was designed as part of a required teaching assignment in the capstone course of a nurse educator certificate program at a large midwestern university. The nurse educator student was also an APRN in the CTICU in which this project took place. The nurse educator student and nurse educator preceptors further reduced expenses by developing their own escape box system without the use of commercially available products (Tables A–B; available in the online version of this article). A total of 10 boxes were assembled to allow for two teams to compete against each other. This enabled all learners to participate because of the smaller number of participants for each team.
The Escape Room Scenario: Care of the Patient With a Blalock-Thomas-Taussig (BTT) Shunt
ESCAPE ROOM BOXES: SETTING UP AND UNLOCKING THEM
The locked escape boxes were placed throughout the CTICU environment, each box containing clues regarding the case study and the location of the next box. Participants were presented with a case study involving an infant with a single ventricle cardiac lesion. Learners first engaged with the patient, “Johnny,” after his admission through the emergency department. Two teams were formed by dividing each participant group in half, resulting in varying levels of experience among members. Teams were then provided with instructions and given a packet with the patient story and starter clues. Table A demonstrates the clues for each phase of the escape room progression with history, vital signs, assessment findings, and the question to progress to the next escape box. Handoff details included Johnny's history of congenital heart disease, single ventricle physiology, and uncertainty regarding palliation. Johnny's admission assessment included hypoxia, fever, and a report of poor oral intake for a few days. The emergency department team had obtained blood cultures and ordered empiric antibiotics of vancomycin, gentamycin, and piperacillin–tazobactam (i.e., the institution's current high-risk antibiotic protocol) although the only medication to be infused thus far was vancomycin.
Teams were then presented with additional clues and a question, which if answered correctly would provide a code to unlock the first escape box. With subsequent clues and successful team interpretations, more escape boxes would be unlocked, leading to eventual progression through the case study about Johnny. The progressive and interactive design of the lesson promoted engagement of the teams in a scavenger hunt for the next escape box. For example, an added benefit was experienced by newer staff who explored and expanded their familiarity with the work environment when given the clue to “go to where the open chest tray is kept.” Actively exploring the location of supplies used in emergent situations could enhance efficiency during those events. Locating the chest tray also coincided with discovery of another escape box.
After successfully answering the first question, learners were able to open escape box #1, where information from Johnny's parents confirmed that he had been palliated with a 3.5-mm BTT shunt. Learners were then presented with a blood gas result and asked to characterize this to unlock the subsequent box. Escape box #2 presented the next stage in Johnny's scenario, where he was now hypotensive and required intravenous fluids and preintubation medications. Learners were asked to prioritize the following treatments for Johnny: intravenous fluid, sedation for intubation, and antibiotics. Progressing to escape box #3 included Johnny's clinical decline, with deteriorating vital signs and extreme oxygen desaturation. Learners were now asked to suggest an imaging study to Johnny's APRN. After filling in the blank with the answer, a corresponding code was revealed whether the answer was correct (echo-cardiogram). Table B demonstrates this different type of question and answer. Incorrect entries for the imaging study (e.g., chest radiograph) did not correspond to the correct code to open box #4.
This final clue led the learners to the fifth and final escape box, which did not contain any clues. This box only contained a statement that the team had successfully transferred Johnny to the catheterization laboratory. The team was instructed to check in with the escape box educator and record the time they used to complete the activity.
If learners answered questions correctly, they could immediately unlock the escape box and progress through the scenario. Incorrect answers required team members to reconsider and discuss the clues and attempt another answer to move forward. This feature of the escape room lesson allowed for immediate learner feedback without instructor interaction, as well as stimulated teams to actively problem solve. All teams completed the exercise and were close in completion times, but the first team to reach the final escape box was acknowledged and given candy as a small reward.
A short debriefing followed the escape room lesson and included all teams from all sessions. Clues presented during the unfolding patient scenario were reviewed and lingering questions were answered. Faculty and the student educator facilitated the debriefing in the escape box activity, which allowed time for participants to reflect more deeply on the activity while sharing with other learners. A structured debriefing along with planned questions and time for reflection has been shown to increase learner engagement and is preferred by learners to a nonstructured debriefing (Monaghan & Nicholson, 2017; Zhang et al., 2018). The escape box lesson was repeated four times each day for 5 days, enabling 20 teams to complete it. Time-keeping was recorded for each group, and at the end of the quarterly skills days the team with the overall fastest time was awarded a voucher for the hospital coffee shop.
Evaluation and Data Collection
Staff were asked to provide feedback after each session of the escape box. Such feedback is routinely collected after continuing education at this institution. The nurse educator preceptors and nurse educator student distributed the paper forms, which were completed and submitted anonymously by 64 participants. Only RNs and APRNs completed the survey although it had been offered to respiratory therapists as well. Respiratory therapists did not complete the evaluations because they were not scheduled dedicated time out of the unit for this education and they felt they needed to resume patient care. Participants were asked to rank the teaching effectiveness and knowledge of the student educator who moderated the learning session and debriefing using the choices of Excellent, Good, Fair, or Poor. A total of 60 respondents ranked the student educator's teaching effectiveness as Excellent and four rated it as Good. Participants ranked the nurse educator student's knowledge of the subject as Excellent (62 responses) and Good (two responses).
Staff were asked to describe how they would apply one concept learned during the session into their current practice. Several themes emerged from these qualitative comments that can be classified into the three learning domains (cognitive, affective, psychomotor) of Bloom's Taxonomy (Bloom, 1956). Evidence supports the use of all three domains of learning in an educational activity to create more pathways for improving recall (Wilson, 2019)
First, the cognitive domain is characterized by knowledge and ranges from the introductory stages of knowing and understanding to the more advanced stages of applying, analyzing, evaluating, and even creating new knowledge (Billings & Halstead, 2016). Participant feedback demonstrated that the escape box activity strengthened knowledge and understanding of BTT shunt anatomy and physiology. Learners noted improved and more timely recognition of shunt complications, such as decreased flow and thrombosis. Staff at various stages of learning based on experience and knowledge articulated awareness of this variance and how the escape box activity improved upon their stage of learning. Comments ranged from “Will be able to recognize signs and symptoms of failing BTT shunt” to “Able to evaluate interventions for a BTT shunt and provide corrections.” Many comments focused on an increased ability to recognize signs and symptoms of BTT shunt failure more accurately and included the improved ability to prioritize interventions. Such comments reflected on clinical judgment and prioritizing, reflecting the learner's knowledge of a failing BTT shunt and the subsequent ability to synthesize and evaluate this data to select the appropriate nursing action. One participant commented that “I learned how to prioritize shunt interventions over routine code interventions” and noted a better understanding of the underlying cause of the patient's decompensation.
The psychomotor domain of learning involves the physical or kinesthetic domain of learning and involves physical functions and reflex actions (Billings & Halstead, 2016). Participants noted examples of learning the physical activity of drawing up code medications, as well as obtaining an echocardiogram in response to a suspected shunt occlusion or accurately interpreting an auscultated murmur.
Finally, the affective domain addresses the feelings or emotions of the learner (Bloom, 1956). Learners on the escape box teams ranged from novices who simply receive and are aware of stimuli to advanced learners who value, organize, and characterize those stimuli based on the learners' values and beliefs (Billings & Halstead, 2016). Participants provided feedback on the high value that they placed on this activity and its positive learning environment. Participants reflected the following: “Love the education on defects and it is so helpful,” “Activity was fun,” “Great topic, activity was fun and educational,” and “Escape Box concept was great.”
Limitations to this project included lack of participation by the full multidisciplinary team. Although APRNs are an integral part of the CTICU team they were only able to participate as their schedules allowed, and this translated to fewer APRN participants. Future planning might include APRNs as mandated and scheduled participants to better reflect the multidisciplinary team that is customary on this unit. Additionally, time and space constraints for the education day kept this project small in terms of participants. Future projects might include doing an escape box or an escape room lesson in an unused locked area of the hospital or on a simulated patient unit in the simulation center.
Although the escape box lesson was successful, several lessons were learned throughout the process. As cited in the literature, creating an escape box is time consuming (Adams et al., 2018; Gómez-Urquiza et al., 2019; Hermanns et al., 2017). Methodically and carefully planning and testing clues and questions requires time but is a major key to success. It is also crucial to ensure that locks are operating properly. Educators discovered that lock numbers would slip while sitting in storage in between sessions, requiring resetting to avoid frustration during subsequent escape box sessions. Teams could have then formed the correct answer but were unable to manipulate the locks due to erroneous settings. Finally, questions in the escape boxes were of varying levels of difficulty, resulting in more or less challenging experiences depending on learners' experience and knowledge. Despite these obstacles, the escape box lesson was a successful activity based on the consistently positive feedback of participants who evaluated its influence on learning.
The escape box lesson provided interprofessional education in the clinical environment, specifically in an inpatient nursing unit. It demonstrates an effective teaching methodology to increase learner engagement and enhance learning, which was noted to be an important factor in progression in the profession by Hudson and Carrasco (2015). The escape box lesson incorporates all three domains of learning—affective, cognitive, psychomotor—and demonstrates the influence on nurses' knowledge and clinical decision making when all three domains are captured in that learning opportunity (Bloom, 1956).
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The Escape Room Scenario: Care of the Patient With a Blalock-Thomas-Taussig (BTT) Shunt
|Data Type||Phase 1: Starter Clue Card||Phase 2: Clues in Box #1||Phase 3: Clues in Box #2||Phase 4: Clues in Box #3||Phase 5: Clues in Box #4|
|Patient history (Emergency department [ED] reporton “Johnny”)||Diagnosis: Complex single ventricle physiology
ED team unsure of palliation
Presenting symptoms: Poor oral intake, hypoxia, fever
Actions: Peripheral intravenous (PIV), blood cultures, empiric antibiotics||Additional history:Parents confirm Johnny's 3.5-mm BTT shunt and his home monitoring program
Per home monitoring program guidelines, Johnny's oxygen saturation results in the 60s are breach of protocol and trigger ED evaluation||Based on arterial blood gas results, advanced practice registered nurse (APRN)asks nurse to prepare medications for intubation
APRN orders fentanyl, vecuronium
Johnny has second intravenous (IV)catheter inserted, with vancomycin infusing in first IV site
Gentamycin, piperacillin–tazobactam still awaiting infusion||Johnny now intubated
Fluid bolus completed|
|Current vital signs||Respiratory rate (RR): 50
O2 saturation: 53%
Telemetry: Sinus tachycardia, rate 172||Blood pressure (BP): 52/25mmHg
APRN orders fluid bolus due to BP||Heart rate (HR):170
|Current assessment||Johnny is hypoxic and tachypneic, active, responsive, but grunting
Audible BTT shunt murmur notedby nurse||APRN assesses Johnny, orders capillary blood gas
Base Deficit: −4||Johnny lethargic, hypoxic||Nurse can no longer confirm presence of BTT shunt murmur||Johnny's echocardiogram demonstrates minimal flow through BTT shunt|
|Question for team (multiple choice design)||While nurse is calling APRN to urgently assess patient, what is priority intervention?
Correct answer: “Applying oxygen”—corresponds to code 123, which unlocks box #1||When calling APRN to discuss blood gas results, what is nurse's interpretation of findings?
Correct answer: “Respiratory acidosis”—corresponds to code 432, which unlocks box #2||How does nurse prioritize use of PIV #1 and PIV #2?
Correct answer: “Stop vancomycin, infuse fluids in peripheral intravenous catheter (PIV)#1, administer intubation meds inPIV#2”—corresponds to code 756, which unlocks box #3||If APRN doesn't order this, whatdoes nurse immediately request?
Correct answer: “ECHO”—corresponds to code 538 to unlock box #4||Who does team need to notify immediately?
Correct answer: “Cath lab and/or cardiothoracic surgery”—corresponds to code 111 to unlock box #5 (final box)|
ESCAPE ROOM BOXES: SETTING UP AND UNLOCKING THEM
|Shoe boxes||Number of boxes is dependent on number of clues and teams|
|Spray paint||All boxes need to be the same color|
|Locks||Small combination locks with numeric settings|
|Process for unlocking boxes:|
|Step One:||Participants must complete a multiple choice exercise during the scenario, yielding a one-word answer.
Example: Name the test indicated for this patient: ECHO
|Step Two:||The letters of that one-word answer are matched to a number as follows (see shaded boxes):|
|Step Three:||The result of matching the letters of the word “ECHO” to numbers results in 5-3-8-15. Only the first three numbers are used to unlock the escape room box (5-3-8).|