Once again, the U.S. nursing workforce is facing a severe shortage of professionals. It is expected that more than 500,000 nurses will retire nationwide in the next 5 years (Grant, 2016). Some of the factors that influence the shortage nationally include the increase in chronic diseases and services, the aging Baby Boomer population, greater access to health care and nursing care, and the use of technology and tech savvy providers. In Nebraska alone, nearly 1,200 RNs will be needed by 2020 to address the shortage (Grant, 2016).
High school students have many career opportunities as they consider their futures. Nursing may not be an obvious career choice for these young adults because they may not be aware of the role of the RN. Recent studies indicate that many high school students, as well as high school counselors, are not aware of the role that RNs play in the U.S. health care system (Flores & Ashe, 2013). It is essential that schools of nursing and the nursing community provide learning opportunities for these youth that portray accurate images of the role and scope of professional nursing. Based on the recent increase of escape room social events that has swept the country (Miller, 2015), the faculty and staff at this rural division of nursing developed an innovative recruitment strategy entitled Escape to Nursing.
According to Miller (2015), the escape room concept began in Japan in 2007, reaching Eastern Europe by 2011, and the U.S. mainland by 2012. In 2012, it was estimated that more than 300 escape rooms would exist in the United States by 2015. Participants in escape room events are locked in a room with clues, puzzles, and challenges they must solve in order to exit the room before time runs out. Some escape rooms offer additional help and clues to participants, while others do not. Escape rooms also vary in the use of high technology and may include evolving story development or may focus on particular themes. Originally developed through computer gaming and for entertainment, the escape room concept has recently gained interest from the workplace to foster team development.
Given that nursing education today is heavily focused on the use of simulation and technology to provide safe environments to practice highly technical skills, the simulation laboratory is an excellent venue to offer an escape room event for prospective students who are considering a career in nursing. The escape room incorporates simulation via gaming into the learning experience (Guo & Goh, 2016; Wiemker, Elumir, & Clare, 2015). During simulation, students can rely on their preferred style of learning while engaging in team learning activities. In addition, they have an opportunity to test their interest in nursing as a career through the real world of nursing. This includes communication skills, the use of technology, and caring behaviors, along with other essential skills (Porter, Edwards, Granger, 2009). Escape rooms have been used in postsecondary education to facilitate acquisition of communication skills (Kapp, 2016), instruction of the scientific method (Stone, 2016), and information literacy (Kapp, 2016). No published literature was found describing the use of escape rooms in nursing education.
For an escape room to be successful, participants must be presented with one or more challenges requiring them to solve a puzzle or challenge and earning a reward. Rewards are usually in the form of a cue. Combinations of cues enable participants to successfully unlock the door and escape. Hints are commonly provided as an aid to solving the puzzle or challenge; sites generally limit the number of hints available to participants (Nicholson, 2015).
Cues may be presented in a linear, sequential format or in an open or random design. Escape rooms utilizing a linear design require less mental effort and are considered less challenging than use of an open design (Nicholson, 2015). Nicholson (2015) reported that a mere 62% of participants successfully escape without assistance in rooms requiring a low mental effort. Success rates decrease to 36% for rooms requiring a high level of mental effort. Perhaps because of the challenges inherent in their design, escape rooms continue to grow in popularity worldwide (Kapp, 2016; Nicholson, 2015; Stone, 2016; Wiemker et al., 2015).
Recruitment for the event focused on both high school and college students interested in nursing. Potential participants were identified through the rural health occupations program, communication with area high schools, and posters that were displayed at a partner community college.
A planning team composed of nurse educators, student services staff, and simulation specialists was formed. The planning team met a total of 6 hours over a 2-week period. The planning team determined topics for the escape room that would be of interest to potential participants within the team's area of expertise. The room topics chosen included pediatric asthma, mental health depression, motor vehicle accident, and newborn infant cold stress. The team collaborated to create the clinical scenarios, activities, and cues leading participants to the key required to escape from the room. The planning team determined that an actual locked room was not desirable, choosing to use a laminated paper key for exit and entry into rooms upon successful completion of the required challenges.
The planning team evaluated each scenario to determine appropriate cognitive levels and inclusion of sufficient kinetic and gaming features. To ensure opportunities for participation, it was decided to limit each group size no more than four participants. Because escape rooms require resetting between participant groups, starting times were staggered and a time limit of 15-minutes was set for each room. Anticipating that there would be times when participants could not move forward in solving the puzzle because of the nursing content embedded in each scenario, each room contained a paper-laminated help button. Participants held up the help button when they were stuck and needed assistance. The team scheduled a pilot test prior to the event. Two graduate assistants served as participants in the pilot test, providing valuable feedback regarding the difficulty level of the scenario. This enabled the planning team to fine tune necessary changes for each escape room. The pilot test validated the appropriateness of the 15-minute time slot for each escape room. The institutional review board indicated formal review was not needed.
Escape Room Design
Each escape room incorporated use of high-fidelity simulation manikins to promote realism in the design. The escape rooms contained nursing care tools such as stethoscopes, dressing supplies, and other props as required in the scenario. Simulation facilitators who controlled the manikin actions were located in an enclosed booth not visible to the participants. Because the participants were students without nursing experience, all cues were directive in nature, specifying correct actions to proceed to the next cue. The pediatric asthma, mental health, and motor vehicle escape rooms used a linear, sequential design for cue delivery. Cues were developed to aid the participants to complete the scenario in a step-by-step manner to solve the challenge. The newborn cold stress escape room used multiple cues that could be solved in any order.
The Pediatric Asthma Escape Room Scenario
The pediatric asthma escape room incorporated an overall puzzle theme related to the nursing process (assessment, nursing diagnosis, planning, implementation, and evaluation). The pediatric manikin was programmed with signs and symptoms consistent with an exacerbation of asthma. Participant groups followed a series of sequential cues leading them through patient care while following the steps of the nursing process. Linear cues included words written backward on a paper that require a mirror for reading, puzzles, riddles, and cues hidden in the patient's bedding. Participant groups earned the escape key after the patient's symptoms were resolved.
The Mental Health Escape Room Scenario
The mental health escape room included posters of young celebrities with quotes to encourage empathy for individuals with mental health needs. The scenario included an 18-year-old female with depression and suicidal ideation who is awaiting inpatient placement in a mental health facility. Linear cues included referring participant groups to written care information, hidden cues, a diagnostic depression scale, and a word scramble puzzle. (Table).
Mental Health Escape Room
The Motor Vehicle Escape Room Scenario
The motor vehicle accident escape room incorporated care of a 20-year-old female patient who had nonlife-threatening injuries. Linear cues directed participant groups to decode proper care of a person with this type of injury. Required care included working through medication management and care of a compound fracture.
The Newborn Cold Stress Escape Room Scenario
The newborn cold stress escape room used an open, nonlinear design. Participant groups received cues to recognize the infant experiencing cold stress and to take measures to warm the infant. Cues could be solved in random order to achieve resolution of cold stress. Cues were overt or hidden and included puzzles, scratch cards, and word associations.
Delivery of the Event
Upon arrival, participants received a brief overview of the plans for the evening by the student services coordinator. Each group included two to four participants. Planning team members and graduate assistants facilitated the movement of participant groups from one room to another and also served as timekeepers for each session.
High school and college student participant groups were debriefed separately immediately following completion of the escape room experience. A modified Plus-Delta method (Fanning & Gaba, 2007) was used for debriefing. In this method, participants are asked to reflect on the experience, specifically considering what went well, what they would do differently in the future, and lessons learned from the experience. Debriefing concluded with the question, “Would you recommend this event to a friend? Why or why not?” Participants were provided with a brochure highlighting components of the event, as well as college of nursing recruitment materials.
Escape Room Results
Effective use of resources of faculty time in the initial development of the escape room provided the opportunity for additional use of the scenarios for other purposes with minimal time investment. For example, other faculty have used these scenarios during a high school summer camp. In addition, supplies were reusable and inexpensive, limiting the overall cost of the event. The scenarios were created in such a way that minor modifications could be made to keep the escape room dynamic from one pool of participants to another without the loss of the element of surprise.
Seven participants completed the escape room recruitment event. High school students (n = 2) and college students (n = 5) attended at different times. Information obtained during debriefing indicated the students enjoyed the fun and challenging experience. Students found the newborn cold stress scenario to be challenging; this was thought to be due to the use of nonlinear cues in the room design. Coaching through the use of manikin vocalizations or the use of the help button was needed for participants to successfully complete each escape room.
Student responses to the question “Has this event had a positive impact on your consideration of nursing as a career choice?” included definitely, absolutely, and yes. Four responses incorporated further comments:
- It made me even more confident in knowing this is the career I want to be in.
- It made me even more excited to enter into nursing.
- Loved seeing classrooms and manikins and how to treat them.
- Gave me insight of what nurses do and how they problem solve.
Participants also indicated they would recommend this event to a friend.
The shortage of practicing nurses challenges educators to creatively recruit young people to consider nursing as a career. Nontraditional recruitment methods, such as escape rooms, may appeal to the current generation of high school and college students and serve to draw more interest into nursing. One of the advantages of having multiple escape room experiences is that it allows participants to experience the many faces of nursing. In addition, participants had hands-on experience in the simulation laboratories that may have a greater impact than a traditional tour of nursing program offerings. The faculty team thought that additional time to recruit for the event would be optimal. Participation in events are enhanced with early invitations to the event.
Lessons learned from this experience include the need to use linear escape room design with nonnursing student populations, early recruitment strategies, and the role of simulation in an escape room experience. The implementation of a linear, sequential, but challenging format, rather than a nonlinear, or open, random design, is recommended for recruitment purposes.
The use of high-tech simulation and gaming enhances our program's capacity to attract potential students who may not be considering a nursing career. Although the number of participants for our first escape room was lower than desired, faculty and staff think the positive student comments demonstrate an opportunity to provide this type of recruitment in the near future. In additional, participant comments recommending an increase in the number of rooms and for more marketing of this recruitment strategy, are priority items for future planning. We plan to incorporate escape rooms into new student orientation, the annual summer camp held by our nursing program, and in current nursing courses. The escape room strategy holds promise as a valuable recruiting tool that may ultimately cultivate a desire to for potential students to enter the nursing profession.
- Fanning, R.M. & Gaba, D.M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2, 115–124. doi:10.1097/SIH.0b013e3180315539 [CrossRef]
- Flores, C. & Ashe, M. (2013). Simulating nursing school to engage high school students. Clinical Simulation in Nursing, 9, e139–e143. http://dx.doi.org/10.1016/j.ecns.2011.11.003 doi:10.1016/j.ecns.2011.11.003 [CrossRef]
- Grant, R. (2016). The U.S. is running out of nurses. Retrieved from https://www.theatlantic.com/health/archive/2016/02/nursing-shortage/459741/
- Guo, Y.R. & Goh, D.HL. (2016). Library escape: User-centered design of an information literacy game. Library Quarterly: Information, Community, Policy, 86, 330–355. doi:10.1086/686683 [CrossRef]
- Kapp, K. (2016). Game-based learning in 3D and real life: “Escape Room Learning.”. Retrieved from http://karlkapp.com/game-based-learning-in-3d-and-real-life-escape-room-learning/
- Miller, S. (2015). The art of the escape room. Retrieved from http://www.newsweek.com/2015/05/01/art-escape-room-323150.html
- Nicholson, S. (2015). Peeking behind the locked door: A survey of escape room facilities. Retrieved from http://scottnicholson.com/pubs/erfacwhite.pdf
- Porter, G., Edwards, P. & Granger, B. (2009). Stagnant perceptions of nursing students: Results of a shadowing interventions study. Journal of Professional Nursing, 25, 227–233. http://dx.doi.org/10.1016/j.profnurs.2009.01.014 doi:10.1016/j.profnurs.2009.01.014 [CrossRef]
- Stone, Z. (2016). The rise of educational escape rooms. The Atlantic Daily. Retrieved from https://www.theatlantic.com/education/archive/2016/07/the-rise-of-educational-escape-rooms/493316/.
- Varcarolis, E.M. & Halter, M.J. (2010). Patient Health Questionnaire-9 (PHQ-9). Foundations of psychiatric mental health nursing: A clinical approach (6th ed.), (pp 253). St. Louis, MO: Saunders.
- Wiemker, M., Elumir, E. & Clare, A. (2015). Escape room games. Game Based Learning, 55. Retrieved from https://thecodex.ca/wp-content/uploads/2016/08/00511Wiemker-et-al-Paper-Escape-Room-Games.pdf
Mental Health Escape Room
|Case and Resources||Details|
|18-year-old “Mia Lowe” who is awaiting placement in a mental health facility following suicidal comments||Mia asks participants to help her finish a crossword puzzle|
|When the puzzle is solved, it asks them to find the next “clue”|
|First letter of One (1) Across, Second letter of 21 Across, Third letter of Five (5) down, Answer to 18 Down ____ ____ ____-____ (Spells PHQ-9).|
|“To start the diagnostic work, around the room you must look” [PHQ-9 Mental Health Assessment form is on a counter.]|
|PHQ-9 form||Mia prompts participants to complete the PHQ-9 form with her. Participants must ask Mia the questions and circle the corresponding response and total the score at the end of the PHQ-9 form.|
|Clue #2 at the end of the form states “If the score is 15 or greater, See page 557, Box 24-4.|
|A textbook of Psychiatric Mental Health Nursing is on the counter with an environmental scan section that speaks to creating a safe environment for someone who is suicidal|
|Foundations of Psychiatric Mental Health–A Clinical Approach (6th ed.)||On the correct page there is a folded paper that reads “Environmental Scan, please ensure the following items are marked for immediate removal”|
|The form contains seven (7) lines to write items staged in the room such as cords, cleaning supplies, glass plates, silverware, sharps, medications|
|The bottom of the form contains a message for “Clue #3” Everything is coming up ‘roses’. [There is a vase with roses on the bedside table.]|
|Clue||“Some PEOPLE have trouble handling this illness” [A People magazine is on the over-bed table.]|
|Inside is taped a paper with pictures of celebrities in different film roles|
|Celebrity paper||“I am a famous actor/comedian who took my own life after being diagnosed with a degenerative disease. Who am I?”|
|The answer [celebrity name] – Clue #4 [There is a framed picture of a bird on the wall]|
|Framed picture of a robin (bird) in the room||Behind the frame is Clue #5. A note taped on the back of the frame reads “I am not the only one who suffers with this diagnosis, other ‘famous’ people have too. We sometimes feel all scrambled. What diagnosis do we have?”|
|There is a NAMI (National Association of Mentally Ill) poster with “Famous Faces of Depression” that is in a plastic acrylic stand-up frame. The word “depression” is scrambled reading “S N E R I D O P S E”|
|On the back of the frame is the “Key” providing exit from the room and directions to the next escape room adventure|