Escape room activities have become a popular attraction in many cities across the world. Escape room scenarios are a form of entertainment in which participants are placed into a room and advised that they have a limited amount of time to work together to solve puzzles in an attempt to unlock a door and exit the room. The use of “edutainment” has become increasingly common in educational environments. Edutainment is a word derived from the marriage of education with entertainment (Colace, De Santo, Pietrosanto, & Troiano, 2006). One of the first uses can be traced to Robert Heyman, who in 1973 was producing documentaries for the National Geographic Society and wanted to make education entertaining (Rey-López, Fernández Vilas, & Díaz-Redondo, 2006). Escape room scenarios fit this definition of edutainment because they are fun and engaging and also provide the facilitator with an opportunity to discuss important concepts related to teamwork and communication.
The term escape room, also known as “escape the room,” is thought to be derived from video and computer games from the late 1990s and early 2000s that required players to click on and interact with objects in order to escape a virtual space. The first live-action escape room game, called Real Escape GameTM, was developed in 2007 by SCRAP, a Japanese company based in Kyoto, Japan. The first Real Escape Game in the United States took place in San Francisco in 2012 (SCRAP, 2016). Since then, more than 1,800 escape rooms have opened in the United States (Spira, 2017), many of which have started to offer corporate training focused on teamwork.
The development of simulation centers for health professional training has also rapidly expanded over the past decade, with nursing and medical schools heavily investing in this immersive learning environment. However, even with the advent of high-technology manikins, highly realistic environments, and a desire to train health professionals (and students) together, challenges remain. One of the most recognized challenges in training health professional students together is appropriately leveling the scenario to make it realistic yet manageable for each type of learner. Often, educators immediately jump to critical event team training as the default scenario to teach students about teamwork and communication. However, in many interprofessional education situations, nursing students may not be competent in the basics of cardiopulmonary resuscitation, medical students may not yet been trained to assume a leadership role, and respiratory therapy students may not yet have been educated about how to speak up, and the basic concepts of teamwork, communication, situation monitoring, and mutual support have not yet been comprehended by all participants. These skills, discussed in TeamSTEPPS® training (Agency for Healthcare Research and Quality, 2014), are often thought of as secondary to the clinical and diagnostic skills that must be comprehended by health professional students. However, the Institute of Medicine (IOM) report from 1999, To Err Is Human, reports that approximately 98,000 patients die in U.S. hospitals every year due to preventable medical mistakes, most of which are attributable to poor teamwork and communication (Kohn, Corrigan, & Donaldson, 2000). More recent estimates place medical error as the third leading cause of death in the United States (Makary & Daniel, 2016).
Interprofessional education is defined by the Center for the Advancement of Interprofessional Education (CAIPE) as “Occasions when two or more professions learn with, from, and about each other to improve collaboration and the quality of care” (Barr, 2002, p. 6). However, in health care, educators often find it challenging to teach interprofessional teams of learners. Suggestions for successfully implementing interprofessional education include using multimodal methods of teaching, including classroom problem-based learning and team-based learning activities, role-plays, and simulations (Barr et al., 2017). However, even with expanding numbers of resources and guides, challenges exist to successfully implementing simulation-based interprofessional education programs, especially when implementing programs for prelicensure learners. To overcome these challenges, a novel use of a simulation facility was developed to teach interprofessional education concepts while overcoming many of the common barriers to interprofessional education. The objectives of this work were to develop a novel interprofessional education program using a simulation facility and to pilot using an escape room scenario to teach teamwork and leadership concepts to an interprofessional group of learners.
The theoretical framework underlying the development of escape room scenarios for educational purposes is the interdisciplinary game theory. Game theory was pioneered by John von Neumann, a Princeton mathematician whose early work revolutionized the field of economics (von Neumann & Morgenstern, 1953). Game theory was initially developed with an emphasis on zero-sum games, or games that involved pure conflict in which one person's gain always resulted in another's loss (Dixit & Nalebuff, n.d.). Over the years, game theory has evolved and now includes positive-sum games, where there is mutual gain, or negative sum games, where there is mutual harm, as well as some conflict among participants. In addition, there are cooperative games in which participants are supposed to choose and implement their actions jointly. More recent research focuses on games where players choose their actions separately, but they have links to others involving both elements of competition and cooperation (Dixit & Nalebuff, n.d.).
During games, there is an interdependence of player strategies. Players can make moves either sequentially or simultaneously. When simultaneous moves occur, players act at the same time, ignorant of the others' actions. In sequential moves, players are aware of the others' action (Dixit & Nalebuff, n.d.). In the development of games, sequential-move games require players to look ahead and reason back, trying to figure out how the other player will respond to their action (Dixit & Nalebuff, n.d.). Each player tries to put themselves in the position of the other player as, for example, in chess.
In simultaneous-move games, there is a logical cycle or circle of thinking. The logical circle is the idea that even though players act at the same time and are not aware of each other's actions, they must be aware that there are other players who are similarly aware of their actions (Dixit & Nalebuff, n.d.). Each player must put themselves in the shoes of all the players and try to calculate the outcome. Their own best action is an integral part of the overall calculation (Dixit & Nalebuff, n.d.). The mathematician John Nash theorized a concept of equilibrium that, when applied to game theory, involves each player looking for a set of choices that are best for them while all of the other players are playing their own strategy. Essentially, each player picks their best response in relation to what others do (Dixit & Nalebuff, n.d.).
In the development of escape room scenarios, there are multiple methods for creating the scenario, including open pathways, sequential paths, and linear paths (Nicholson, 2015). Each of these methods has a foundation in game theory, which progresses into how the players interact with the environment. During an escape room scenario, participants must work together to solve the puzzles successfully. However, more often than not, participants are operating simultaneously, unaware of what is taking place around them, as opposed to acting cooperatively. When a leader fails to emerge, and participants fail to communicate effectively with each other, the ability to successfully solve the puzzles is diminished. Numerous other theories underlie how teams develop and communicate, including industrial and organizational psychology theories developed by Salas, Sims, and Burke (2005).
Materials and Method
The purpose of developing the escape room was to pilot an activity—that did not require any previous clinical knowledge—suitable for use with an interprofessional learner group to educate them about teamwork and communication. The pilot groups consisted of a convenience sample of graduate-level nursing students taking classes related to education. A total of 10 individuals participated in the escape room, as this replicates the typical number of individuals that takes part in a commercial escape room at one time. All of the participants were currently employed RNs who worked in a variety of clinical settings, ranging from the operating department to outpatient areas, and who were completing graduate nursing degrees to become adult nurse practitioners, family nurse practitioners, or nurse educators. Although all learners came from the same clinical nursing background, their different specializations as RNs and different courses of study as graduate students should allow for the results of this pilot to be transferred to other groups of interprofessional learners.
As part of their graduate education classes, an introduction to simulation was provided, which included an overview of the simulation equipment, environment, and teaching techniques. To introduce this learner group to teamwork and communication concepts, an escape room scenario using the simulation environment was developed. The course faculty was not involved with the escape room scenario, and the facilitator had no input toward the students' grades for the semester.
This curriculum enhancement was implemented to meet the American Association of Colleges of Nursing's Essentials of Master's Education in Nursing (2011) requirements related to: leadership, interdisciplinary communication, and teamwork. Because the project was defined as a program evaluation, institutional review board approval was not required. The objectives of the escape room scenario were to:
- Identify the importance of teamwork and communication among health care teams.
- Describe the methods through which teams form and how leaders emerge.
- Identify communication barriers that prevent effective teamwork.
To successfully develop an escape room scenario, a previously constructed simulated hospital room was used. A group of learners were introduced to the concept of an escape room in a classroom setting and were advised that they would be given 45 minutes to solve a collection of puzzles to unlock the door and escape the room successfully.
The scenario provided to the learners was that a nurse went into a patient's room to assess them as per protocol. The patient had been admitted to the hospital for lethargy and dehydration. His friends and family had previously booked a trip overseas and wanted him to join them when he gets better. The patient had to be restrained due to him pulling at medical devices. The nurse went to assess the patient and on removing one wrist restraint as per protocol, was struck and knocked unconscious (Figure 1). The learners have 45 minutes to solve the puzzles, unlock the door, and get the nurse to safety.
The initial room setup with a patient in bed and nurse on the ground.
The collection of puzzles included two pathways. The first pathway included the following:
- Finding an outline of syringes on a paper in the garbage and aligning the syringes around the room to the outlines.
- Using the answer to the syringe puzzle to unlock an iPad® located on the bedside table.
- Finding the clues in the iPad to unlock a five-letter combination lock, which reveals a lockbox that contains wrist restraints (and the key to unlock the wrist restraints) (Figures 2–4).
- Unlocking the wrist restraint and finding the password to unlock a computer that contains an electronic health record (Figure 5).
- Unlocking the electronic health record leads to a medication that is administered to the patient. Then, the patient begins to speak and states, “Look past the pain with the light.” Then, the vital signs change.
Examples of locks found around the room.
Examples of locks found around the room.
Examples of locks found around the room.
The password hint states, “Release me and you will see,” leading the learners to unlock the wrist restraint to see the password.
The second pathway included:
- Finding the “get well card” on the bedside table and finding the numbers listed in the card, which unlocks the suitcase located in the room (Figure 6). The suitcase is locked with a three-digit combination lock. The suitcase has pictures of Rio de Janeiro, Brazil; Paris, France; London, England; and Sydney, Australia on it (Figure 7). The card states: “We hope you get better soon and can join us on our trip. If you get cleared to go, we packed a bag for you. Come join us! We are going to Rio for 1 week, Paris and London for 4 days each, and then Sydney for 3 weeks. Get well soon!”
- Reading the patient meal menu on the bedside table and finding the circled letters, which unlocks a cabinet in the room (Figures 8–9). The cabinet contains a patient belonging bag, which contains the patient's pants and shirt. In the patient's pants are a set of keys.
- Using the keys from the patient's pants to unlock a locked box, which was inside the suitcase.
- Once the box is unlocked, the participants find a black light. The black light is the “light” referred to by the patient. The learners must use the black light to look at the patient communication board in the room. At the end of the pain scale is a formula, HR + SpO2 + SBP = (Figures 10–11).
- The learners complete the formula and enter the answer into a computer, which advises them if they have unlocked the door or not (Figures 12–13).
A card on the bedside table, related to the suitcase.
The suitcase with images on it.
The menu on the bedside table, with letters circled, unlocked the cabinet lock.
A simulated communication board with invisible ink on it. Using a blacklight found in a locked box, participants “looked past the pain with the light.” A formula was written after the number 10 on the pain scale.
Using the blacklight revealed the formula.
The participants had to enter a combination into the computer to unlock the door.
The screen that appears when participants successfully escaped the room.
Following the activity, participants were debriefed to call attention to specific instances of team dynamics, team cohesion, team forming, leadership development, and communication tactics that enabled them to be successful or hindered their completion of the tasks. Throughout the scenario, there was a lot of confusion among the team, as communication was not funneled through a single leader and there were many groups working independently from one another with a lack of situational awareness and a lack of mutual support. These observations were made by the faculty observer, as well as described by the participants during the guided debriefing. However, at times, a single leader did emerge to try to organize the group, communication callouts occurred that allowed the team to solve a puzzle, and the team celebrated accomplishments when they unlocked a puzzle. These TeamSTEPPS (Agency for Healthcare Research and Quality, 2014) moments were discussed during the debriefing, and the team related these challenges and successes to the clinical scenarios they had witnessed.
Results and Discussion
On conclusion of the session, participants completed a survey to identify whether the objectives were met. A 4-point Likert scale questionnaire developed for the assessment of this program was used to assess whether the escape room allowed the participants to work as a team, required the participants to communicate effectively, and professional health care providers (nurses, physicians, respiratory therapists, etc.) would benefit from attending an escape room event. On the 4-point scale, responses averaged 3.7 to each of the above questions. Open-ended responses to the question “What is one thing you learned from participating?” focused on the importance of teamwork and communication to successfully complete challenging events and the importance of organization in team dynamics.
In addition, the simulation facility that had been constructed for health professionals training sat unused for a portion of the week due to scheduling conflicts and resource constraints. Use of a previously constructed simulation environment allows educators to minimize the cost to the organization, more fully use their built space, and teach teamwork and communication concepts in a unique and exciting way. The target audience for future implementations of this program would be health professional students from interprofessional backgrounds or interdisciplinary teams of health professionals requiring education on teamwork, communication, and leadership.
Escape room-type educational environments provide an opportunity for interprofessional teams of health care providers to learn about teamwork and communication principles in a safe learning space. Using nonclinical experiences creates a level playing field for health professional students and licensed clinicians. This allows for health professional students from varied backgrounds to learn together without having to worry about their clinical understanding or previous clinical education. For licensed health care providers, using a nonclinical case allows for a flattening of the hierarchy that may consciously or unconsciously exist due to educational backgrounds or clinical roles. Edutainment not only provides for a sense of team building and comradery through the entertainment component of the program, but it also allows for teams to gain a deeper understanding of what it takes to function at the highest level and be successful utilizing important concepts from TeamSTEPPS (Agency for Healthcare Research and Quality, 2014).
The participants in this program identified that they felt that the escape room allowed them to function as a team and required them to communicate effectively. Simulation users know that by creating a critical event scenario they can force participants to use these same concepts. However, critical events add an element of stress to the situation and often, if teams do not perform well, will leave participants feeling defeated. This, in turn, may lead to participants questioning their ability to treat patients in the clinical setting. Although the goal is for them to be debriefed effectively so they can quickly and accurately call on their simulation experience to employ either similar thoughts and actions (if successful) or different thoughts and actions (if unsuccessful), the escape room does not introduce the same stressors that a clinical event may introduce. Instead, it provides an opportunity to learn the importance of teamwork and communication in a fun environment. The participants in the program all stated that they could see value in having colleagues from their hospitals participate in an escape room event if held as part of an interprofessional education program.
Materials for creating an escape room, such as locks, cable ties, and associated items, can be purchased through online retailers or local vendors. The scenario can be recreated using the information contained in this article—or a new scenario developed in collaboration with a local interprofessional faculty group can be designed.
Future research can compare the effectiveness of an escape room edutainment scenario and a clinical scenario on students' abilities to learn and use TeamSTEPPS-related concepts. Determining whether clinical scenarios are the best way to introduce nonclinical skills is an area for investigation that needs further study. In addition, assessing stress levels during clinical scenarios and nonclinical scenarios, such as the escape room, is also an area for future research. Previous studies have shown that limited amounts of stress can aid in the learning process; however, clinical simulations—with their increasing fidelity—may cause too much stress for novice learners who are trying to understand the concepts of team formation and group dynamics. Designing a randomized controlled trial to assess student anxiety before an escape room scenario versus a clinical simulation scenario would provide interesting insights into whether simulation increases anxiety alone or if anxiety is increased because of the clinical component of the simulation.
Escape room scenarios are becoming increasingly common for entertainment purposes. Their use as an educational tool is also increasing to demonstrate the importance of teamwork and communication among newly formed teams. To successfully produce an escape room scenario, significant planning needs to occur by the faculty member. A scenario or backstory, puzzles, and pathways need to be created and tested to ensure that they link together correctly and are able to be completed by participants. Ensuring there is logic and linkages between each puzzle clue and participant action is critical to successfully creating an escape room scenario.
Escape room scenarios can be built in already established simulation centers without significant added costs. Developing an escape room scenario is a feasible way of teaching health professional learners the importance of teamwork and communication in a nonclinical setting, thereby allowing learners from multiple disciplines to learn with, from, and about each other without having to integrate their clinical knowledge, which could detract from their ability to learn and comprehend the teamwork and communication concepts.
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