Journal of Nursing Education

Educational Innovations 

Escape Tasks: An Innovative Approach in Nursing Education

Brandy Haley, PhD, RN; Jamie Palmer, MSN, RN

Abstract

Background:

Innovative teaching strategies that incorporate active learning could be beneficial to the nursing student's performance not only in the classroom but also in the clinical setting. The article provides implementation steps for integrating escape room tasks into a baccalaureate nursing program.

Method:

Thirteen escape room tasks were developed by faculty and a dean to facilitate Quality and Safety Education for Nurses (QSEN) competencies. The tasks challenged seven senior students to think critically outside of the normal classroom and clinical setting.

Results:

Students reported the tasks empowered them to think critically, collaborate, and ultimately enhanced their knowledge. They enjoyed the group work and hands-on challenges.

Conclusion:

Escape room tasks can be active learning teaching strategies that facilitate learning QSEN competencies. Nurse educators can easily implement the 13 escape room tasks outlined in this article. The positive outcome of this activity revealed future opportunities for nurse educators to design easy escape room tasks centered around curriculum learning objectives. [J Nurs Educ. 2020;59(11):655–657.]

Abstract

Background:

Innovative teaching strategies that incorporate active learning could be beneficial to the nursing student's performance not only in the classroom but also in the clinical setting. The article provides implementation steps for integrating escape room tasks into a baccalaureate nursing program.

Method:

Thirteen escape room tasks were developed by faculty and a dean to facilitate Quality and Safety Education for Nurses (QSEN) competencies. The tasks challenged seven senior students to think critically outside of the normal classroom and clinical setting.

Results:

Students reported the tasks empowered them to think critically, collaborate, and ultimately enhanced their knowledge. They enjoyed the group work and hands-on challenges.

Conclusion:

Escape room tasks can be active learning teaching strategies that facilitate learning QSEN competencies. Nurse educators can easily implement the 13 escape room tasks outlined in this article. The positive outcome of this activity revealed future opportunities for nurse educators to design easy escape room tasks centered around curriculum learning objectives. [J Nurs Educ. 2020;59(11):655–657.]

Active learning has been shown to correspond with increased student performance (Freeman et al., 2014). Innovative teaching strategies that incorporate active learning could be beneficial to the nursing student's performance not only in the classroom, but also in the clinical setting. Nursing faculty should incorporate innovative teaching strategies in order to meet the diverse learning needs of nursing students. Nursing lectures are becoming outdated and are being used less often. Research shows that student-driven nursing education promotes retention far better than lecturing (Rao, 2019). Nursing faculty can use several educational strategies, including simulation, games, case studies, and mind maps. Another innovative teaching approach is to incorporate escape rooms as an alternative teaching strategy.

Escape rooms are a fun and exciting way to have nursing students work together to find clues and figure out puzzles to escape the room before time runs out (Miller, 2015). There are several ways to design an escape room to make it inviting and educational for nursing students. The escape room can include single or multiple rooms and be as elaborate as needed for the content being presented. Escape rooms are becoming more commonplace within the education realm; however, research is limited on their use and benefits in nursing education.

One benefit of using escape rooms in nursing education is the fostering of critical thinking skills, teamwork, and leadership, which helps with the application of nursing subject knowledge to clinical practice (Gomez-Urquiza et al., 2019). It is an expectation that nursing students make decisions and solve problems through the application of critical thinking and knowledge integration in the provision of patient-centered care (de Costa Carbogim et al., 2019). Nursing students can then apply that knowledge while providing direct patient-centered care.

Another benefit of using escape rooms in nursing education is the promotion of nursing collaboration, knowledge, prioritization, and effective communication skills. For example, researchers created an innovative teaching strategy using an escape room with junior nursing students enrolled in a maternal clinical course (Edwards et al., 2019). Nursing students in this activity reported via a 5-point Likert scale that the escape room was a positive experience and knowledge was gained. Faculty reported that the escape room promoted collaboration, prioritization, and communication skills among students. One mixed-methods study with 33 baccalaureate degree nursing students used locked boxes instead of locked rooms as an escape room activity (Brown et al., 2019). Findings showed that both students and faculty thought the escape room was an engaging teaching strategy. Other researchers created five escape rooms with different scenarios as an innovative recruitment strategy for high school students and prenursing majors (Connelly et al., 2018). In this study, students reported the escape room activity increased their confidence, increased excitement about entering nursing, and introduced them to critical thinking skills. Students also reported that they would recommend this recruitment activity to their friends.

Most escape rooms can be created with minimal cost and can be replicated or changed with minor modifications (Connelly et al., 2018). More research is needed in using escape rooms for nursing education and to determine whether escape rooms make a difference in the learning outcomes for nursing students.

Escape Room Creation and Implementation

Occasionally, nursing program clinical sites and availability can have diminished learning and opportunities for students (Bouchaud & Swan, 2016). As a backup plan for such instances, faculty from a rural university wanted to create escape room activities as an alternate clinical assignment. In this university's nursing program, the average size clinical group for the senior-level baccalaureate course is six to seven students. The overall goal of designing the escape room tasks was to help students meet clinical learning objectives that focused on formulating nursing judgements using a problem-solving process that is goal directed, ethical, and based on standards of professional nursing practice to provide safe and effective care.

The dean and faculty designed the escape room tasks around classroom content currently being taught in the medical–surgical course (renal diseases). Objectives included a focus on Quality and Safety Education for Nurses (QSEN) competencies (QSEN, 2020) and nursing code of ethics (American Nurses Association [ANA], 2015). One faculty explained and provided written copies of objectives to students prior to each escape room activities. The objectives were: (a) identify the six focus-area QSEN competencies (ANA, 2015); (b) calculate one-, two-, and three-factor medication problems based on the weight of the patient and time required for safe administration (calculation problems were retrieved from the drug calculation textbook used by the nursing program); (c) demonstrate American Heart Association basic life support guidelines for cardiopulmonary resuscitation (CPR) on an adult and infant manikin (American Heart Association, 2016); (d) create a concept map and complete two case studies on an assigned renal disease; (e) explain the use of different intravenous solutions; and (f) identify all the nursing code of ethics (ANA, 2015) from a video (Education Portal, 2014).

Early in the fall semester, the opportunity arose for one clinical group (N = 7) to participate in the escape room learning activity. Prior to the seven students coming to campus, several faculty members set up 13 different escape room tasks according to the student learning objectives (SLOs). Supplies used were already available from the nursing program. These supplies included small Post-it® notes, adult and infant CPR manikins, printed math problems and case studies, four printed blank posters for concept maps, dry erase markers, laptops with speakers, a projector, and several different bags of intravenous solutions (retrieved from the nursing simulation laboratory). There were no added expenses to the nursing program to conduct these escape room tasks.

When the seven students arrived at campus, they were verbally informed about the escape room learning goal and tasks by one faculty. That faculty gave students the written SLOs and allowed students time to ask questions. There was no time limit given per task given that this was the first experience using an escape room. Electronic resources and textbooks were permitted to help students as needed. Each task was in a different room, all in the same building. The faculty gave typed instructions to students in a folder, which was located at each task station. Students were told they had three “helps.” A “help” is considered a clue to move progression along through tasks. The 13 different tasks, along with the SLOs and QSEN competencies, are listed in Table A (available in the online version of this article).

Escape Room Task DescriptionEscape Room Task DescriptionEscape Room Task DescriptionEscape Room Task DescriptionEscape Room Task DescriptionEscape Room Task Description

Table A:

Escape Room Task Description

Because this was a planned learning activity, no institutional review board approval was needed. The escape room experience began at 8:30 a.m. Students were given verbal instruction by a faculty on escape room tasks, room locations, and task written instructions during a prebriefing period. During the experience, one faculty member facilitated, observed student participation and reactions, and remained with the students at each task location. During task two, noises were played to simulate clinical practice distractions that might occur (e.g., music, moaning, call lights going off, traffic, telephones ringing). A 60-minute lunch break was given after completing task five. Students completed the final task at 3:45 p.m. The longest task completion time was task two (1 hour and 6 minutes) followed by task six (1 hour and 3 minutes). The shortest completion time was task seven (4 minutes) followed by task one (6 minutes).

After completion of all escape room tasks, students were debriefed by the faculty member who facilitated the experience. Students were informally asked by faculty what they thought about the experience. Several students reported loving this hands-on group style learning and believed that the experience taught them more about renal disease processes, QSEN, and the Nursing Code of Ethics. A formal evaluation was conducted at the end of the medical–surgical course. All qualitative feedback from students was positive with some students writing “I really liked the CPR part,” “We had to critically think and rely on each other,” “It challenged us,” and “This was so beneficial to my learning.”

Conclusion

Active learning strategies using escape rooms activities are new to nursing education. The design of escape rooms can vary from one locked room requiring task completion to “get out” or include multiple tasks and tabletop activities in various rooms. Most escape rooms can be created with minimal cost (Connelly et al., 2018) and replicated or changed with minor modifications. More research is needed in using escape rooms for nursing education and to determine whether escape rooms make a difference in the learning outcomes for nursing students. The rising popularity is still in early development; however, what little research that has been done shows a positive impact on learning (López-Pernas et al., 2019). Escape rooms are one way to engage students in active learning through solving mysteries and entertainment (Hermanns et al., 2018).

Using an escape room presents an exciting way to engage nursing students in specific content material, which can support further development of content knowledge (Eukel et al., 2017). Student feedback from this planned learning activity supports the findings in the published literature, which show positive perceptions from escape room tasks (Eukel et al., 2017; Hermanns et al., 2018). Research regarding nursing educational benefits of this type of escape room activity is lacking.

References

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Escape Room Task Description

Task and InstructionsTask Details and Supplies UsedStudent Learning ObjectivesQuality and Safety Education for Nurses
Task One: Puzzle Instructions: “Unscramble the letters to answer: ‘What does QSEN stand for?’” Completed: Entire groupAnswer: Quality and Safety Education for Nurses (QSEN). Supplies: Letters written on individual Post-it® notes. Some letters were circled for future task puzzle; other letters were given as distractors.Identify the six focus-area QSEN competencies (American Nurses Association [ANA], 2015).
Task Two: Safe dosage calculations Instructions: “Work alone to answer five drug problems. You must answer each problem correctly before the entire group can move to the next task. Once you have answered all problems correctly, you may help a peer.” Completed: IndividuallyAnswer: One faculty member proctored the task and graded each student's answers. If the student did not answer all questions correctly, the faculty noted which problems were incorrect and allowed the student reattempts until the correct answer was obtained. Supplies: Five different drug problems issued to each student. Distractors included loud noises to simulate an active nurse's station (e.g., call lights, phone ringing, conversations)Identify the six focus-area QSEN competencies (ANA, 2015). Calculate one-, two-, and three-factor medication problems based on the weight of the patient and time required for safe administration.
Task Three: QSEN identification Instructions: “Watch the QSEN video The Lewis Blackman Story (QSEN, 2020), and identify QSEN competencies that were violated.” Completed: Entire groupAnswer: Errors made by the healthcare team explained in the video. Supplies: Laptop, projector, QSEN video, whiteboard and dry erase markers.Identify the six focus-area QSEN competencies (ANA, 2015).
Task Four: Team health care provider adult cardiopulmonary resuscitation (CPR) Instructions: “Work in two groups. Make the following assignments in the group: Documenter, automated external defibrillator (AED), and compression/airway” Completed: Two groups (divided)Answer: American Heart Association (AHA) guidelines. Supplies: Two adult CPR manikins, two AED trainers, and two Ambu® bags. Time to complete: Each group had to perform correct CPR for 20 minutes.Identify the six focus-area QSEN competencies (ANA, 2015). Demonstrate AHA basic life support guidelines for CPR on an adult and infant manikin (AHA, 2016).
Task Five: Evidence -based practice over QSEN practice Instructions: “Go the computer laboratory and find a research article regarding safety issues. The research article must meet the following criteria:

Published in last 5 years

Nurse author

Write the citation of the article down in APA format and bring to the faculty. Completed: Individually
Answer: Individual articles that relate to safety. Supplies: Computer with internet access to retrieve articles.Identify the six focus-area QSEN competencies (ANA, 2015).
Task Six: Concept mapping Instructions: “Create a concept map based on your assigned case. You may use your textbook. When everyone is finished, you will explain your concept map to the group.” Completed: Students worked in pairsAnswer: According to assigned disease on concept map. Supplies: Three predesigned concept maps taped to the wall (laminated posters), and dry erase markers.Identify the six focus-area QSEN competencies (ANA, 2015). Create a concept map and complete two case studies on an assigned renal disease.
Task Seven: QSEN competencies Instructions: “Unscramble the letters to answer: ‘What are the QSEN competencies?’” Completed: Entire groupAnswer: Patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Supplies: Letters written on individual Post-it notes. Some letters were circled for future task puzzle; other letters were given as distractors.Identify the six focus-area QSEN competencies (ANA, 2015).
Task Eight: Analysis of intravenous (IV) solutions Instructions: “Go to the nursing laboratory and find the IV solutions. Bring back every type of solution. Select a peer to explain the different types of solutions.” Completed: Entire GroupAnswer: All forms of IV solutions (e.g., isotonic, hypertonic, and hypotonic). Supplies: All forms of simulated IV solution bags.Identify the six focus-area QSEN competencies (ANA, 2015). Create a concept map and complete two case studies on an assigned renal disease. Explain the use of different IV solutions.
Task Nine: Team health care provider infant CPR Instructions: “Work in two groups. Make the following assignments in the group: Documenter, AED, and compression/airway.” Completed: Two groups (divided)Answer: AHA guidelines. Supplies: Two infant CPR manikins, two AED trainers, and two Ambu bags. Time to complete: Each group had to perform correct CPR for 20 minutes.Identify the six focus-area QSEN competencies (ANA, 2015). Demonstrate American Heart Association (AHA) basic life support guidelines for cardiopulmonary resuscitation (CPR) on an adult and infant manikin (AHA, 2016).
Task Ten: Nursing ethics Instructions: “Watch the video Nurses Making Ethical Choices (Education Portal, 2014). Identify all the Code of Ethics on a sheet of paper.” Completed: Entire groupAnswer: ANA (2015) Code of Ethics. Supplies: Laptop, projector, video, whiteboard, dry erase markers.Identify the six focus-area QSEN competencies (ANA, 2015). Identify all the Nursing Code of Ethics (ANA, 2015)
Task Eleven: Renal system focused knowledge Instructions: “Unscramble the letters to answer: ‘As renal function declines, this happens in the blood?’” Completed: Entire groupAnswer: Accumulation of protein metabolism end products. Supplies: Letters written on individual Post-it notes. Some letters were circled for future task puzzle; other letters were given as distractors.Identify the six focus-area QSEN competencies (ANA, 2015). Create a concept map and complete two case studies on an assigned renal disease.
Task Twelve: NCLEX-style questions and case study Instructions: Answer the NCLEX questions and case study. You must score a 100% on both the NCLEX questions and the case study to move to the next task.” Completed: Entire groupAnswer: Specific to NCLEX-style question and case study selected. Supplies: 25 NCLEX-RN questions and one case study.Identify the six focus-area QSEN competencies (ANA, 2015). Create a concept map and complete two case studies on an assigned renal disease.
Task Thirteen: Renal system focused knowledge Instructions: “Use the circled letters from previous puzzles. Unscramble the letters to come up with the answer to the following question, ‘What three things (not diseases) can contribute to the pathophysiology of chronic renal disease?’” Completed: Entire groupAnswer: Proteinuria, hypoxia, and extensive angiotensin II productions. Supplies: The answer came from previous puzzle letters that were circled.Identify the six focus-area QSEN competencies (ANA, 2015). Create a concept map and complete two case studies on an assigned renal disease.
Authors

Dr. Haley is Dean and Associate Professor of Nursing, and Ms. Palmer is Assistant Professor of Nursing, University of Arkansas at Monticello, Monticello, Arkansas.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Brandy Haley, PhD, RN, Dean and Associate Professor of Nursing, University of Arkansas at Monticello, PO Box 3606, Monticello, AR 71656; email: haley@uamont.edu.

Received: February 06, 2020
Accepted: June 08, 2020

10.3928/01484834-20201020-11

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