Low-fidelity skills laboratory experiences provide learning opportunities for nursing students that increase clinical competency (Hayden et al., 2014). There is a gap in the literature related to immersive learning activities or gamification to evaluate student learning outcomes and competencies through staged nursing practice scenarios within the skills laboratory (Humphrey, 2017). Gamification is defined by Wiggins (2016) as game-based learning that may include teams, rewards such as trophies, and competition as a means of engaging the learners; however, the primary goal is to promote immersive learning (Ambrosio Mawhirter & Ford Garofalo, 2016; Wiggins, 2016).
An immersive learning skills laboratory activity, such as an escape room–themed relay race, is also considered a formative evaluation method that can provide students and teachers with immediate feedback related to obstetric clinical skills and can identify areas where more clinical practice may be needed (Oermann & Gaberson, 2020). Therefore, an immersive obstetrics skills laboratory was designed to evaluate five learning needs. This article describes the instructional process of creating this innovative formative assessment within an obstetric skills laboratory and proposes recommendations for future research.
Research exploring the use of immersive learning, such as an escape room relay race, as an evaluation method is limited. Roman et al. (2019) incorporated escape room elements within an objective structured clinical examination summative evaluation. It was reported that the escape room complemented the way in which students were evaluated, but most importantly, students reported how indispensable communication within their teams was to future success as nurses.
There were no articles related to relay races in nursing education; however, Simarmata and Indriani (2016) used classroom action research to implement an immersive learning activity—a relay race—to teach English to elementary students. The authors found that gaming complemented didactic instruction for their students. Likewise, computer science professors have used immersive game-based learning formats, such as escape rooms, to facilitate motivation and learning with computer science students (Borrego et al., 2017). Eukel et al. (2017) used educational gaming to complement didactic instruction for pharmacy students. They found that immersive educational gaming had benefits beyond novelty. Strickland and Kaylor (2016) proposed that experiential learning associated with gaming is both a theoretical framework and a teaching methodology.
Immersive Gaming for Education and Training
Companies have used games and simulations to provide employees with a fun, immersive way to have on-the-job training (Weinstein, 2016). Gaming has also been used as a recruitment tool for high school and college students interested in nursing (Connelly et al., 2018). Games, simulation, and escape room concepts have also been used in higher education to teach topics such as mathematics (Naik, 2017; Wiggins, 2016). Although Wiggins (2016) and Naik (2017) did not use relay races, they defined gamification as simply using immersive game-design elements in nongame contexts, which is consistent with the purpose and intent of this project.
Immersive Gaming as a Teaching Strategy in Nursing Education
Adams et al. (2018) used game-based simulation to target unexpected experiences that a nurse resident or experienced nurse might face at the bedside, such as critical laboratory reporting and catheter-associated urinary tract infections (Adams et al., 2018). Ambrosio Mawhirter and Ford Garofalo (2016) designed patient safety games that incorporated a period of reflection. Interestingly, students found that self-reflection of their learning needs was beneficial to the learning process, as well as evaluating the teams' effectiveness. Hermanns et al. (2018) used nondigital, game-based learning, or an escape room, in an undergraduate nursing pharmacology course to help students to learn about cardiovascular medications. Simulation experiences with escape room elements are considered an innovative learner–centered teaching strategy (Brown et al., 2019). Robertiello et al. (2019) found that an escape room was effective in encouraging teamwork during a prebriefing orientation to the simulation. Likewise, Kutzin (2019) used an escape room in a nonclinical setting as an orientation to the simulation laboratory and as an introduction to teamwork and collaboration among interprofessional graduate students. Gómez-Urquiza et al. (2019) used an escape room as a nonclinical activity to motivate students to prepare for examination success. Edwards et al. (2019) described that using escape room activities during an obstetrical simulation laboratory provides educators with opportunities to incorporate experiences that may be difficult to obtain at clinical sites, as well as creating a space that promotes teamwork and collaboration among students. In contrast, it was reported by Roman et al. (2019) that an escape room can also be used by educators as an evaluation method.
Faculty identified five learning needs including sterile gloving, sterile field, interpretation of fetal monitoring strips, cervical examinations, and postpartum medication side effects and administration. A teaching plan was created that incorporated two gaming teaching strategies, a relay race and an escape room (Table 1). Rouse's (2017) steps for creating a Breakout EDU escape room were implemented. Because we had experience in creating and implementing a Breakout EDU escape room scenario, the scenario was relatively easy to create (Brown et al., 2019). Working in smaller groups of three to four students was a strategy used in the skills laboratory to advance individual performance. Each team received a prebriefing session, which included a guided tour of the stations. Students were then given an opportunity to collaboratively select a team leader and to identify areas of strengths from within the team members. This allowed members to choose, based on their individual strengths, which station they would complete during the race. To begin the simulation skills laboratory, the team leader was given an Olympic-style torch, made of colors to simulate fire, which he/she would pass to the next team member upon accurately completing the skill. Each member of the team was required to demonstrate sterile gloving technique before moving to one of the four remaining stations. The first relay station was created to provide an opportunity to interpret various fetal monitoring strips and implement appropriate nursing interventions. At station two, students performed three sterile cervical examaniations and analyzed the findings in congruence with the client's stage of labor. Students at station three demonstrated the setup of a bedside sterile vaginal delivery table without contamination. Finally, at station four, the students had to accurately administer postpartum medications and communicate the appropriate purpose and side effects with the client (Figure 1).
Teaching Plan: Learning Needs, Outcomes, Roles, and Materials
Escape room and skills laboratory layout.
Students were allotted a total of 60 minutes to complete all the stations. A Breakout EDU box with a preset three-number lock was used as a gaming tool, which would require accurate demonstration of clinical skills to open. A countdown clock was projected on a screen to account for the time it took each team to complete the activity. The teams were charged with performing skills within preset stations, as well as answering three NCLEX®-style questions that were strategically placed throughout different stations. When each of the questions were answered correctly, a piece of the preset numerical lock code was given to the student. Students were able to share information verbally throughout the simulation, and specific communication had to occur to open the locked box, which ended the relay simulation. The timer was stopped when the team successfully opened the locked box and all team completion times were recorded on a whiteboard for other teams to see as they progressed through the laboratory. The team with the most amount of time left at the end of the relay received Olympic-style gold medal status. Viewing other teams' times on the whiteboard contributed to the overall sense of competition. Because this escape room relay represented a competition, the notion of sharing information among other clinical groups at the completion of the simulation skills laboratory was decreased as the nine teams competed against one another for obtaining either gold, silver, or bronze medals.
After the locked box was opened and the team time was recorded, each facilitator had team members randomly select two cards from a deck of Breakout EDU reflection cards (Breakout EDU, n.d.). The open-ended questions on the Breakout EDU cards provided opportunities for the team members to think about the experience, share personal thoughts on knowledge gained from the experience, and reflect on team collaboration. Facilitators guided the debriefing discussion. These debriefing sessions allowed for feedback related to learning needs and promoted dialogue between faculty and clinical instructors (Jeffries, 2012). A postskills laboratory celebration consisted of an Olympic-style torch procession to a prominent ceremony site on campus, as well as a presentation of medals to the winning groups.
“Go for the gold” was a phrase that described the adaptability and creativity exemplified with the creation and implementation of this formative assessment. Clinical instructors modeled spontaneity and adaptability when a manikin malfunctioned, and the clinical instructor volunteered to be a live patient. Also, faculty reflected on the need to ensure students have access to and experience using resources that could be used to solve problems, such as questions related to pharmacology and preferred route for medication administration. As facilitators, we not only functioned as educators, but also assumed the role of learning coaches, offering frequent feedback, which is key to formative evaluation. With the use of red light/green light tools, we were able to motivate students to continue to pursue the correct path or deter away from the wrong path. Not only was the escape room relay race an effective teaching strategy, but it also was a motivational formative evaluation method.
The theme of adaptability was also evident using a timer during the relay. The timer was beneficial to the facilitators because it allowed us to see how one group was performing in comparison to other groups, how much time was left to complete the skills laboratory experience, and as a motivational tool to encourage students to increase their efforts to complete the task at hand. Constant communication between students was essential to effectively solve problems and perform skills associated with each station. As with all escape room activities and relay races, teamwork was the key to successfully completing the skills laboratory.
Although a primary focus of the skills laboratory was achievement of learning outcomes and improving competencies identified through a learning needs assessment, the competitive aspects of the escape room elements and the relay race were perceived as exciting and motivating by the educators and students. Anecdotal comments from students were very positive. Faculty felt that these activities could transform a bland skills laboratory into an engaging, immersive learning experience.
When games are used in nursing education, there are specific advantages, including an increase in cognitive and affective learning, a sense of excitement, the ability to bridge practice experiences to theory, and motivation for nursing students to assume more responsibility for their own learning (Billings & Halstead, 2014). We concur with Shahsavari et al. (2017) regarding the fact that clinical skills refresher courses and formative assessments can be beneficial at various levels. This formative assessment activity revealed a high level of communication among the teams that were most successful in completing skills and “escaping” the simulation in a timely fashion. The incorporation of immersive learning experiences in the simulation skills laboratory successfully integrated all types of learning styles, provided opportunities for problem-based learning, and enhanced critical thinking and teamwork. Most importantly, this formative evaluation method provided students with immediate feedback related to their obstetric clinical skills and identified areas where more clinical practice was needed in an exciting, nonthreatening learning environment.
Future research is needed related to game-based learning activities as evaluation methods in nursing skills laboratories, as well as simulation laboratories. The goal for the skills laboratory was to simulate real nursing problems that allow students to practice problem-based decision making centered around real-life situations (Rogers, 2011). Future research should include measuring the relationship between gaming, problem-based learning, and knowledge retention.
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Teaching Plan: Learning Needs, Outcomes, Roles, and Materials
|Learning Need and Station||Student Learning Outcomes||Facilitator Role||Teaching Materials|
|1. Sterile gloving technique: Warm-up station.
Each leaner must complete the warm-up skill before moving to their assigned station. The 60- minute timer starts when learner 1 begins the warm-up exercise.||Apply gloves without breaking sterile technique.||Clue 1: “One for all and all four (4) one”
The number 4 was the first number to the Breakout EDU box.
Facilitator used red light/green light method. Red light for incorrect and green for correct.
Students must get a green light to proceed in relay.||Breakout EDU three-digit lock box.
Timer: Online countdown timer used.
Skills laboratory set up:
Two female patients in hospital beds
TelephoneHint card placed at the warm-up table.
|2. Fetal monitoring strips Evaluation: Station #1.
Learner 1 successfully completes station #1 and passes the torch/baton to learner 2, who will go to station #2.||Analyze fetal monitor strip.
Evaluate need for intervention.
Perform appropriate interventions.
Correctly answer one of four NCLEX questions.||There is no clue.
Red light/green light cue.
According to the given fetal monitor strip, what is the correct intervention? Select all that apply.||Supplies needed for all skills and interventions are located on supply cart.
Students were instructed to identify and perform any interventions essential to patient safety.
Choice of four prepared electronic fetal monitor strips.|
|3. Cervical examinations: Station #2.
Learner 2 successfully completes station #2 and passes the torch/baton to learner 3, who will go to station #3.||Identify the correct cervical dilatation for three different models. (*Must label correctly from 0 to 10 dilatation card choices.)
Correctly answer an NCLEX question.||Which cervical examination correlates with transitional labor? Answer to question place here.
Clue 2: Clue card with number given to students by the facilitator.||Three cervical models are in random order and can be changed up between groups as needed.|
|4. Maintaining a sterile field: Station #3.
Learner 3 successfully completes station #3 and passes the torch/baton to learner 4, who will go to station #4.||Demonstrate sterile surgical table set up.
Add Hibiclens® to bowl.
Wear correct attire (sterile gloves, hat, and mask).
|There is no clue. Red light/green light cue.||Sterile field diagram. Table with equipment necessary to set up a sterile field for imminent birth.|
|5. Medication administration: Station #4.
Learner 4 successfully completes station #4. The group must then open the Breakout EDU lock box using the three numbers provided during the skills laboratory. The timer stops when the lock box is opened.||Administer one correct postpartum medication according to physician order.||Facilitator will be the voice of the patient and ask the following questions: Why am I getting this medication? Are there any side effects?||Written physician order for medication along with medication ordered.
Medications were randomly alternated between groups.