Nurse educators are continually challenged to engage students in learning. Deep, meaningful learning must include advancing from knowledge acquisition to clinical reasoning and application of evidence-based care (Getha-Eby, Beery, Xu, & O'Brien, 2014; Johnsen, Fossum, Vivekananda-Schmidt, Fruhling, & Slettebø, 2018). Generation Z college students often prefer individualized, immediate, exciting, self-directed, immersive learning experiences (Chicca & Shellenbarger, 2018). Faculty are encouraged to overcome the dissonance between traditional teaching methodologies and generational learning needs through active learning, concept mapping, simulations, reflective learning, flipped classrooms, and educational gaming (Brown, 2018; Chicca & Shellenbarger, 2018; Getha-Eby et al., 2014; Shatto et al., 2019).
Educational gaming boosts student engagement and increases student knowledge (Cain, 2019; Clarke et al., 2017; Eukel, Frenzel, & Cernusca, 2017; Friedrich, Teaford, Taubenheim, Boland, & Sick, 2018; Morrell & Ball, 2019). Educational escape rooms are a form of live action, serious gaming in which teams of players use content knowledge to complete tasks and puzzles to escape a room or solve a final puzzle (Nicholson, 2015). They have been designed and evaluated to teach complex educational content such as diabetes mellitus, interprofessional communication and teamwork, pharmacy management, and vascular surgery (Cain, 2019; Clarke et al., 2017; Eukel et al., 2017; Friedrich et al., 2018; Kinio, Dufresne, Brandys, & Jetty, 2017). Specifically, previous studies in pharmacy and interprofessional health education demonstrate that educational escape rooms are positively received by students, increase knowledge, and serve as a platform for active application of teamwork and team-based communication (Cain, 2019; Clarke et al., 2017; Eukel et al., 2017; Friedrich et al., 2018).
In undergraduate nursing education, cardiovascular critical care content is some of the most complex to master. To engage students in the learning process, enhance content application, and better connect knowledge to practice, faculty designed and evaluated a cardiovascular-themed escape room. The purpose of this pilot study is to evaluate the impact of a cardiovascular escape room on student knowledge, as well as to understand student perceptions of the educational innovation. Furthermore, students' reflections on the innovation's influence on learning and future practice were explored.
Educational Innovation Methods
The escape room was implemented in a second-semester, face-to-face, 15-week, junior-level undergraduate didactic nursing course. Prior to the escape room, students learned the cardiovascular content through 14 hours of traditional lecture, flipped classroom, and simulation techniques, provided over 4 weeks. One week prior to the examination on this content, all students enrolled in the course participated in the cardiovascular escape room as a required course component. The escape room was delivered in a traditional classroom to student teams facilitated by one faculty member. Randomly assigned teams of three to four students worked in separate groups to solve sequential puzzles to save a fictional patient. Of the 31 students enrolled in the class, all participated in the escape room, and 29 (93.5%) participated in the research study.
Teams had 60 minutes to complete nine sequential puzzles, designed to review and apply content-specific learning objectives through various tasks (Table 1). Tasks included the use of relevant props, such as pictures, locks, boxes, and black lights, which directed teams to the next puzzle. Student teams were allowed the use of four hints, including medical references and calling on an expert (the faculty proctor). The final task opened a lock box, allowing students to stop time before receiving a telephone call that a fictional character had advancement of cardiogenic shock. A faculty member (B.L.M.M.) proctored the event.
Cardiovascular Escape Room Content and Structure
The study is a nonexperimental mixed-methods pilot study using concurrent triangulation. A pre- and post-knowledge assessment was administered electronically immediately before and after the escape room. Responses to the pre- and postknowledge assessment were matched with unique identifiers. In the preknowledge assessment, students completed 10 questions related to the content covered in the course. Of these items, one was at the knowledge level, five were comprehension, three were application, and two were analysis on Bloom's taxonomy, building a meaningful assessment of cardiovascular didactic content (Bloom, 1956). Students were not provided the answers to these items to decrease response bias. Immediately following the activity, a convenience sample of students completed the postknowledge assessment, which included the same knowledge assessment plus 11 items regarding participants' perceptions. The perception scale was adapted from an instrument for educational escape room gaming perceptions related to a diabetes-themed escape room (Eukel et al., 2017). Modifications were made to fit the content and design of this escape room (Table 2). Two weeks later, a convenience sample of four students participated in a focus group regarding their perceptions of the escape room. A sociology faculty who was not involved in other study components led the sessions. A professional transcriptionist transcribed the audiorecorded discussion verbatim, which the researcher reviewed and corrected for accuracy.
Escape Room Perception Scale (N = 29)
To enhance trustworthiness, the researchers engaged in a structured process to review and code the transcripts (Ravitch & Carl, 2016). Researchers engaged in memoing before and during coding to bracket assumptions, discuss emerging learnings, and record remaining questions. The researchers independently engaged in open coding by manually coding line by line. Researchers then met to engage in axial coding, which involved the clustering of codes into themes. After agreeing on final themes and relevant quotes, they reviewed the transcript again to ensure that the themes reflected the data. The university's Human Research Protections program determined that the protocol qualified for exempt status.
Twenty-nine students completed the pre- and postknowledge assessment. An independent samples t test indicated that students' mean score for the postknowledge assessment (61%) was statistically significantly higher than students' mean score for the preknowledge assessment (58%), t(28) = −2.5, p < .05. In addition, a linear regression analysis indicated that students' mean score for the preknowledge assessment significantly predicted students' mean score for the postknowledge assessment, F(1, 27) = 36.9, p < .001) and also explained a significant proportion (58%) of variance in postknowledge assessment scores. The cardiovascular escape room increased student knowledge and showed statistically significant results when comparing the pre- and postknowledge assessments.
Through the use of the escape room perceptions survey (Eukel et al., 2017) modified for this escape room, student perceptions of the cardiovascular escape room were measured and analyzed. A one-sample t test indicated that students' gaming perception mean was statistically significantly higher than the mean value of the evaluation scale (3 = neutral), t(28) = 5.12, p < .001 (Table 2). Results showed that students agreed or strongly agreed that the cardiovascular escape room helped them to review content and encouraged them to think about material in a new way, and they would recommend the activity to other students.
Four key themes emerged from the qualitative analysis of the focus group discussions. The themes were (a) Logistics of the Learning Activity, (b) Cognitive Learning, (c) Team Learning, and (d) Professional Practice Skills. Student quotations and analyses provide evidence of each theme.
Logistics of the Learning Activity
Participants discussed their perceptions of the educational innovation. They found the escape room to be “pretty enjoyable” and “interesting,” also discussing an appreciation for the “variety of learning materials” and “content” used throughout. One student reflected, “I thought the content was the best part of it...all the different methods. It was something different every time to make you think in a different way.” One student noted, “I like to study on my own. I can't really focus in group things, but with this escape room I felt like I did learn stuff that I didn't know because of my peers.”
Participants reflected on the relationship between the event and the content examination. Some treated it as a guide to future study efforts: “It gave you a basis of what you knew and what you didn't. So then when you went to go study, you kind of knew what to focus more on.”
Participants also discussed cognitive learning gains. They indicated that certain topics were reinforced, such as heart rhythm recognition and “knowing what medications [treat] different rhythms.” Participants also included comments on the cognitive level of learning that was required during the escape room. One discussed:
I enjoyed being able to apply the knowledge that we already learned into it. And being like, “Oh, wow, we actually did learn some stuff.” Or seeing that you retained stuff and understand and it was just fun to have a different way to go about reviewing it and applying it.
Although the educational innovation was not an appropriate method to learn new material, participants discussed effective application of previously learned material: “You learned the material previously and you're applying that.... You have to pull your education and knowledge to get through the game.” Another student discussed how they already had a basis in the content and added “It's like actually critically thinking and applying it when you're in the escape room.”
The participants also reflected on the team-based approach to learning that occurred in the escape room, mentioning team-work, leadership, and communication. They discussed the benefits of teamwork in discussing different ideas, building on strengths, and correcting misconceptions. One participant discussed how her team “had to work as a team to come up with the answer...because everyone I think had…different areas that they were stronger at than others so it helped because we were able to teach each other.” They learned to be “open to other people's ideas and thoughts and [use] them as resources.” This student discussed individual team member strengths and how each was able to advance the knowledge of their team members.
Participants reflected on the communication that occurred during the event, allowing students to build on the knowledge of others. For example:
We were talking about Prinzmetal's angina and regular angina. Because somebody was like, “Oh angina is just when you have chest pain.” But the difference that I told her was like, “Well if it's Prinzmetal then it's when you're like sleeping or at rest when you get angina.”
Sometimes, participants would have to correct their peers. They were “learning how to...take correction from others and kindly give it in a professional way.” One student remembered:
If someone thought differently instead of the majority saying, “No that's wrong.” They'd ask, “Oh wait, why do you think that?” And listening to it and taking it into consideration and coming, all coming together to figure out what answer to choose.
Participants said that they were supportive of one another, ensuring “that everybody understood or everybody had answered it” before moving on to the next activity. Participants noted value in practicing communication.
Professional Practice Skills
Participants recognized the relevance of the escape room event to professional nursing practice skills. The experience made them “critically think” in a timely manner. One participant recognized that the nurse has “to figure out your patient's problem within a certain amount of time. Like you don't just have forever. So I think it like makes it more real life kind of in a way.” Thus, the event encouraged rapid reasoning.
Participants recognized that the opportunity to use “helps” during the escape room mirrored professional practice. One student thought, “sometimes you don't understand something so you don't just walk into a patient's room and pretend you know because I mean you could potentially...harm them.” Another student agreed that the cardiovascular escape room:
reinforced that it is okay to ask for help too when you don't understand things. And you didn't feel like it was bad that you had asked for help. Like you were almost encouraged to if you didn't understand, which I think is something that's really important to take away for real life too.
Students indicated that the teamwork and communication required during the event mimicked real life. Students had to work “together as a team,” remain “open to other people's ideas and thoughts,” and use “them as resources.”
The educational innovation incorporated techniques tailored to generational characteristics of learners, including immediate feedback, peer communication, individualization, and excitement (Chicca & Shellenbarger, 2018). Avoiding the discord that exists between traditional lectures and students' needs, the cardiovascular escape room enhanced problem-solving skills, teamwork, and content knowledge (Allen, 2010). Statistically significant gains in knowledge were shown and student perceptions of the educational innovation were positive. Furthermore, the event linked knowledge to professional practice expectations, such as thinking clinically, soliciting assistance, communicating professionally, and working as a team.
This study had some limitations. As a pilot study with 29 participants, the results may not be generalizable. The focus group involved a small convenience sample, so it is not clear if their perceptions represent those of the class. Also, the cohort students who participated in the escape room were taking the course out of traditional curricular sequence. It is unknown whether the factors that led to students being out of sequence had any impact on the relatively low knowledge assessment scores and findings of this study. Future studies will investigate the impact of a longer, structured debrief on student perceptions and learning. Debriefing has been shown to increase educational escape room impact (Clarke et al., 2017). Future studies will also explore differences in examination performance and long-term knowledge retention in the participants and a comparison group.
The escape room allowed students to actively engage in recall and application of course cardiovascular critical care content. The method immersed students in learning and provided immediate feedback. A connection between knowledge acquisition and practice-ready skills, such as critical thinking, communication, and collaboration, was made. Students improved their knowledge in cardiovascular critical care and reported a positive perceived value of this learning activity.
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Cardiovascular Escape Room Content and Structure
|Puzzle Title||Educational Topic||Learning Objective||Gaming Task|
|Puzzle 1: Shock and Awe||Shock||Differentiate between types and etiologies of types of shock||Black light reveal|
|Puzzle 2: Unbreak My Heart||Cardiac medication names||Recognize medication names used in cardiovascular care||Rebus puzzle|
|Puzzle 3: You'll Be in My Heart||Cardiac medications||Differentiate between key features of cardiac medications to select the appropriate medications||Clue-based search|
|Puzzle 4: How Do I Breathe Without You?||Chest tube management||Identify parts of the chest tube system
Solve chest tube related problems||Chest tube skill demonstration|
|Puzzle 5: Another One Bites the Dust||ECG rhythm interpretation||Analyze ECG rhythm strips||Decoding: ECG rhythm strip analysis|
|Puzzle 6: Stayin' Alive||Ventilator-associated pneumonia||Identify prophylactic ventilator-associated pneumonia care||Multiple choice question|
|Puzzle 7: Under Pressure||Critical care calculations||Calculate dosages of intravenous drip medications and mean arterial pressure||Decoding: drug dosage calculation problems|
|Puzzle 8: Achy Breaky Heart||Chest pain||Differentiate between types and causes of chest pain||Math-based code application|
|Puzzle 9: Piece of My Heart||NCLEX-RN®-style questions||Apply concepts of cardiovascular care in NCLEX-style approach||Decoding: unlock box to stop the countdown to shock progression|
Escape Room Perception Scale (N = 29)
|The escape room encouraged me to think about material in a new way.||4.14||1.22|
|I would recommend this activity to other students.||4.28||1.31|
|I learned from my peers during the cardiovascular escape room.||4.28||1.25|
|The escape room was an effective way to review the topic of cardiovascular conditions.||4.24||1.33|
|The escape room was an effective way to learn information related to cardiovascular conditions.||4.21||1.29|
|I learn better in game format than in a didactic lecture.||3.38||1.35|
|I feel I was able to engage with my teammates to learn material.||4.31||1.23|
|It was difficult for me to focus on learning because I was feeling stressed or overwhelmed.||2.62||1.40|
|The non-educational portions (e.g., lock boxes, puzzles) distracted me from learning about cardiovascular conditions.||2.34||1.40|
|I prefer assembling information from a variety of sources when learning material.||3.45||0.98|
|In general, I enjoy playing games (e.g., video games, board games, social media games).||3.86||1.25|