Teaching complex nursing skills to the current generation of students can present challenges to faculty due to the diversity of individual student learning needs. Organizations such as the National League for Nursing (NLN, 2006) and the American Association of Colleges of Nursing (AACN, 2009) encourage and endorse the use of active learning strategies. Strategies also should use a student-centered approach to learning (Caputi, 2015). Studies have demonstrated that active learning is more likely to occur when students are actively engaged in the andragogy of learning. In a national study by Prokess and McDaniel (2011), data revealed students reported active learning strategies were not being used in the classroom. It also is critical for nursing educators to develop innovative active learning activities that can engage all domains of learning. Bloom's classic taxonomy of skills (1956) identified three domains of learning: affective, cognitive/sensory, and psychomotor. The measurement of outcomes related to cognitive, affective, and psychomotor skills can present challenges, especially in the clinical setting (Baumlein, 2010). According to Jang et al. (2010), students are more apt to learn if they are enthusiastic and are allowed autonomy with involvement in the selected activity.
Research has demonstrated (Cain & Piascik, 2015) the use of serious gaming (escape rooms) can promote student engagement and persistence on task, both of which can foster deep, rather than superficial learning. Designing an escape room can offer an innovative solution to engage students with creative scenarios directly related to student learning outcomes. Stimulating activities can promote excitement about learning and reinforcing new concepts. Such activities also promote teamwork and encourage analytical thinking and problem solving, all of which are important skills for nurses to develop and refine.
Escape rooms have become a global phenomenon since this form of entertainment gaming was introduced in Japan in 2007 (Nicholson, 2015). According to Wise et al. (2018), escape rooms can provide an avenue for “moving away from ‘information transmission’ models of induction and towards a student-centered approach, resisting the temptation to tell students everything we want them to know” (p. 88). Escape rooms can engage students, promote critical thinking, and enhance team cooperation by solving real-life puzzles (Hermanns et al., 2018). Puzzles within an escape room are solved by finding clues that can be used to unlock a series of locked boxes, which then solve the final, ultimate puzzle. Escape rooms are gaining in popularity and can be found internationally as a form of entertainment for participants of all ages (Nicholson, 2015).
Before implementing this learning strategy, the author experienced the activity firsthand with a colleague through participation in an escape room. Participation and firsthand immersion into an escape room type of gaming experience is an important step to comprehend the complexity of the linked puzzles, locked boxes, and strategies involved. It is comparatively straightforward to locate an escape room in the United States, especially in major metropolitan areas of the country. In our first attempt, the team was not successful in completing all of the puzzles required to escape but came close to solving all of the puzzles. Our team consisted of only two people, which made the activity more challenging. The team was successful solving some of the more difficult puzzles in the room, according to the co-owner of an escape room (I. Greene, personal communication, July 12, 2018).
The second step included a literature review of the topic. A CINAHL search was conducted using the search terms escape room, engage, and active learning, and two scholarly articles were identified. Because escape rooms were a relatively new concept being used in academia at the time the literature search was performed, only a limited number of articles on this topic were identified. Eukel et al. (2017) created an escape room as an educational strategy to impact student learning on the concept of diabetes disease management. The results from the study demonstrated an increase in students' knowledge, and students perceived the escape room to be a valuable educational strategy. Kutzin (2019) developed an escape room as a method to enhance teamwork with interprofessional students. The results of the study revealed escape rooms can be an effective and innovative strategy to teach interprofessional students about teamwork and communication.
An Internet search provided some constructive suggestions for creating an escape room and an array of ideas for different types of puzzles and locks to use. The search also revealed suggestions for linking the various puzzles so that all of the puzzles must be solved; participants cannot “escape” by solving just one puzzle or by solving a puzzle by chance (Nicholson, 2015). Each puzzle, when completed, provides a clue to unravel a consecutive puzzle, which also must be solved. Students must use problem solving, analytical skills to match the clues to the different puzzles arranged around a predominating theme.
Planning the Room
Escape rooms can have anywhere from two to eight participants. For the best experience, an escape room should have approximately five participants (I. Green, personal communication, July 12, 2018). Any size room can be used, but most escape rooms are created within a limited amount of space, which also can limit the number of participants. Each escape room is usually built around a theme, and the theme is threaded among the different puzzles, clues, and locked boxes. All of the puzzles must be solved in a limited amount of time, usually 60 minutes, depending on the degree of complexity of the design. Multiple clues and puzzles usually must be solved simultaneously. To accomplish this challenging feat, it is imperative for the group members to delegate and communicate effectively with each other.
Communication, collaboration, and teamwork are critical skills needed to “escape” in the time allowed. After a theme has been selected, a variety of puzzles and clues leading to the locked boxes must be configured. To ensure that all of the puzzles are solved, the puzzles must be linked and be dependent on each other. A flow chart is one method that can be used to arrange the interdependent puzzles and clues (Figure 1). This step in the planning typically takes the longest and can be challenging. The Internet can be a great resource to find a variety of different types of puzzles, ciphers, and clues that can be used. A deck of playing cards, Sudoku, or glow-in-the-dark pens and black lights are some examples of items that can be used. Some clues also can be hidden in the room or hidden in plain sight.
Flow chart showing the locked boxes and contents used in the escape room.
Some escape rooms use red herrings or false clues to distract the participants, but too many of these can cause frustration for the participants; thus, red herrings should be used sparingly. It is noteworthy to evoke a sense of urgency, and this sense of urgency should be conveyed within the overarching theme. The urgency can be enhanced by providing the participants a timer or clock—the bigger, the better! The device should be visibly counting down so that everyone is aware of the remaining minutes left.
A sense of urgency also can cause frustration, so a crucial step is to monitor the progress of the team in the escape room using a one-way mirror. Clues can be provided as needed to reduce or prevent the frustration of the participants. For this escape room, the application Double (Double Robotics, 2018) was downloaded from the Internet to an iPad. The iPad and application are used together to monitor and interact with participants by using an additional electronic device. This allows the instructor to interact with the participants and provide clues, if necessary. Video monitors, cameras, or a two-way mirror also can be used for monitoring without being physically present in the room, which allows autonomy for the learners.
Before initiating the activity, it is crucial to explain that anyone can leave at any time. It also is helpful to emphasize that no doors are secured to prevent escape. A written set of rules also is required to ensure the safety of all participants. No hidden objects should be placed in areas that require climbing or that involve electrical outlets. Participants can be encouraged to ask for clues, rather than becoming frustrated. It is urgent to remind participants that no objects in the room should be disassembled, destroyed, or taken apart, and that the boxes have to be unlocked by solving the puzzles. The rules also should include a statement that students will not share or discuss any clues or any part of the escape room with anyone but their group. Before the escape room is piloted, it is practical to invite several groups of friends or coworkers to evaluate escaping from the room to identify any potential glitches or bugs within the overall design.
Design, Sample, and Procedure
The escape room took several months to design and create a theme, identify puzzles, and secure items needed for the activity. The escape room was designed around a potential emergency scene in an assisted living facility for older adults. A vacant, approximately 120-square foot faculty office was used to enact the scene. Institutional review board approval for exempt status was obtained, and approval to use a vacant office was obtained from the Dean of the College of Nursing.
A nonrandom convenience sample (N = 22) was selected from second-year nursing students enrolled in a baccalaureate nursing program at a midwestern university. Data were collected in the fall of 2018 and the spring of 2019. The participants included students from two semesters: fall 2018 (n = 15 divided into three groups of five students) and spring 2019 (n = 7 in one group). The escape room was created as an optional, nongraded learning activity for all of the students enrolled in the mental health course. Students also were provided the option of choosing to participate or choosing an alternative activity if they desired. All of the students were informed prior to the activity that they had the option of leaving the escape room at any time, as the door was never locked. All of the teams were allowed 45 minutes to solve all of the puzzles and “escape.”
The design included a postsurvey to be completed by the students after the conclusion of the activity. The survey contained five statements created by the author to provide data on the students' perceptions of the learning activity and whether the activity was appropriate for those who had never participated in an escape room (Table 1). The five questions were: “This is my first experience in an escape room,” “The activity engaged me,” “The activity made me ‘think outside the box’ and be creative when trying to find solutions,” “The activity required teamwork,” and “The number of puzzles and the degree of the challenge was appropriate for my level of learning.”
Survey Results (N = 22)
To measure the impact of the activity on the participants' critical thinking, the survey also included questions intended to analyze the “Habits of Mind” involved with critical thinking identified by Scheffer and Rubenfeld (2000). Scheffer and Rubenfeld (2000) identified the “Habits of Mind” and defined the skills involved in critical thinking; they suggested these clearly defined concepts could be used to develop valid and reliable instruments to measure critical thinking. The seven skills were “analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge (p. 352)” and were used to create a survey to measure participants' impressions on the use of these skills. Test-retest reliability between the two groups of students assured the reliability of the survey.
The scenario centered around “Millie,” a resident who recently was admitted to an assisted living facility. “Millie” was a manikin sitting in a wheelchair surrounded by items that had been brought with her from her home. The items were things such as photo albums, vintage postcards, and memorabilia to help construct Millie's room to be more like her home. The theme of the activity was introduced to the participants by a letter, written by Millie to her only known relative, a niece. The letter also included some clues to the puzzles as it contained a list of medications that can cause some adverse effects, especially when combined with other central nervous depressants or beverages containing alcohol. The challenge (or to “escape”) was to unlock the box and select the correct vial of medication needed as an urgent intervention for Millie. In this case, naloxone was required because Millie had combined alcohol with several medications (benzodiazepines and opioids) that are contraindicated or dangerous when combined with alcohol.
Empty vintage boxes and chests were purchased from local flea markets and antique stores. The boxes required locks (some with keys), which were purchased online and were used to secure the boxes. Locks using a combination of at least four numbers or letters are best to reduce the chance of someone guessing or randomly choosing combinations.
The escape room theme was built on principles of pharmacology, patient safety, and monitoring for adverse effects of medications. One of the puzzles required students to use cognitive skills to identify pharmaceutical classes of medications. Another task required psychomotor skills to correctly read prefilled syringes, which provided numbers to a combination padlock. One of the last challenges for students to “escape” required them to identify the correct medication to administer to Millie to counteract the additive effects of several central nervous depressants combined with alcohol.
After all of the participants in each cohort attempted the activity, a 15-minute debriefing session was held in a conference room, and participants completed a postsurvey. The first section of the survey revealed that 81.1% of students reported this was their first experience in an escape room. These data demonstrate the activity was appropriate for beginners as well as those experienced in solving escape room puzzles. All of the students highly agreed (100%, n = 22) that the puzzles required team-work, cooperation, critical thinking, and concentration. The final question focused on the design of the puzzles to ensure the level of difficulty was appropriate for the students' level of learning. Results indicated 15 students highly agreed and seven students agreed the number of puzzles and the degree of the challenge was appropriate for their level of learning (Table 1).
To analyze the use of the students' critical thinking skills, the second section of the survey contained questions related to the cognitive skills of critical thinking identified by Scheffer and Rubenfeld (2000). The seven cognitive skills or “Habits of Mind” were similar to the analytical thinking required to unravel the various puzzles. Data from the section of the survey evaluating critical thinking skills indicated 20 (91%) students highly agreed and 2 (9%) students agreed that the activity required the use of the seven cognitive skills listed by Scheffer and Rubenfeld (2000). Each question pertained to the use of the following skills required for critical thinking: analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge (Table 2).
Skills of Critical Thinking in Nursing
A 15-minute debriefing with participants revealed the students were excited about participating in the activity. The students also reported they felt it was an effective strategy to learn or improve critical thinking and reinforce previously learned content. One student who was experienced with escape rooms stated, “Wow, this was so fun, you could make a fortune and charge admission.” Another student stated, “I can't stop thinking about how awesome the escape room was. You succeeded in having our entire team learning on a completely different level, and the experience has transformed the way I approach learning.” This statement by the student is an example of the impact on the affective domain of learning that the activity provided. According to Luparell (2015), the affective domain of learning is associated with increasing levels of achievement and can stimulate an emotional response. The psychomotor domain of learning outcome also was evaluated using puzzles in the escape room.
The puzzles were built on the Quality and Safety Education for Nurses (QSEN, 2019) knowledge, skills, and attitudes (KSAs) of safety. One example of this outcome related to safety was measured by students demonstrating skills to correctly read insulin dosing syringes. The students then were required to use the four correct numbers to unlock a box. The cognitive domain of learning was evaluated by the students being able to solve the multiple arrays of puzzles within the escape room in the allotted time.
Some limitations in this study should be considered. The sample of students (N = 22) was small and consisted of a convenient, nonrandom sample. A multisite and larger randomized sample would provide results that could be applied on a larger scale and could provide a framework when creating future learning strategies such as escape rooms.
A well-designed escape room requires a great deal of planning and creativity. Once the activity is created, it can be an effective teaching and learning strategy to promote active learning and student engagement. An escape room also can represent an effective strategy to engage the affective, psychomotor, and cognitive skills of Bloom's taxonomy of domains (1956) and to reinforce QSEN KSAs related to patient safety. As the puzzles increase in difficulty, students are required to use more complex cognitive skills. Using this innovative approach to learning can foster teamwork, collaboration, and communication, as well as critical thinking and enhanced problem solving skills. Most, if not all of these skills, are essential competencies recommended by nursing organizations for nurses.
- American Association of Colleges of Nursing. (2009). Annual report: Advancing higher education in nursing. https://www.aacnnursing.org/Portals/42/Publications/Annual-Reports/AnnualReport09.pdf
- Baumlein, G.K. (2010). Degrees of success: Bridging the gap: Preparing the nursing leaders of tomorrow. Minority Nurse, 38–39.
- Bloom, B.S. (1956). Taxonomy of educational objectives: The classification of educational goals. Longman.
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- Caputi, L. (Ed.). (2015). Certified nurse educator review book: The official NLN guide to the CNE exam. Wolters Kluwer.
- Eukel, H., Frenzel, J. & Cernusca, D. (2017). Educational gaming for pharmacy students—Design and evaluation of a diabetes-themed escape room. American Journal of Pharmaceutical Education, 81(7), 6265.
- Hermanns, M., Deal, B., Campbell, A.M., Hillhouse, S., Opella, B., Faigle, C. & Campbell, R. (2018). Using an “escape room” toolbox approach to enhance pharmacology education. Journal of Nursing Education and Practice, 8(4), 89–95.
- Jang, H., Reeve, J. & Deci, E.L. (2010). Engaging students in learning activities: It is not autonomy support or structure but autonomy support and structure. Journal of Educational Psychology, 102(3), 588–600 doi:10.1037/a0019682 [CrossRef]
- Kutzin, J.M. (2019). Escape the room: Innovative approaches to interprofessional education. Journal of Nursing Education, 58(8), 474–480 doi:10.3928/01484834-20190719-07 [CrossRef]
- Luparell, S. (2015). Facilitate learner development and socialization. In Caputi, L. (Ed.), Certified nurse educator review book. The official NLN guide to the CNE exam (pp. 33–48). Wolters Kluwer.
- National League for Nursing. (2006). Excellence in nursing education model. Author.
- Nicholson, S. (2015). Peeking behind the locked door: A survey of escape room facilities. http://scottnicholson.com/pubs/erfacwhite.pdf
- Prokess, A.M. & McDaniel, A. (2011). Are nursing students engaged in learning? A secondary analysis of data from the National Survey of Student Engagement. Nursing Education Perspectives, 32(2), 89–94 doi:10.5480/1536-5026-32.2.89 [CrossRef]
- Quality and Safety Education for Nurses. (2019). QSEN competencies. https://qsen.org/competencies/pre-licensure-ksas/
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- Wise, H., Lowe, J., Hill, A., Barnett, L. & Barton, C. (2018). Escape the welcome cliche? Designing educational escape rooms to enhance students' learning experience. Journal of Information Literacy, 12(1), 86–96.
Survey Results (N = 22)
|Question||Totally Agree||Agree||Neutral||Disagree||Totally Disagree||% of Totally Agree and Agree|
|This is my first experience in an escape room.||18||0||0||0||4||81.1|
|The activity engaged and stimulated my attention.||19||3||0||0||0||100|
|The activity helped me to “think outside the box” and be creative when solving problems.||18||4||0||0||0||100|
|This activity requires teamwork and cooperation.||22||0||0||0||0||100|
|The amount of puzzles and degree of challenge was appropriate for my level of learning.||15||7||0||0||0||100|
Skills of Critical Thinking in Nursing
|Question||Totally Agree||Agree||Neutral||Disagree||Totally Disagree||% of Totally Agree and Agree|
|Analyzing—separating or breaking a whole into parts to discover their nature and functional relationships (example: “I studied it piece by piece”)||20||2||0||0||0||100|
|Applying standards—worked to solve puzzles according to established personal, professional, or social rules or criteria||21||1||0||0||0||100|
|Discriminating—recognizing differences and similarities among things or situations and distinguishing carefully as to category or rank (examples: “I rank ordered the various…” and “I grouped things together”)||21||1||0||0||0||100|
|Information seeking—searching for evidence, facts, or knowledge by identifying relevant sources and gathering objective, subjective, historical, and current data from those sources (example: “I knew I needed to look up/study,” and “I kept searching for data”||19||3||0||0||0||100|
|Logical reasoning—drawing inferences or conclusions that are supported or justified by evidence (example: “I deduced from the information that…” or “My rationale for the conclusion was. . .”||19||3||0||0||0||100|
|Predicting—envisioning a plan and its consequences (example: “I envisioned the outcome would be…” or “I was prepared for…”||19||1||2||0||0||91|
|Transforming knowledge—changing or converting the condition, nature, form, or function of concepts among contexts (example: “I improved on the basics by…” or “I wondered if that would fit the situation of…”||19||3||0||0||0||100|