Operation Outbreak: A Periop 101 Exam Review Escape Room

Abstract

Background:

Perioperative nursing is expected to see a 20% reduction in the workforce due to retirement within five (5) years. To recruit and retain nurses within this specialty, the Association of Operating Room Nurses (AORN) Periop 101: Core Curriculum™ OR was added to an existing nurse residency program. Periop 101 is an online learning program providing evidence-based guidelines for practice and requires the learner to pass a final exam with a score of 80% or higher. Following a didactic final exam review session, most nurse residents at a midwestern community hospital failed to pass the final exam on their first attempt.

Aim:

To address this knowledge gap, the clinical educators decided to create a more interactive review session by creating an escape room. Current literature supports the use of escape rooms to increase knowledge and learner engagement.

Method:

Nurse residents participate in Operation Outbreak during the exam review session. A convenience sample of twenty-two (22) registered nurses were included in the quality improvement project. Group one consisted of 18 participants who received only the didactic review session. Group two had four participants who participated in the didactic review session as well as the Operation Outbreak escape room.

Results/Conclusion:

Overall, there was improvement in the average final exam scores and average percentage of residents to pass the exam on the first attempt after the addition of the escape room. Statistical analysis was not performed due to sample limitations.

Keywords

exam review nurse residency operating room periop surgery

Background

Perioperative nursing is expected to see a 20% reduction in the workforce due to retirement within five (5) years (Association of Operating Room Nurses [AORN], 2020). To recruit and retain nurses within this specialty at a midwestern community hospital, the Association of Operating Room Nurses (AORN) Periop 101: Core Curriculum™ OR was added to an existing nurse residency program in 2016. Periop 101 is an online learning program based on AORN’s guidelines for perioperative nursing practice. These evidence-based guidelines include sterile technique, surgical hand asepsis, prevention of retained surgical items, and reduction of safety hazards for both patient and staff. At the end of the Periop 101 program the learner must pass a final exam with a score of 80% or higher. Following a didactic final exam review session, fifty percent (50%) of operating room (OR) nurse residents did not pass the final exam on their first attempt. A needs assessment was performed gathering information from the exam reports on low scoring content areas and feedback from the OR nurse residents. The clinical educators revised the exam review session to focus on low scoring content areas and increase learner engagement.

After a review of the literature, Kolb’s theory of experiential learning was selected to guide instructional methods. Kolb’s theory defines learning in four different styles with overlapping themes of reflective observation, concrete experience, and hands-on experimentation (Poore et al., 2014). In order to appeal to all of Kolb’s learning styles, the escape room format was selected. An escape room allows for application of knowledge, active observation of others performance, and self-evaluation through active experimentation (Adams et al., 2018). Furthermore, participants can engage in their “preferred style of learning” (Connelly et al., 2018) during escape rooms because multiple methods of learning are available. Perioperative educators selected a linear format for the escape room to decrease mental load; as the activity was performed at the end of the review session (Connelly et al., 2018). Escape rooms with an open format, where clues do not follow a sequential order, can be more difficult for the participants.

Introduction to the Scenario

Operation Outbreak was developed using the results from previous Periop 101 exams. The content areas with the lowest scores on the final exam were included in the escape room. Topics include: environmental cleaning, Spaulding classifications, phases of anesthesia, surgical hand scrub, wound classification, patient safety, and wound closure. Operation Outbreak is focused on knowledge retention rather than verification of skills. Participants are “locked” in the operating room and must complete a surgical case before they are able to “escape.” The scenario was designed to follow the natural flow of a surgical case while reviewing the exam content. Participants are divided into teams of 2-4 people. IRB approval was obtained through the hospital research administration.

Flow of Escape Room

Pre-Brief

Participants begin in a pre-brief to prepare them for the escape room. The pre-brief includes: general definition of an escape room, identification of “in bounds” areas of simulation lab (i.e. scrub sink and operating room), how to ask for a hint, number of hints allowed, and supplies needed (pen or pencil and smart phone) (See Online Appendix A). The participants are given an envelope with the first clue (See Online Appendix B) and instructed to not open it until they are inside the operating room.

Puzzles

The first puzzle is related to environmental cleaning. The participants must damp dust the room in the correct order to find the next clues. Clues are taped to various surfaces including the overhead lights, equipment boom, OR bed, and back table. On the back of the initial clue are outlined areas where the taped clues should be placed in order of top to bottom (See Online Appendix B). To make it more challenging, the clues are spelled backwards so they use the mirrored wall of the simulation lab to read the clue. The completed clue leads them to a patient chart located within the room.

The participants find a patient safety awareness crossword puzzle within the patient chart. The puzzle contains patient safety topics such as latex allergies, positioning, and surgical site infections (See Online Appendix C). The participants are instructed to use a black light to illuminate their next steps once the crossword is completed. Certain letters within the crossword are highlighted prior to the start of the scenario using a black light pen. The participants then unscramble the letters to create the word “Anesthesia.” This clue leads them to the anesthesia area at the head of the bed. The participants find an envelope on the anesthesia machine with a fill in the blank worksheet (see Online Appendix D). The worksheet reviews the types and phases of anesthesia. Once completed, the participants use the circled letters to identify their next clue of “scrub sink.”

Participants leave the OR suite and go to the scrub sink right outside the room. The facilitators can still see the participants through a glass window. At the scrub sink, the proper steps of performing a surgical hand scrub are individually taped onto the wall in an incorrect order (see Online Appendix E). The participants must rearrange the steps and place into the correct order. Once completed, they take a picture of the steps with their smartphone and text it to the facilitator. If incorrect, the facilitator texts back “try again.” If correct, the facilitator texts the next clue to the participants leading them to a suture cabinet in the operating room.

An envelope is placed in the suture cabinet containing a worksheet with a list of descriptors (types of suture, characteristics, or areas of use) (see Online Appendix F). The participants must match up the descriptors with the different types of suture and needle tips. Once complete, the participants fill in the number of descriptors matched with select suture types to receive a four-digit code. The code is then used to open a lockbox containing the next puzzle located in the suture cabinet.

The next puzzle is a wound classification code breaker cipher (see Online Appendix G). The participants use the cipher provided to decode the surgical procedure names. Once decoded, the participants determine the appropriate wound class for each surgical procedure. The wound classification used the most is then used to fill in the blank for the listed numerical code. The cipher puzzle prompts them to go to the computer where charting would be performed. On the computer is a lockbox which can be opened with the numerical code from the cipher puzzle.

After the second lockbox is open, the participants are prompted to find a critical, non-critical, and semi-critical item to clean (see Online Appendix H). The participants must find soiled instruments, a blood pressure cuff, and a laryngoscope blade. Each of the items has a small piece of paper with the letter C, S, or N attached to them that the participants collect. Next, they can go to the exit door and enter the 3-letter alpha code “SCN” to get the key to “exit” the room. A full outline of the escape room is included in Online Appendix I.

Time

The facilitator of Operating Outbreak should allow 15-20 minutes for set-up and tear down of the puzzles. Participants should be given 30-45 minutes to complete the activity. A maximum time limit, such as 60 minutes, should be set by the facilitator to eliminate frustration from the participants. Once the maximum time limit is reached, the participants can then debrief the experience and discuss puzzles not completed.

Equipment

Room Set Up

Operation Outbreak is set up in a simulated operating room. The room needs to at least include overhead lights, equipment boom or cart, basic OR bed, back table, and a computer. A simulation lab or empty surgical suite is ideal due to needing a scrub sink right outside the door. The simulation lab that was utilized had a door to separate the operating room simulation suite from other suites, thus this is where the “key” to escape was placed. An anesthesia area at the head of the bed is needed, but an anesthesia machine is not required. A simulated sterile field with instruments, water basin, and surgical sponges is required. At the beginning of the escape room the back table is covered and then after the learners go out to the scrub sink the facilitator removes the cover. Other supplies in the room should include a blood pressure cuff and a laryngoscope blade with handle.

Puzzle Components

The supplies needed for each puzzle/topic within the escape room are presented in Table 1. Total cost for the supplies is $47.00. Standard office supplies, such as paper and envelopes, was not included in supply cost.

Table 1.

Supplies.

Topic	Puzzle type/items needed	Qty	Description
Environmental Cleaning	Paper with words printed in mirror writing “Patient” “Chart” “for next” “Clue”	3	Place in order of damp dusting: overhead lights = patient, equipment boom/cart= chart, OR bed= for next, back table=clue
Patient Safety	Printed Crossword Black Light Pen	1 1	Mark letters on crossword to spell out “anesthesia”
Anesthesia Knowledge	Fill in the Blank Activity printed Envelope	1 1	Place activity paper in envelope & place at head of bed in anesthesia area
Surgical Hand Scrub	Printed steps of surgical hand scrub Sticky tack/dots	1 1 pkg	Cut out steps into individual strips. Place strips in incorrect order with sticky tacks/dots. Ensure ease of removal for participants.
Wound Closure	Printed Wound Closure activity Envelope Lock box Numerical lock (4 digits)	1 1 1 1	Place wound closure activity in envelope and place in suture cabinet. Lock box with numerical lock next to envelope with Wound Class codebreaker activity inside.
Wound Class	Printed Codebreaker Activity Lock box Numerical lock (4 digits)	1 1 1	Place lock box on nurse’s desk where documentation would occur. Printed Spaulding classification clue placed inside the lock box.
Spaulding Classification	Printed Spaulding classification clue Printed Letters “C” “S” “N” Red washable paint	1 1 1	Place each letter on a critical, semi-critical, & non-critical item in room. Examples: surgical instrument, laryngoscope blade, blood pressure cuff. Use red paint on surgical instrument to signify it is “used” and needing cleaned.
Exit	Key Lock Box (i.e. realtor key box)	1	3 alpha characters; Final lock to open with generic key inside.

Outcomes

A total of twenty-two (22) operating room residents have participated in the Periop 101 final exam review between 2017-2020. Group one consisted of 18 participants who received only the didactic review session. Group two had four participants who participated in the didactic review session with Operation Outbreak escape room. Test results and first-time attempt pass rates are included in Table 2. Statistical analysis was not feasible due to the heterogenous nature of the groups and small sample size. Limitations also included lack of controlling other variables such as time spent studying and methods of self-study.

Table 2.

Exam Results.

	n	Percent passed on first attempt	Average test score
Group 1	18	44.4%	79.7%
Group 2	4	75%	84%

During debriefing, participants in Group 2 reported increased confidence in content areas such as wound closure and anesthesia phases. Debriefing also resulted in positive feedback from participants on using the escape room in place of more didactic presentations. One participant stated, “Hands on is how I learn best and the escape room forced me to use my brain. I like different combinations and ways of learning material.”

Discussion

Overall, there was improvement in the average final exam score and percentage of participants to pass the exam on the first attempt after the addition of Operation Outbreak. Due to limitations, statistical significance could not be determined. Currently there is limited research available on the effectiveness of escape rooms as an instructional methodology for operating room nurses or for Periop 101 exam review. However, other healthcare disciplines have demonstrated statistically significant increases in knowledge and test scores after implementing escape rooms in their curricula (Aubeux et al., 2020; Eukel et al., 2017; Liu et al., 2020). Eukel et al. (2017) demonstrated statistically significant increase in post test scores with pharmacy students using an escape room in addition to their didactic teaching on diabetes medication management. Liu et al. (2020) studied radiology students’ knowledge retention of pediatric radiology practices after participation in an escape room. The study resulted in statistically significant increases in test scores immediately after the escape room activity as well as two weeks post instruction. Furthermore, Aubeux et al. (2020) demonstrated statistically significant increases in post test scores with dental students following an endodontic themed escape room.

The literature also supports the use of escape rooms in order to increase learner satisfaction and enjoyment during learning experiences (Aubeux et al., 2020; Eukel et al., 2017; Liu et al., 2020). Participant feedback from the Operation Outbreak pilot reported preference of the escape room to didactic lectures, thus further contributing to the existing body of knowledge on learner satisfaction. Operation Outbreak provides perioperative nursing educators an alternative to didactic exam review to engage their learners and influence average test scores & first-time test pass rates.

Future Applications of the Room

Operation Outbreak will be used for Periop 101 test review with future operating room residents. By increasing the sample size and adding more subjects to the intervention group, the escape room intervention can be further studied for effect on test scores. Content of the escape room can be altered if exam reports show a knowledge gap in other content areas. The puzzles and activities can all be adapted to various content for multiple exam preparation purposes, such as certification exam review. Further research is needed to demonstrate the effectiveness of the escape room teaching methodology on standardized exam scores and pass rates.

Supplemental Material

Operation_Outbreak_Appendices – Supplemental material for Operation Outbreak: A Periop 101 Exam Review Escape Room

Supplemental material, Operation_Outbreak_Appendices for Operation Outbreak: A Periop 101 Exam Review Escape Room by Ashley N. Frederick and Jessica A. Reed in Simulation & Gaming

Footnotes

Notes

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Ashley N. Frederick

Jessica A. Reed

Author Biographies

Ashley N. Frederick, MSN, RN, CNOR is a Clinical Educator for Surgical Services at Franciscan Health Indianapolis and Carmel, Indiana. She is the lead facilitator of the Operating Room Nurse Residency Program.

Contact: Ashley.Frederick@franciscanalliance.org

Jessica A. Reed, MSN, RN, CNOR, NPD-BC is a Staff Development Coordinator for Perioperative Service Line at Franciscan Health Central Indiana Region. She is a primary facilitator within the Operating Room Nurse Residency Program.

Contact: Jessica.Reed@franciscanalliance.org

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Supplementary Material

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