Escape Room Blueprint: Central Orientation Contagion Crisis

Background

Millennial nurses now compromise one-third of the nursing workforce (Advisory Board, 2017). In the midwestern region of the United States, there are several opportunities for employment in acute care hospitals. Healthcare systems must engage and retain these nurses to avoid the financial impact of registered nurse (RN) turnover which is approximately $90,000 per RN (Snavely, 2016). The turnover rate at a midwestern community hospital was 30% for new graduate nurses within the first two years of hire. A revision of central clinical orientation by the education department was initiated to address the high turnover rate.

Central clinical orientation for new hire registered nurses and care assistants was heavily executed via didactic format. The instructors of central clinical orientation classes observed behaviors associated with boredom and disengagement during the didactic sessions. Some of the behaviors were standing in the back of the classroom, side conversations, and use of personal cell phone during lecture. Presenters reported a desire to make the course more engaging and stated they felt “the day was boring and too long.” In addition, post clinical education training evaluations resulted in an average score of 49% of attendees reporting less than “very confident” in ability to apply clinical skills learned in central orientation to role.

Didactic teaching format can leave learners without adequate “soft skills”, whereas the use of simulation and gaming enhances teamwork and communication skills (Baily, 2020). A literature review suggests the use of game-based learning improves knowledge retention, interprofessional communication, and engagement for learners (Adams et al., 2018; Mullen & Seiler, 2019). Furthermore, millennial traits, such as preference for teamwork and frequent timely feedback, align with the escape room teaching strategy (Ulep, 2018).

The clinical educators decided to create an escape room with the goal of improving learner satisfaction, confidence with interprofessional communication, and confidence of applying clinical skills to role. Per institutional policy, institutional review board (IRB) approval was obtained through the facility’s research administration. The IRB categorized this as a quality improvement program not requiring participant consent.

Introduction to the scenario

The content from central clinical orientation was reviewed by the authors to determine areas that were required by accrediting bodies. Inclusion criteria for content required applicability to both nurse and care assistant scope of practice, contained a skill component, and currently delivered via didactic or computer-based modules. Topics selected for the escape room were personal protective equipment (PPE), hand hygiene, medication administration, limb restraints, and emergency response.

The escape room scenario is a “Zombievirus” outbreak. A patient has arrived in the hospital, placed in contact isolation, and the participants are the care team coming on shift assigned to this patient. Their goal is to provide care to the patient without contracting the “Zombievirus” and escape the patient room alive. Facilitators observe the participants to determine the completion of the following objectives:

Flow of escape room

Participants begin in a pre-brief where the facilitators define an escape room and provide the Contagion Crisis scenario (Hasenstein, 2019). The pre-brief also includes how to use the various locks present in the room, call for help, communicate out loud to team members, and include all team members in challenges (Appendices in Supplementary Information A). The participants are given the opportunity to ask questions and then led to the door of the patient room where the first challenge is presented.

The first challenge is to enter the room wearing the appropriate personal protective equipment (PPE) for contact isolation precautions (Figures in Supplementary Information B2). Once PPE is successfully donned, the participants are led to a crossword puzzle with prompts on when to perform hand hygiene (Figures in Supplementary Information B3). During set-up, the facilitators highlight specific squares on the crossword with black light ink. Once this crossword puzzle is complete, participants use a black light pen to illuminate specific letters. These letters are then unscrambled to answer the clue at the bottom of the crossword puzzle. The clue tells them to enter the room and provide care to their patient complaining of pain.

The next challenge is drug calculation for pain medication. Physician orders are used to determine which medication to administer and what dose to calculate (Figures in Supplementary Information B4). Correct calculations lead to a four-digit code to unlock a locked box. Inside the box is a prompt leading them to the computer to watch a video. The video reveals progression of the “Zombievirus” in their patient and includes a verbal order to apply limb restraints. As the participants apply the restraints, they discover puzzle pieces on the patient’s limbs, rolled in the limb restraints, and under the mattress where restraints should be secured (Figures in Supplementary Information B5). The completed puzzle leads the participants to activate the emergency response system.

A facilitator answers the emergency call and instructs participants to apply oxygen until help can arrive. A prompt is hidden in the oxygen device informing them help has arrived and now they must doff their PPE to leave (Figures in Supplementary Information B6). On the lid of the linen bin is a list of the steps of doffing with specific letters in a different color than the rest of the text (Figures in Supplementary Information B7). By unscrambling these letters into the word “LAST” the participants unlock the alpha lock with the key attached. Once they have the key, they are complete and have “escaped”!

Equipment

Challenge Components

The supplies needed for each challenge within the escape room are presented in Table 1. Refer to appendices for challenge puzzles and photos of set up.

OPEN IN VIEWER

Table 1:

Supplies

Challenge	Puzzle Type/Items Needed	Qty	Description
Personal Protective Equipment (PPE) Donning	PPE Poster	1	Choices of possible PPE. Each example has a QR code, confirming the correct application. Place on the door leading into the patient’s room. (Appendix C)
	Isolation Gown	6	Place the gowns on the isolation cart outside the room.
	Gloves	12	Place on isolation cart.
	Protective Eyewear	6	Place on isolation cart. (These are a distractor, they will not be used.)
Hand Hygiene	Poster explaining challenge	1	Place poster on top of crossword. (Appendix D)
	Printed Hand Hygiene Crossword	1	Place under isolation gowns with poster. (Appendix E)
	Black Light Pen	1	Place with crossword. Participants will use to solve the clue after completion of the crossword. Facilitator marks the letters T E N with marker during set-up.
Medication/Drug Calculation	Envelope	1	Orders are folded in envelope.
	Orders sheet	1	Orders will include an order for IV morphine. (Appendix F)
	Dose answer sheet	1	Place on table away from orders. All answers correspond with a 4-digit code. (Appendix G)
	Lock box	1	Place next to Dose Answer sheet.
	Numerical Lock (4 digit)	1	Place on lock box. Participants will use the code to open lock & box.
Restraint Application	Instruction sheet	1	Instructions to view video on desktop computer. (Appendix H)
	YouTube Video Link	1	Video portrays a “zombie” becoming agitated and a nurse instructing learners to apply 4-way restraints per physician order. (Appendix I)
	Soft Limb Restraints	4	Wrap a puzzle piece in each restraint. Place restraints on counter.
	Patient bed with mannequin	1	Mannequin lying in bed, dressed as the “zombie” in the video.
	12-piece Puzzle	1	Puzzle reads “Help! I can’t breathe!!! Press the Staff Assist Button after applying all 4 restraints!”. Puzzle piece placement: 1 wrapped in each restraint; 1 taped to each limb of mannequin; 1 taped to bed frame where restraint is to be anchored.
Emergency Response	Staff Assist Button	1	Once pressed, the facilitator in the control room will respond informing the participants that Rapid Response has been called and to apply oxygen.
	Non-rebreather Mask	1	Instruction sheet containing next steps wrapped in mask.
	Instruction sheet	1	Includes instruction “Rapid Response has arrived and is transferring patient. Remove PPE to safely exit room.” (Appendix J)
PPE Doffing	Instruction Sheet	1	Sheet gives sequential steps of the doffing process. Letters are highlighted that provide the code to unlock the room. (Appendix K)
	Alphabet Lock	1	Placed on handle of exit.
	Generic Key	1	Place on shackle of lock so when it is opened key is released.

Outcomes

The pilot group of twenty-three (23) participants was divided into seven (7) groups. The average completion time was 16:35 minutes. Participants were asked to complete a voluntary, anonymous survey after completing the escape room (Appendices in Supplementary Information L). The survey was written by the clinical educators and measured responses with a 5-point Likert Scale (1=Not at all, 5=Absolutely). Each question was scored independently. Fifteen (15) participants returned the survey, resulting in a 65.2% response rate. All participants reported high satisfaction with the learning experience and their confidence with inter-professional communication. Average scores for satisfaction and communication were 4.67 and 4.0 respectively. Participants reported an average score of 4.72 on confidence in ability to apply knowledge from activity to their clinical role. Statistical analysis was not performed due to small sample size. Subjective responses collected from participants during debriefing sessions. Responses included, “It was a fun way to cover the information,” and “I enjoyed the ‘Escape Room’ and liked how all the pressure was off on just one; not individualized.” Learners reported preference of the escape room format versus a high-fidelity simulation, due to it being less “high stakes” and not a judgement of individual performance. Content analysis was not performed on participant subjective responses.

Future applications of the room

The Contagion Crisis escape room was incorporated into an onboarding program for new registered nurses. Educators use the escape room as an alternative to high-fidelity simulation due to the flexibility of space and easy mobilization of equipment. An additional benefit is the escape room allows for more than one to two learners to have hands-on learning at one time.

Multiple clinical disciplines can use this escape room, as it covers topics from central hospital orientation. Additional skills can be added to the escape room such as a more robust emergency response challenge. Facilitators can either alter challenges falling out of scope for other disciplines or encourage interprofessional education by including those who are licensed for medications and restraint application.

Supplemental Material