Shocking Escape: A Cardiac Escape Room for Undergraduate Nursing Students

Background and Rationale

Cardiovascular content is some of the most challenging for undergraduate nursing students to master. Educational escape rooms have been shown to increase student content knowledge, immerse students in learning, and facilitate soft skill growth (Adams et al., 2018; Borrego et al., 2017; Caldas et al., 2019; Eukel et al., 2020; Kavanaugh et al., 2020; Morrell & Ball, 2020; Morrell & Eukel, 2020; Morrell et al., 2020; Wu et al., 2018; Zhang et al., 2018). One faculty member, BM, designed a cardiac-themed nursing escape room to engage students in learning, help students identify areas of weakness, and build collaborative interaction with classmates. The objective of this article is to provide readers with a description of a nursing educational simulation, including educational objectives, design considerations, and all materials for seamless transferability into other curricula. Quantitative and qualitative results of this innovation have been previously published (Morrell & Eukel, 2020; Morrell et al., 2020).

The Scenario

In this sequential-style escape room, junior-level undergraduate nursing student groups complete nine puzzles in 60 minutes. The game content is previously taught in the critical-care portion of the course, using lectures, activities, case studies, videos, assigned readings, and a chest pain simulation. To boost student confidence and facilitate game progression, new content is not introduced during the game.

Students first view a video trailer and are randomly assigned to teams of four or five; they are read the scenario and game rules (Appendix A). The team members must work together in the allotted time before receiving a call that a fictional patient at risk for further clinical deterioration related to cardiogenic shock, a form of low blood flow related to cardiac events, has declined (Miley, 2020). The event takes place in a mock hospital environment in a traditional classroom. Students complete nine puzzles, including drug dosage calculations, rebus puzzles, multiple choice items, and clinical reasoning activities. Rebus puzzles are a series of images and letters in the form of a calculation that create a word or phrase. Puzzles, named after popular songs, require comprehension and application of course material for completion (Morrell & Eukel, 2020). Each five to fifteen minute puzzle reveals a clue identifying the next task in the sequence. To escape the room, groups work to solve all the puzzles to gain access to a final box, housing a phone with countdown timer. Patients with shock symptoms can decline clinically without appropriate intervention (Miley, 2020). Thus, in the game, when the time expires, the phone rings, simulating a call from a nurse that indicates that the patient’s health has declined.

One faculty member remains in the room to track progress and assist as needed. Groups have the use of four helps, including nurse assistance, physician input, and use of the pharmacy or medical library resources. To lighten the mood, the faculty also play heartbreak music, a pun related to the content of the game. Upon game conclusion, faculty lead a guided debriefing to discuss student experiences allowing them time to reflect on their learning.

The escape room has been implemented for groups ranging from 31 to 68 students in each cohort. Atop each set of tables in the classroom is a team box, painted the team color with task kits inside. While most game supplies are in the team box, the room has marked pharmacies, billing departments, and a medical library. The lock box for Puzzle 1 is located in the Billing Department. The medication bottles for Puzzle 3 are located in the pharmacy. Printed text resources are in the medical library.

Escape Room Puzzles

Puzzle 1: To solve the first puzzle, the team has to correctly identify the type of shock related to various causes and characteristics (Appendix B). The first letter of each answer on the page is circled. These letters complete a sentence, indicating that the next task is located ON CASH in the billing department. In the billing department, students find a lock box as well as various office supplies, dollar bills, and black light pen with lights scattered around. When used, the black light reveals the name of the subsequent task written on the cash.

Puzzle 2: Inside the team’s box, the students locate a labeled envelope, containing two rebus puzzles (Appendix C). The pictures and letters, when used together, spell out the name of a cardiac medications the students had previously studied. They also receive instructions to go to the pharmacy to locate their medications.

Puzzle 3: At the pharmacy, students complete the next task (Appendix D). Medications in the pharmacy are not labeled with the medication name but with characteristics of each medication listed on the label. Inside, if they select the wrong medication bottle, the strip of paper in their team’s color indicates nursing care that is inappropriate or unsafe. However, if the students correctly select their team’s medications, they find matching strips of paper, indicating the name of the subsequent puzzle.

Puzzle 4: Inside the next task’s envelope, students find a unique case study, images, and medical supplies (Appendix E). The case describes a patient situation involving the use of a chest tube. Students decide which type of chest tube system the patient has and label the parts of the system. Based on the case, they indicate how the system is functioning and which supplies are needed to address a problem with the patient’s chest tube. This generates a sequence of numbers, used to open up a small three-digit lock box inside their large team box.

Puzzle 5 and 6: A small box includes the supplies for the two following puzzles (Appendix F). Students analyze the four electrocardiogram (ECG) rhythm strips in the box. A question in the box uses the first letter of three ECG strip rhythms to complete the sentence. These three letters spell, V.A.P., or ventilator-associated pneumonia, a form of pneumonia that may develop after a patient is placed on mechanical ventilator without appropriate care (Brissie, 2020). Students have to answer the multiple choice question, selecting interventions that prevent the occurrence of V.A.P. The question directs students to send a text message with their answer to the physician. The physician, an off-site faculty member, indicates if answers are correct or not. When answered correctly, the physician responds that she cannot text anymore because she is “Under so much Pressure.” Students use this hint to open the next task with a similar name.

Puzzle 7: Puzzle 7 is a task involving calculations for mean arterial pressure, a number related to blood pressure, and for drug dosages (Appendix G). Students add up these answers on the form to arrive at a code. This code opens a three-digit lock on a mesh bag in their team box.

Puzzle 8: For this task, students find a poster board and mesh bag (Appendix H). The poster board includes characteristics of each condition in a math equation. Inside the mesh bag are various cardiac disorders that can result in feelings of chest pain with an associated number. Students match the cardiac conditions with the characteristics on the board to complete the calculation. This creates a numeric code, which opens a box in the classroom.

Puzzle 9: For the next task, students solve multiple-choice cardiac questions (Appendix I). Their correct answers to each question create a code used to open the final box in the front of the room. Students stop time before a phone rings. If the phone rings, students receive notice that the fictional at-risk patient has clinically declined as a result of shock symptoms (Miley, 2020).

Teams who complete all of the tasks before the time elapses have “escaped.” While other teams complete tasks, those who have escaped receive QR code links to practice questions. Upon game completion, faculty facilitate a debriefing session. The debriefing questions, adapted from the University of Minnesota (2018), relate to the game tasks, teamwork behaviors, communication practices, experiences of providing feedback, and perceptions about help-seeking, thus addressing both content and soft skills. Students are able to share discoveries they made about their abilities and that of other team members during the game, ask questions of faculty, and make plans for studying course content.

Implementation

To encourage successful implementation, we suggest faculty keep brief notes during the game, including human errors in game set-up, areas of confusion, team dynamics, and the amount of time tasks tended to take. Areas of confusion are evident when clues are requested—or based on students’ verbal and non-verbal communication. At times, certain teams stagnate and need guidance. Additionally, faculty can learn about students’ skills as they observe various characteristics of leadership, withdrawing from a challenge, teaching others, and constructively correcting others, for example. This escape room is designed for about 80 to 90% of teams to “escape” within the timeframe in order to create a challenge but avoid creating an unattainable goal.

The cardiac escape room, entitled Cardiogenic Shock, was first implemented in the fall of 2017. At that time, faculty had to confirm answers to several tasks, which caused delays in the game. After game changes, it was piloted in the fall of 2018 with students who had previously completed the course to facilitate further game improvements. The escape room was implemented during class time during the fall of 2018 but was optional the spring of 2019 based on student input. This was, actually, not well-received by students as some were unable to attend. It has since been a required part of class time.

Outcomes

Research has been conducted on this cardiac escape room to assess its impact. For the qualitative sequence, two focus groups were conducted, using a semi-structured focus group guide. Data analysis revealed that students learned skills useful for future professional practice, including soft skills and working in a realistic environment (Morrell et al., 2020). They indicated growth in confidence, critical thinking, and teamwork (Morrell et al., 2020).

Researchers also assessed changes in knowledge through pre- and post-knowledge assessments as well as perceptions with an educational escape room perception tool, adapted for this experience. Pre and post-knowledge assessment scores showed statistically significant improvements in knowledge (p < 0.05). Student perceptions were statistically significantly higher than the mean value for the evaluation scale (p < 0.001). Qualitative and quantitative findings have been previously published (Morrell et al., 2020; Morrell & Eukel, 2020).

Limitations

Escape rooms require financial, time, and personnel resources (Morrell & Ball, 2020). The items for one team are $50 with each additional box adding about $20. The classroom space must be large enough to accommodate the student groups. Game set-up, ensuring that each box is stocked and codes are accurate took approximately 20 hours for a group of 68. It is highly encouraged that faculty check and re-check codes and supplies for accuracy. Room set-up takes an additional 45 minutes. One faculty member can facilitate the work of four teams effectively, so additional faculty assist with larger classes. These facilitators receive a cheat sheet that briefly identifies the tasks, instructions, and answers (Appendix J). While the escape room itself is 60 minutes, the introduction takes approximately 15 minutes, and the debrief requires about 30 minutes. However, based on time constraints, alterations may be made. Puzzles may be eliminated and/or debriefing may occur in a subsequent class period. Room clean up takes approximately one hour.

Faculty continue to work to encourage student engagement and openness during the debriefing time. Some students indicate that they are mentally exhausted after the game and less willing to share. Additionally, students may be less willing to discuss their perceptions in a large group setting than if they were in smaller groups.

Transferability

All materials for those wishing to implement the cardiac escape room are included in the supplements section of this journal. The educational game can be adapted and transferred to other schools of nursing or clinical sites and could be considered, with minor alterations, for an interprofessional application. Faculty should ensure that game tasks relate to their course objectives and student needs.

Conclusion

Cardiovascular care is a challenging content area for undergraduate nursing students. The Cardiogenic Shock sequential educational escape room includes nine unique tasks to facilitate formative assessments of learning and grow knowledge. Unlike other teaching strategies, this approach allows students to work toward a common goal while collaborating, critiquing one another, and seeking help (Morrell & Eukel, 2020). Each task is described for educators to adapt the escape room design and puzzles to their own academic or clinical setting.

Supplemental Material