Teamwork and clinical judgment unlocked: Elevating health assessment with an escape room experience

Health Assessment is an essential nursing class where students gather data to make decisions regarding potential health concerns. Recognition of abnormal was difficult for the students; they lacked the ability to apply the concepts outside of the classroom. Often students memorized the assessment of each system which hindered the identification of abnormal. National Council of State Boards of Nursing (NCSBN)^[1] states knowledge is essential but, is not enough for safe clinical practice; “having content knowledge does not always translate to having clinical judgment skills.” The NCSBN^[2] clinical judgement measurement model is an evidence-based tool utilizing cues, analyzes, prioritizes hypotheses, generates solutions, and takes actions that incorporate nursing knowledge as well as the ability to maintain a safe client environment. Recognizing cues through assessment is the foundation to all other steps in the clinical judgement measurement model.^[3]

Tired of the memorization tactic during their head-to-toe final health assessment checkoff, faculty knew change was necessary. The discussion derived around how to implement teamwork, integrative learning and fun all while enhancing critical thinking and clinical judgement.^[4,5] A typical escape room is an experience where a group of people are “locked” into a themed room and work together to solve puzzles, riddles and find hidden clues, using logic and teamwork to “escape” within a set time limit. The challenge was creating a non-traditional escape room focusing on integrating teaching/learning principles based on client interviews and physical assessments. When researching game-based learning Pit et al.,^[6] emphasized escape rooms rely on experiential learning aiming to make memories instead of memorizing. The elements of an escape room help with preparation for judgement, communication, knowledge and confidence to deliver safe patient care.^[7] The objectives were to promote engagement, enhance teamwork, critical thinking and clinical judgment during performance-based checkoffs. The purpose of this paper is to describe an innovated pedagogical strategy that successfully bridges the gap between knowledge and clinical education. Utilizing an escape room as an immersive experience students solved puzzles and found hidden clues creating an intriguing experience that challenged participants to use decision making and critical reasoning skills.^[8,9,10]

This innovative learning activity sought to address the gap between didactic, lab, and clinical practice by utilizing critical thinking within a team approach. The health assessment class occurs in the first semester in a licensed practical nursing to baccalaureate of science in nursing (LPN-BSN) program, enrolling 50 students per year. Two faculty members and simulation support staff began working on the escape room concept in spring of 2023. Faculty meet for two hours each week over a nine-week period to formulate, design and pilot assessment criteria. The team identified the primary systems for assessment would include neurological, heart, lungs, abdominal, musculoskeletal, and skin. Prior to the building process faculty needed to determine how students would move through each assessment within the allotted time frame, while ensuring system assessments followed a faculty designed rubric. Using a Mardi Gras theme, four symbols and three-room colors were chosen to help coordinate rooms and lockboxes. Three rooms ran simultaneously; thus, each room was assigned a specific color to help organize equipment. Each system assessment (heart, lung, neuro, skin and abdomen) was assigned a unique symbol to help students recognize the cues for progression. A scenario was chosen and included traditional escape room features such as boxes, programable combination locks, QR codes, poem, puzzles, and clues. Each of the boxes presented clues to the next assessment and tasks needed to be completed as the students worked in a team to “escape”. The clues correlated to each individual locked box, which were associated with different puzzles and assessment components. Students were asked to do all assessments on each other. The codes for each system assessment, for example, neuro was 6,711, chosen to clue students to assess the six cardinal gazes, 7th and 11th cranial nerves. For example, the neuro assessment, Mardi Gras masks were hidden around the room. Each of the masks depicted one of the six cardinal gazes, guiding students to the fill-in-the blank puzzle, when solved, spelled out the number seven. The number 11 was hidden on a “channel 11” news report within the room.

Figure 1 details escape room mock-up. To help ensure the escape room would run smoothly and could be accomplished within the allotted time frame, faculty piloted and recorded the innovation. Gaps were identified in the flow of the escape room, so modifications were implemented. Changes included adding more detail to puzzles and connecting clues from lock boxes to those found in the room. The second pilot involved participation of different colleagues, to iron out timing, assessments and clues. There were no further changes needed, and the Mardi Gras Escape room was ready to launch with the students.

Figure 1.

Escape room mock-up

Prior to the Mardi Gras escape room, an invitation was emailed to students as a pre-brief providing tips, instructions, and expectations. On the day of the event three groups of four randomly selected students were welcomed into Mardi Gras room with a 45-minute escape time. Faculty read the scenario (pre-brief), followed by students reading a news clipping, which highlighted letters throughout the article directing students to unscramble the word “neuro” setting the stage for the first assessment. During the assessment, clues lead them to a code unlocking the first box. Students discovered a fictitious poem highlighting the components of a musculoskeletal assessment giving the students clues and cues moving them forward to box two. After completing the four musculoskeletal assessments, the puzzles lead them to box three, heart and lungs. The code for box three was associated with each of the heart and lung assessment, which included puzzle pieces hidden in envelopes with a bead draped on the envelope. During the skin and abdomen assessment a QR code for the final box, four was discovered under a saturated dressing on the manikin, leading them to a police report. Inside box four, a blank crossword puzzle once solved allowed them to escape. All 12 students were debriefed for 15 minutes using an abbreviated Tanner’s model. Table 1 lists the escape room assessment content in detail.

After watching students navigate the escape room, a realistic time frame and pre-briefing are needed to enhance the process to improve clarity and understanding for all participants. Additionally, a fifth box was added for future cohorts due to the skin assessment being overlooked because it was combined with the abdominal assessment. The final crossword puzzle was updated to facilitate an effective exit process by making the puzzle state “congratulations you have escaped”. Completing a mockup and walkthrough prior to running the escape room each year is essential.

Outcomes Observed: The success of any educational project is determined by the overall satisfaction and application of gained knowledge by the students. All 50 students who participated completed a modified debriefing and an evaluation. Students initial feedback was overwhelmingly positive. The evaluation was a six-question short answer survey. Students were asked questions related to their experience, teamwork, approach, and how it enhanced clinical judgment. The evaluation confirmed that the innovative project met the objectives as planned. Faculty and learners alike concluded the escape room was successful and provided exceptional learning opportunities.

Some of the teams were more effective in navigating the escape room where others struggled to navigate group dynamics. Additionally, students who were familiar with escape rooms finished more quickly. The groups used the strengths of each other to maximize teamwork efforts. Students feared working in a group might lead to a team member monopolizing the time, and their own strengths would not be demonstrated. However, during debriefing and reading evaluations students reported the opposite, it added to a real-life experience at a fast pace.

Escape room student evaluation

In an ever-changing health care field educators are tasked to think outside the box to promote teamwork and enhance clinical judgment. Escape rooms are a beneficial, creative method to promote student learning. A health assessment escape room added a new twist to a health assessment final check-off. In spite of challenges, benefits of a health assessment escape room can be successful in promoting engagement, enhancing teamwork, critical thinking and clinical judgment.

Genell Stites, MSN, RNC, C-EFM and Dena Banta Corona, MSN, APRN, FNP-BC read and approved the final manuscript in which they equally contributed to the design, draft and revisions.

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The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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The Publication Ethics Committee of the Association for Health Sciences and Education. The journal’s policies adhere to the Core Practices established by the Committee on Publication Ethics (COPE).

Not commissioned; externally double-blind peer reviewed.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

No additional data are available.