The Use of Escape Room Simulations in Undergraduate Medical Education
Authors
Alexa R. Lauinger, BS1, Athena Ryals BS3, Mae Vogel, MS3, Shandra Jamison, MA1,3 Carlos E. Brown Jr, MD1,2
1 University of Illinois Urbana- Champaign, Carle Illinois College of Medicine, Urbana, Illinois
2 Carle Foundation Hospital, Emergency Department, Urbana, Illinois
3 University of Illinois Urbana-Champaign, Health Care Engineering Systems Center, Urbana, Illinois
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Corresponding Author
Shandra Jamison, MA, University of Illinois Urbana-Champaign, Carle Illinois College of Medicine, Urbana, Illinois
Email: shandraj@illinois.edu
Brief Description
Undergraduate medical education is constantly growing and adapting to offer students diverse learning strategies while aiming to improve engagement from students and competency of medical skills. Two changes that have been implemented in recent years include the use of simulation and gamification of teaching experiences. Combining aspects of simulation with gamification has led to the use of escape rooms. Studies into the benefits of using escape rooms demonstrate improved student reactions and retention of content. However, there have been few studies looking at the effectiveness of escape room simulations in medical undergraduate education. Most of the research in this area uses nursing students as participants. This review examines the current evidence of outcomes for escape rooms in medical school and the overall format of designing and implementing escape rooms as a teaching strategy. However, there are limitations of small sample sizes, limited follow-up, and heterogeneous methods for implementing this type of simulation, but current research supports the integration of escape room-type sessions into medical schools.
Introduction
Medical education is an evolving and adapting field that works to incorporate modern teaching techniques and technologies. Traditional teaching strategies implemented a didactic-based approach for the first part of undergraduate medical education followed by clinical experiences (Pock, et al., 2013). Recently, there has been a shift to earlier clinical experiences, including simulated sessions to give students a safe context to facilitate learning (Herrera-Aliaga, 2022). The outcome of this change led to increased interest in the material, confidence in decision-making, and overall performance (Kimura et al., 2021; Everson et al., n.d.; McInerney et al., 2022). With the development of technology and the continued integration of simulated sessions into medical school, we would expect future simulations to improve these aspects of learning even further. Along with the push for more simulated experiences, gamification has infiltrated undergraduate medical training to allow for diverse educational opportunities with similar benefits to those we saw in simulation-based education (Krishnamurthy et al., 2022). Gamification and the advancement of technology both play a role in escape room simulations for medical education.
Escape rooms are a type of interactive experience in which a team of players are locked inside a room and must work together to solve puzzles and accomplish tasks within a given timeframe to escape. Recently, escape rooms have been integrated into educational environments to improve student engagement (Backhouse & Malik, 2019; Kinio, 2019). The use of escape room simulations has also been implemented in professional settings to consolidate knowledge, improve interdisciplinary relationships, and evaluate competency (Zhang et al., 2019; Reinkemeyer et al., 2022). An escape room simulation can be a health-care-focused simulated interactive activity that incorporates traditional parts of an escape room into training (Anderson et al., 2021). Educational escape rooms have been adopted across different medical settings, such as nursing schools and medical graduate or residency programs. Healthcare programs using this method of education show improvement in retention, engagement, and teamwork through escape room simulations (Zhang et al., 2019; Reinkemeyer et al., 2022). However, there has been a lack of undergraduate medical programs or medical schools adopting this teaching strategy up to now.
Although escape room simulations have shown promising results in several healthcare training programs, there is not a validated framework to adapt these teaching strategies to undergraduate education. A more thorough understanding of the key aspects and longitudinal outcomes of escape room simulations is needed before implementation into the current education system. This review aims to 1) describe the current format of escape room simulations, especially in the wake of the COVID-19 pandemic, 2) examine the types of skills which can be effectively taught in medical escape rooms, and 3) summarize the outcomes of studies that evaluate the inclusion of escape room simulations in undergraduate medical training programs.
Methods
Three databases (PubMed, Web of Knowledge, and Scopus) were queried for publications relating to the implementation of escape room simulation in medical education with a focus on the undergraduate level. The search strategy for the databases used was: (Escape AND Room) AND (Medical AND School) OR (Residency) OR (Nursing AND school). The included papers were limited to full-text articles published in English. Abstracts, editorials, and reviews were excluded. The included papers were reviewed for skills utilized in the simulation, assessment types, and outcomes. Results are summarized in this literature review.
Results
Our literature search hit upon nine papers that focused on the outcomes and effectiveness of utilizing escape room simulations in medical undergraduate education (Table 1). Together these studies involved 568 medical students as participants, with most sessions catering to preclinical students.
Of the studies included, eight out of nine integrated a post-simulation assessment to gauge students' attitudes toward the escape room experience, conversely only one study conducted a pre-simulation survey. Additionally, two out of nine studies employed both pre- and post-simulation tests to evaluate participants of which one study assigned grades to the assessment while the other included a follow-up test two weeks after the session.
Published papers included a debriefing session to answer questions and discuss objectives with participants following the escape room activity. Only one study compared the escape room simulation with another type of learning session, specifically case-based learning. Notably, the escape room simulation was implemented across a diverse array of medical topics (Table 1).
Table 1: Publications that evaluate the use of escape room simulations in undergraduate medical education.
Discussion
Format of Escape Room Simulations
Since the implementation of escape room simulations into medical education, there have been specific frameworks and key aspects that have been suggested as necessary for successful outcomes (Hawkins et al., 2020). There has also been an increase in the number of studies which outline the process of designing, testing, and implementing escape rooms into the curriculum (Dittman et al., 2022; Eukel & Morrell, 2021). The important facets to include when creating and implementing an escape room simulation are:
· Objectives: define specific, measurable skills the simulation will teach participants
· Design: determining the resources and time available for the simulation then develop appropriate puzzles and tests for the escape room
· Piloting: testing the simulation, especially for the inability to skip clues
· Prebrief: preparation by participants for the simulation
· Debrief: discussion post-simulation to discuss questions and review objectives with participants
The above aspects of the experience allow for an informal and low-pressure challenge for students (Hawkins et al., 2020). The use of these tactics can help standardize the development of simulations to ensure the effectiveness of escape room simulations and can improve the ability of programs to incorporate escape room models into their curriculum without increased obstacles from trial and error.
Adaptation to Remote Simulations
In the wake of the COVID-19 pandemic, there has been a push to convert some lessons into remote learning opportunities which includes simulated sessions. The study of escape room simulations in this context demonstrates the adaptability of strategies such as escape rooms that are encouraging Donovan et al. outlines the creation, implementation, and outcomes of a remote escape room using create-your-own-adventure software combined with online surveys and educational programs (Donovan, n.d.). Horn also used a combination of standalone, online programs to create and publish a remote escape room based on cardiac physiology (Horn, 2023). The use of remote platforms for the medical escape room demonstrates similar responses in engagement, enjoyment, and functionality as the in-person sessions (Grupel et al., 2022; Diaz et al., 2021). Results further support the use of escape room simulations since they are adaptable and can accommodate a variety of school curriculums and resources. The use of virtual escape rooms has shown the ability to be targeted towards developing nontraditional skills such as information searching and summarization (Diaz et al., 2021). This can add to the variety of skills that simulations have been used to build and solidify students’ education.
Context of Teaching
Apart from objectives, piloting, and briefing, it is also important to examine the learning content that is being targeted. Escape room simulations have been employed within medical residency programs, nursing schools, and pharmacy schools to not only teach procedures, dosage calculations, and conduct assessments, but also to foster the development of interpersonal skills and other such soft skills (Powers et al., 2022; Millsaps et al., 2022; Fusco et al., 2022; Rosenkrantz et al., 2019); studies focused on medical schools have targeted nontechnical skills, orientation to simulations, knowledge development, and assessments (Liu et al., 2020; Akatsu et al., 2022; Martin & Gibbs, 2022). Across the different objectives previously listed, there have been similar outcomes in the engagement and enjoyment of students throughout the experiences.
The broader context demonstrates the ability of escape rooms to teach soft skills, such as teamwork, communication, and leadership; the use of escape room simulations to solidify procedures suggests that similar experiences can be applied to medical schools to teach students technical practices (e.g., intubation and CPR). An unexpected application of simulation escape rooms is their use in the assessment of the aforementioned skills. Unlike traditional simulations, escape rooms vary in the puzzles used and the possible measurements which can be used to assess success. Consequently, the frameworks and objects of the simulation must be set well before implementing the assessment.
Outcomes of Escape Room Simulations
As previously mentioned, escape room simulations have been used for several years across healthcare training programs. In comparison, there have been few studies on the impact of escape room simulations within undergraduate medical education. However, the studies found do support the use of escape room simulations to create a low-pressure setting to teach a variety of material, including nontechnical skills and competency (Akatsu et al., 2022; Rosenkrantz et al., 2019). Overall, the studies demonstrate improved student reactions, retention, and teamwork in the teaching sessions (Wu et al., 2018; Rosenkrantz et al., 2019; Podlog et al., 2019). Escape room simulations are an effective teaching method compared to case-based learning (Faysal et al., 2022). In each study, there were a variety of puzzles and challenges implemented to evaluate and practice different technical skills. Apart from the technical knowledge utilized in the simulation, each study noted a degree of development in communication and teamwork. Consistently, there was an increase in student engagement and enjoyment during the sessions (Wu et al., 2018; Rozenkrantz et al., 2019; Podlog et al., 2019). Overall, early studies examined the use of escape room simulations in undergraduate medical education and support the integration of these techniques into medical schools.
The Future of Escape Rooms in Medical Education
Escape room simulations have been successful for several years across a range of healthcare training programs, and early evidence of their integration into undergraduate medical education has shown encouraging results (Diaz et al., 2021; Cerenzio & Ocheretyaner, 2021; Khanna et al., 2012). The simulations have the potential to train students in an exciting, low-pressure environment that improves engagement, enjoyability, and consolidation of the material. In addition to being effective, simulations are also highly adaptable to a variety of skills, resources, and settings (Grupel et al., 2022). Drawing from the reported results, escape room simulations are likely to be integrated further into undergraduate medical education in the next several years. As escape room simulations become more standardized across schools, we will better understand the long-term impacts of the sessions and their ability to improve students' learning experiences. We will also see the adaptation of such methods to a wider variety of skills that are necessary for students to practice.
Limitations of Current Research
Limitations of current research in this field are the short length of studies that have been published. Only recently have escape rooms been used in medical schools. As a result, there is limited information on the long-term effects of these teaching methods. Most outcomes are measured using a post-simulation survey and lack a baseline or a follow-up assessment for retention. The current studies also include a limited number of participants. As demonstrated in Table 1, several of the studies mentioned a limitation being sample size due to enrollment and the difficulty of running the escape room (Backhouse & Malik, 2019; Kinio et al., 2019; Guckian et al., 2020; Liu et al. 2020). The small sample sizes of the studies reported on naturally lend themselves to higher potential errors in the data; it is more difficult or impossible to eliminate outliers. Further research is needed comparing the outcomes of escape room simulations to other forms of teaching with more objective outcome measures and a longer follow-up time.
Conclusion
Undergraduate medical education is an ever-changing field that must utilize a range of teaching strategies to improve student engagement, confidence, and competency. The newest addition to teaching strategies is the simulated medical escape room which combines medical simulation and gamification into interactive, low-pressure sessions. Although these methods have been integrated into other healthcare training programs, there are limited studies of their effectiveness in medical schools. While early evidence indicates success with integrating the methods, escape room simulations should be explored further for long-term outcomes and improved sample sizes during the integration of these strategies into standard practice.
References
Pock, A. R., Pangaro, L. N., Green, C. B., & Laughlin, L. (2013). Undergraduate Medical Education: Past, Present, and Future. Military Medicine, 178(5), 474–478. https://doi.org/10.7205/MILMED-D-12-00456
Herrera-Aliaga, E., & Estrada, L. D. (2022). Trends and Innovations of Simulation for Twenty-First Century Medical Education. Frontiers in Public Health, 10, 619769. https://doi.org/10.3389/fpubh.2022.619769
Kimura, T., Kojo, K., Shiga, M., Chihara, I., Ikeda, A., Kandori, S., Kojima, T., Haruta, J., & Nishiyama, H. (2021). Impact of Early Exposure to Simulation Program on Undergraduate Medical Students’ Interest in Urology. Journal of Medical Education and Curricular Development, 8, 23821205211020750. https://doi.org/10.1177/23821205211020750
Everson, J., Gao, A., Roder, C., & Kinnear, J. (n.d.). Impact of Simulation Training on Undergraduate Clinical Decision-making in Emergencies: A Non-blinded, Single-centre, Randomised Pilot Study. Cureus, 12(4), e7650. https://doi.org/10.7759/cureus.7650
McInerney, N., Nally, D., Khan, M. F., Heneghan, H., & Cahill, R. A. (2022). Performance effects of simulation training for medical students – a systematic review. GMS Journal for Medical Education, 39(5), Doc51. https://doi.org/10.3205/zma001572
Krishnamurthy, K., Selvaraj, N., Gupta, P., Cyriac, B., Dhurairaj, P., Abdullah, A., Krishnapillai, A., Lugova, H., Haque, M., Xie, S., & Ang, E.-T. (2022). Benefits of gamification in medical education. Clinical Anatomy, 35(6), 795–807. https://doi.org/10.1002/ca.23916
Backhouse, A., & Malik, M. (2019). Escape into patient safety: Bringing human factors to life for medical students. BMJ Open Quality, 8(1), e000548. https://doi.org/10.1136/bmjoq-2018-000548
Kinio, A. E., Dufresne, L., Brandys, T., & Jetty, P. (2019). Break out of the Classroom: The Use of Escape Rooms as an Alternative Teaching Strategy in Surgical Education. Journal of Surgical Education, 76(1), 134–139. https://doi.org/10.1016/j.jsurg.2018.06.030
Zhang, X. C., Diemer, G., Lee, H., Jaffe, R., & Papanagnou, D. (2019). Finding the ‘QR’ to Patient Safety: Applying Gamification to Incorporate Patient Safety Priorities Through a Simulated ‘Escape Room’ Experience. Cureus, 11(2), e4014. https://doi.org/10.7759/cureus.4014
Reinkemeyer, E. A., Chrisman, M., & Patel, S. E. (2022). Escape rooms in nursing education: An integrative review of their use, outcomes, and barriers to implementation. Nurse Education Today, 119, 105571. https://doi.org/10.1016/j.nedt.2022.105571
Anderson, M., Lioce, L., M. Robertson, J., O. Lopreiato, J., & A. Díaz, D. (2021). Toward Defining Healthcare Simulation Escape Rooms. Simulation & Gaming, 52(1), 7–17. https://doi.org/10.1177/1046878120958745
Wu, C., Wagenschutz, H., & Hein, J. (2018). Promoting leadership and teamwork development through Escape Rooms. Medical Education, 52(5), 561–562. https://doi.org/10.1111/medu.13557
Guckian, J., Sridhar, A., & Meggitt, S. J. (2020). Exploring the perspectives of dermatology undergraduates with an escape room game. Clinical and Experimental Dermatology, 45(2), 153–158. https://doi.org/10.1111/ced.14039
Liu, C., Patel, R., Ogunjinmi, B., Briffa, C., Allain-Chapman, M., Coffey, J., Kallam, N., Leung, M. S. T., Lim, A., Shamsad, S., El-Sharnouby, F., Tsang, E., Whitehead, J., Bretherton, J., Ramsay, L., & Shelmerdine, S. C. (2020). Feasibility of a paediatric radiology escape room for undergraduate education. Insights into Imaging, 11(1), 50. https://doi.org/10.1186/s13244-020-00856-9
Donovan, C. M., Cooper, A., & Kim, S. (n.d.). Ready Patient One: How to Turn an In-Person
Critical Care Simulation Scenario Into an Online Serious Game. Cureus, 13(9), e17746. https://doi.org/10.7759/cureus.17746
Akatsu, H., Shiima, Y., Gomi, H., Hegab, A. E., Kobayashi, G., Naka, T., & Ogino, M. (2022).
Teaching “medical interview and physical examination” from the very beginning of medical school and using “escape rooms” during the final assessment: Achievements and educational impact in Japan. BMC Medical Education, 22(1), 67. https://doi.org/10.1186/s12909-022-03130-2
Faysal, L. R., Yasmin, R., Zaman, A., & Khan, R. A. (2022). Effectiveness of medical escape room on learning of undergraduate medical students in comparison with case-based learning in teaching of clinical dermatology. Rawal Medical Journal, 47(1).
Martin, A., & Gibbs, S. (2022). An Escape Room to Orient Preclinical Medical Students to the Simulated Medical Environment. MedEdPORTAL : The Journal of Teaching and Learning Resources, 18, 11229. https://doi.org/10.15766/mep_2374-8265.11229
Hawkins, J. E., Wiles, L. L., Tremblay, B., & Thompson, B. A. (2020). Behind the Scenes of an Educational Escape Room. AJN The American Journal of Nursing, 120(10), 50. https://doi.org/10.1097/01.NAJ.0000718636.68938.bb
Dittman, J. M., Amendola, M. F., Ramraj, R., Haynes, S., & Lange, P. (2022). The COMET framework: A novel approach to design an escape room workshop for interprofessional objectives. Journal of Interprofessional Care, 36(1), 161–164. https://doi.org/10.1080/13561820.2020.1870442
Eukel, H., & Morrell, B. (2021). Ensuring Educational Escape-Room Success: The Process of Designing, Piloting, Evaluating, Redesigning, and Re-Evaluating Educational Escape Rooms. Simulation & Gaming, 52(1), 18–23. https://doi.org/10.1177/1046878120953453
Horn, M. A. (2023). Design and evaluation of a new consolidation exercise for students studying cardiac physiology: A digital escape room. Advances in Physiology Education, 47(1), 82–92. https://doi.org/10.1152/advan.00176.2022
Grupel, D., Wennstroem, E., & Moran-Gilad, J. (2022). Escape room—The next generation of problem-based learning? Clinical Microbiology and Infection, 28(6), 768–770. https://doi.org/10.1016/j.cmi.2022.03.017
Diaz, D. A., McVerry, K., Spears, S., Díaz, R. Z., & Stauffer, L. T. (2021). Using Experiential Learning in Escape Rooms to Deliver Policies and Procedures in Academic and Acute Care Settings. Nursing Education Perspectives, 42(6), E168. https://doi.org/10.1097/01.NEP.0000000000000691
Powers, K., Brandon, J., & Townsend-Chambers, C. (2022). Preparing nursing students for home health using an escape room: A qualitative study. Nurse Education Today, 108, 105215. https://doi.org/10.1016/j.nedt.2021.105215
Millsaps, E. R., Swihart, A. K., & Lemar, H. B. (2022). Time is brain: Utilizing escape rooms as an alternative educational assignment in undergraduate nursing education. Teaching and Learning in Nursing, 17(3), 323–327. https://doi.org/10.1016/j.teln.2022.01.013
Fusco, N. M., Foltz-Ramos, K., & Ohtake, P. J. (2022). An Interprofessional Escape Room Experience to Improve Knowledge and Collaboration Among Health Professions Students. American Journal of Pharmaceutical Education, 86(9). https://doi.org/10.5688/ajpe8823
Rosenkrantz, O., Jensen, T. W., Sarmasoglu, S., Madsen, S., Eberhard, K., Ersbøll, A. K., & Dieckmann, P. (2019). Priming healthcare students on the importance of non-technical skills in healthcare: How to set up a medical escape room game experience. Medical Teacher, 41(11), 1285–1292. https://doi.org/10.1080/0142159X.2019.1636953
Podlog, M., Husain, A., Greenstein, J., & Sanghvi, S. (2019). Escape the Trauma Room. AEM Education and Training, 4(2), 158–160. https://doi.org/10.1002/aet2.10410
Cerenzio, J., & Ocheretyaner, E. R. (2021). Impact of an interactive, clinical decision-making workshop on student learning of antimicrobial stewardship principles. Currents in Pharmacy Teaching and Learning, 13(11), 1492–1497. https://doi.org/10.1016/j.cptl.2021.09.006
Khanna, A., Ravindran, A., Ewing, B., Zinnerstrom, K., Grabowski, C., Mishra, A., & Makdissi, R. (2021). Escape MD: Using an Escape Room as a Gamified Educational and Skill-Building Teaching Tool for Internal Medicine Residents. Cureus, 13(9), e18314. https://doi.org/10.7759/cureus.1831