Finding the 'QR' to Patient Safety: Applying Gamification to Incorporate Patient Safety Priorities Through a Simulated 'Escape Room' Experience

The effects of flipped learning and gamification on nursing students' patient safety education: A mixed method study

Background

The importance of enhancing education to promote nursing students' patient safety competency is increasing. Hence, implementing diverse educational programs and assessing their outcomes is essential.

Objectives

To examine the effects of flipped learning and gamification on nursing students' patient safety education.

Design

A mixed-method design employing a quasi-experimental design with a pre-post control group design and qualitative thematic analysis.

Methods

The study was conducted at a South Korean university in W City from September to December 2022. It included 55 s-year nursing students. The experimental group (n = 28) participated in a 30-h patient safety education course using flipped learning and gamification, whereas the control group (n = 27) received only written patient safety education materials. Learning motivation, collective efficacy, patient safety competency, and game evaluations were measured. Data were analyzed using the χ2 test, Fisher's exact test, t-test, repeated-measures multivariate analysis of covariance, repeated measure analysis of covariance, and generalized estimating equations. Self-reflection journals on game participation experiences were analyzed using qualitative thematic analysis.

Results

Learning motivation scores did not differ significantly between groups for time, or interactions between groups and time, but collective efficacy and patient safety competency scores showed significant differences in the interactions between groups and time. The experimental group showed a high satisfaction score in game evaluation. Qualitative analyses were used to extract four themes-three positives: "fun and immersion differentiated from existing classes," "improved the learning outcomes and learning motivation," and "realized the value of collaboration and communication," and one negative: "feeling down due to unfamiliarity."

Conclusions

This program creates positive learning experiences and enhances nursing students' collective efficacy and patient-safety competencies. It is expected to be utilized in various future nursing courses.

Implementing a Large-Scale Escape Room: An Intervention to Increase Electronic Health Record Downtime Competence

The purpose of this project was to evaluate an escape room's impact on electronic health record downtime competence. Seventy-four nurses simultaneously completed a sequentially designed, tabletop escape room to escape a zombie invasion. Results showed 92% of participants were motivated by the escape room; 90% reported it significantly influenced their learning. Findings were reinforced when the institution had an unplanned electronic health record downtime 2 days after the event.

Disaster day: a simulation-based competition for educating emergency medicine residents and medical students on disaster medicine

BACKGROUND

Disaster medicine is a growing field within the specialty of emergency medicine, but educational training typically focuses on hospital drills or other educational strategies, such as didactics, simulation, or tabletop exercises. With the success of gamification in other medical education applications, we sought to investigate if a novel gamified curricular innovation would lead to improved test performance and confidence in the ability to manage a real mass casualty incident (MCI).

METHODS

This was a prospective observational study of medical students and emergency medicine residents who participated in a 4-h simulation-based competition consisting of 4 unique stations. Each station had learning objectives associated with the content taught. Learners completed a pre-event survey, followed by participation in the competitive gamification event, and subsequently completed a post-event survey. Differences between pre- and post-event responses were matched and analyzed using paired and unpaired t tests for medical knowledge assessments, the Mann-Whitney U test for perceptions of confidence in the ability to manage an MCI event, and descriptive statistics provided on perceptions of the effectiveness of this educational strategy.

RESULTS

We analyzed data from 49 learners with matched (and unmatched) pre- and post-event survey responses. There was a statistically significant increase in medical knowledge assessment scores in both unmatched group means and available matched data (47 to 69%, p < 0.01, and 50 to 69%, p < 0.05). Self-reported confidence in the ability to handle an MCI scenario also significantly increased (p < 0.01). Finally, 100% of respondents indicated they "agreed" or "strongly agreed" that the event was an effective education tool for disaster preparedness and training.

CONCLUSIONS

In this study, we found that learners perceived a novel gamification event as an effective educational tool, which led to improved learner knowledge and self-reported confidence in the ability to manage a real MCI.

Game-based learning in medical education

At present, medical education is rapidly evolving. Game-based learning (GBL) has been gradually used for education, and several innovations have emerged. The emergence of serious games and gamification provides alternative approaches for educators to improve the medical teaching process. Both serious games and gamification exert their education-promoting function by providing the possibility of combining learning activities such as feedback, testing, and spaced repetition with active participation and autonomy as well as positive experiences for students. Developing effective GBL modalities has the potential to bring immersive experiences for medical students and improve their study outcomes. Herein, we reviewed recent studies employing GBL in medical education, including serious games and gamification teaching. Furthermore, we also discussed the effectiveness and limitations of GBL to suggest future directions for the development and application of GBL in medical education.

The research escape hunt: An escape room-scavenger hunt for resident education

Objectives

Research and evidence-based medicine (EBM) education are important elements of emergency medicine (EM) residency training; however, curricular time is limited and integrating novel strategies to engage learners and improve understanding of complex concepts is challenging. We sought to develop a unique research escape hunt educational experience to teach EM residents basic research and EBM skills using an active-learning, team-based strategy.

Methods

A nine-station escape room-scavenger hunt was designed around educational content including (1) predictive statistics and diagnostic test characteristics, (2) interpretation of data and statistical analysis, (3) study design, (4) informed consent for research, and (5) the ethical principles guiding research. Stations required participants to use a variety of strategies to solve puzzles, with a correct response required to progress through the escape hunt. Teams worked together to solve each station's puzzles, with opportunities to reinforce the content in real time. Subsequent sessions were presented in a virtual format using Zoom breakout rooms over the past 2 years.

Results

Postactivity assessments were grounded in Kirkpatrick's model and focused on participants' reactions, learning, and behavior. Participants reported high levels of satisfaction (100% [21/21] "satisfied" or "extremely satisfied") and engagement (95% [20/21] "engaged" or "very engaged") with the activity, as well as increased comfort with the research and EBM concepts covered (91% [19/21] "agree" or "strongly agree" increased comfort), and demonstrated improvements in knowledge across each content area presented (91% [19/21]).

Reflective Discussion

This practical, team-based curriculum was found to be a successful way to engage residents with research methodology and EBM content. This curriculum is feasible for both in-person and virtual formats and we will continue to use this as a component of our EM residency program moving forward.

New Resident Training Strategy Based on Gamification Techniques: An Escape Room on Sepsis in Children

AIM

Adapting "escape rooms" for educational purposes is an innovative teaching method. The aim of this study was to ascertain the degree of learning of the residents. A secondary objective was to determine their degree of satisfaction.

METHODS

A prospective, observational study took place in October 2019. A sepsis-based escape room was designed and carried out. A mix of paediatric medical residents and paediatric nursing residents were enrolled. A prior knowledge test was carried out, which was repeated right at the end of the escape room and then again three months later. Furthermore, all participants completed an anonymous post-study survey.

RESULTS

We enrolled 48 residents, 79.2% of whom were women. The mean score for the pre-escape room exam was 7.85/9 (SD 1.65), that for the post-escape room exam was 8.75/9 (SD 0.53), and for the exam three months later, it was 8.30/9 (SD 0.94). Among the participants, 18.8% did not manage to leave before the established 60 min time limit. The results of the satisfaction survey showed high participant satisfaction.

CONCLUSIONS

The escape room proved to be a valuable educational game that increased students' knowledge of sepsis management and showed a positive overall perceived value among the participants.

Gamification of graduate medical education in an emergency medicine residency program

OBJECTIVES

Our program implemented East EMWars, a year-long, longitudinal game that added competition to our existing curricular content. We surveyed residents to investigate the impact of gamification in emergency medicine residency training. We hypothesized that residents would report higher levels of motivation, engagement, and challenge with gamification compared to traditional didactics. Furthermore, we hypothesized that residents would exhibit generally positive perceptions about gamification as a learning tool and that it would translate to improved performance on the annual in-training examination.

METHODS

This was a single-center, prospective pre- and post-intervention survey study at a community-based emergency medicine residency program. Given the multiplicity of research questions and inherent nature of educational research, a mixed methods approach was utilized. We utilized nonparametric testing for quantitative data with paired responses pre- and post-intervention. We solicited comments on the post-intervention that were categorized under thematic approach and presented in complete and unedited form in the results.

RESULTS

Eighteen (100%) of eligible residents in our program participated in both surveys. There were statistically significant increases in reported levels of motivation, engagement, and challenge with gamification compared to traditional didactic methods. Residents also reported overwhelmingly positive general perceptions about gamification and its broader generalizability and applicability. We did not reach statistical significance in determining if in-training exam scores were associated with our gamification initiative.

CONCLUSIONS

This study was a first-of-its-kind look into a longitudinal game in an emergency medicine residency program. Although our results are encouraging, medical educators need further research to determine if this increase in motivation, engagement, and challenge will be associated with an increase in examination scores or, more importantly, healthcare outcomes. Theory-based, broader-scale, prospective studies are needed to further explore and help establish these associations and outcomes.

Escape box and puzzle design as educational methods for engagement and satisfaction of medical student learners in emergency medicine: survey study

BACKGROUND

Gamification in medical education has gained popularity over the past several years. We describe a virtual escape box in emergency medicine clerkship didactics to teach chest pain and abdominal pain and compare this instructional method to a traditional flipped classroom format.

METHODS

A virtual escape box was designed at our institution and incorporated into the mandatory two-week emergency medicine clerkship. The game consisted of a PDF with four cases containing puzzles to unlock a final clue. Likert scale surveys were administered to assess participants' perceptions of the escape box format; of clerkship didactics as a whole; and of the clerkship overall. These responses were compared to the prior year's evaluations on flipped classroom didactics and clerkship.

RESULTS

One hundred thirty-four learners participated in the escape box and completed the survey. Eighty-six percent strongly agreed with feeling more engaged with the escape box, 84% strongly agreed with learning something new, 81% strongly agreed with finding the escape box to be satisfying, 78% strongly agreed with being able to apply knowledge gained, and 74% strongly agreed with wanting more escape boxes incorporated into medical education. The escape box showed a higher average score (3.6 ± 0.63) compared to chest pain (3.5 ± 0.67) and abdominal pain (3.2 ± 0.77) flipped classroom sessions (p = 0.0491) for the category of "lecturer explaining content clearly and at the proper level of complexity." For the category of "lecturer provided effective instructional materials," the escape box showed higher scores (3.6 ± 0.63) compared to flipped classroom for chest pain (3.4 ± 0.77) and abdominal pain (3.1 ± 0.80) (p < 0.001).

CONCLUSIONS

Escape boxes are adaptable to a virtual format and can teach abstract concepts such as teamwork and communication in addition to traditional lecture content. Ratings of didactics were higher for the escape box compared to the flipped classroom, while ratings of overall clerkship experience were not found to change significantly.

Emergency and critical care professionals' opinion on escape room as a health sciences evaluation game: A cross-sectional descriptive study

New teaching and evaluation methods are growing in health sciences. The escape room is a game that is showing benefits for assessing knowledge and important competencies in healthcare professionals. The aim of this study is to analyse the opinion of emergency and critical care professionals on the use of escape rooms as an evaluation game.A quantitative, descriptive, cross-sectional study was conducted using an ad-hoc questionnaire with a Likert-type scale. The study included emergency and critical care professionals who participated in the escape room "The Frustrated Emergency and Critical Care Professional," that took place during an emergency and critical care national congress. Data collection was carried out in June 2019.The sample was composed of n = 50 emergency and critical care professionals, 52% of whom were physicians and 48% were nurses. Professionals believe that this is a good teaching game for evaluation and useful for strengthen knowledge (4.7 points), as well as to improve teamwork and the ability to work under pressure (4.9).The escape room is a useful evaluation game in the context of emergency and critical care units that also allows training the teamwork and working under pressure competencies.

Can Students Create Their Own Educational Escape Room? Lessons Learned from the Opioid Crisis Escape Room

Educational escape rooms (EERs) are live-action, team-based games used to teach content-related and generic knowledge and skills. Instead of students just playing the EER, we believed that giving them the opportunity to create their own EERs would augment the learning effects of this teaching method. We report on the feasibility, evaluation, and lessons learned of our assignment on an opioid epidemic-based EER. This original teaching method appealed to most students, but the workload was evaluated to be too high. Our lessons learned include the need for sufficient (extrinsic) motivation, careful explanation of the assignment, and small group sizes.

Ready Patient One: How to Turn an In-Person Critical Care Simulation Scenario Into an Online Serious Game

Introduction

Serious gaming has become popular in healthcare education as an engaging way to train learners. When coronavirus disease 2019 (COVID-19) forced the cancellation of in-person simulation sessions, we designed a serious game to deliver content in an interactive format with no out-of-pocket expense. We describe the design process and game reception so that others may replicate it.

Methods

We designed an online game using Choose-Your-Own-Adventure (CYOA) and Escape Room concepts. Using online survey software, we presented an interactive story based on an existing simulation scenario and included interactive puzzles as roadblocks to scenario progression. Each puzzle represented a critical care concept, and many contained hyperlinks to prior basic science lecture material to reinforce learning. A post-game survey assessed students’ experience.

Results

All (N=88) students enrolled in a scheduled simulation session participated in the game, and 75% (66/88) responded to a post-participation survey. All respondents (100%) were able to complete the game. The majority (57.6%) completed the game in 30 minutes to 1 hour. Most students strongly agreed or agreed that the game enhanced their understanding of critical care concepts (93.9-97.0%), and that they were interested in doing more CYOA games (90.9%).

Conclusion

The game was well-received, delivered critical care content, and challenged students to apply basic science principles to medical decision-making from the safety of their own homes. The game was self-guided, requiring minimal active facilitator involvement. We plan to expand the use of the game to other settings and explore its use in formative/summative assessment and remediation.

A Didactic Escape Game for Emergency Medicine Aimed at Learning to Work as a Team and Making Diagnoses: Methodology for Game Development

Background

In the health care environment, teamwork is paramount, especially when referring to patient safety. We are interested in recent and innovative solutions such as escape games, which is a type of adventure game that may be highly useful as an educational tool, potentially combining good communication skills with successful gamification. They involve teams of 5 to 10 individuals who are “locked” in the same room and must collaborate to solve puzzles while under pressure from a timer.

Objective

The purpose of this paper was to describe the steps involved in creating and implementing an educational escape game. This tool can then be put into service or further developed by trainers who wish to use it for learning interprofessional collaboration. Therefore, we started with an experience of creating an educational escape game for emergency medicine teams.

Methods

We chose to develop an educational escape game by using 6 successive steps. First, we built a team. Second, we chose the pedagogical objectives. Third, we gamified (switched from objectives to scenario). Next, we found the human and material resources needed. Thereafter, we designed briefing and debriefing. Lastly, we tested the game.

Results

By following these 6 steps, we created the first ambulant educational escape game that teaches people, or nurses, doctors, and paramedics, working in emergency medicine to work as a team.

Conclusions

From a pedagogic point of view, this game may be a good tool for helping people in multidisciplinary fields (medical and paramedical teams) to learn how to work collaboratively and to communicate as a group. Above all, it seems to be an innovative tool that complements medical simulation–based learning and thus consolidates traditional education.

Effectiveness of an escape room for undergraduate interprofessional learning: a mixed methods single group pre-post evaluation

BACKGROUND

Interprofessional practice (IPP) has been shown to contribute to quality service provision and improved health outcomes. This knowledge has led to the integration of interprofessional education into course curricula for many health-care disciplines. Offering interprofessional education in rural areas to students undertaking work integrated learning placements is challenging particularly because of the diversity of students and placement dates combined with the student focus on the assessable placement curriculum. This research investigated and evaluated the utility of an escape room as an educational modality that facilitates learning whilst providing a supportive and motivating learning environment. Our project focused on the acquisition of interprofessional practice knowledge and experience by a health professional student cohort.

METHODS

This study used the novel intervention of an escape room combined with an interactive teaching session to test student engagement and learning about interprofessional practice and teamwork. The research used a mixed methods single group pre-post design.

RESULTS

Fifty students (78% female) from seventeen universities and seven professions participated in teams of three to six members. Most participants (66%) had not previously completed an escape room. The results showed that the intervention provided effective and engaging learning and was intrinsically appealing to students despite its non-assessable nature. Individual student reflection on their participation showed developing insight into the critical importance of clear communication and intentional team member collaboration in the provision of effective interprofessional practice.

CONCLUSIONS

The escape room intervention added value to the placement curriculum and proved flexible for a heterogeneous student cohort.

Comparing the Effectiveness of a Virtual Toxicology Escape Room at Two Emergency Medicine Residencies

Introduction Physical distancing guidelines during the coronavirus disease 2019 (COVID-19) pandemic forced medical residency programs to move a large portion of required didactics to virtual settings. Toxicology, a core component of emergency medicine (EM) education, was forced to adapt to similar constraints. An in-person escape room style puzzle was modified to a virtual format for educational purposes, and shared with and evaluated by two different residency programs. Materials and methods A virtual escape room, "Escape the Toxin: Online!" was created to test knowledge of toxicologic ingestion and antidote utilizing Google Forms and delivered using Zoom teleconference software to two EM residency programs in the Philadelphia region. After small groups completed the gamified activity, their scores were calculated and they completed an anonymous evaluation. Results Residents at the program where a Medical Toxicology fellowship is located found the virtual escape room to be more effective and enjoyable compared to the second program. Despite some differences in perceived effectiveness, the majority of participants were able to correctly solve the puzzle and get to the antidote. Conclusion The majority of learners who participated from both residencies agreed that they would recommend this virtual program to other EM residents.

Assembly Line Education: A Novel Educational Technique for Today's Learners

Background

Education is undergoing a transformation. The traditional passive lectures are failing to capture and inspire the new generation of learners who value more active and collaborative learning techniques.

Objective

We sought to create a novel educational technique to integrate into our curriculum that would be more personalized, employ more active learning and collaboration, and allow for an effective assessment of resident strengths and weaknesses.

Discussion

We created a monthly assembly line education academic half-day that evolved to replace one of the typical in-classroom didactics each month. Faculty run small-group simulation rooms, procedure workshops, competitive ultrasound, and wellness stations through which residents and medical students rotate.

Conclusion

This novel education technique resulted in a more personalized approach that increased resident interest, sparked the creation of a very popular MedEd-Simulation elective, and allowed the faculty to gain a better sense of resident strengths and deficiencies.