Method

The American Association of Colleges of Nursing (AACN) has identified competencies pertinent to emergency preparedness in pre-licensure nursing programs, underscoring nurses’ crucial role in responding to emergencies and disasters. ⁵ Emphasizing areas such as public health preparedness, disaster triage principles, and the nursing role in disaster response, these competencies equip pre-licensure nursing students with the essential knowledge and skills to address community and public health challenges during crises. Escape room games offer a unique way to teach nursing students competencies related to disaster preparedness by immersing them in realistic scenarios that simulate high-stakes situations, mirroring the dynamic challenges they may face in real-life disaster response.

Our escape room game and unfolding simulation were developed to prepare nursing students for disaster preparedness and outbreak investigation using guiding principles for escape room games outlined by Hawkins et al.,Reference Hawkins, Wiles and Tremblay ⁶ Tassemeyer, Rowland, and Barnason,Reference Tassemeyer, Rowland and Barnason ⁷ and the National League of Nursing’s (NLN) Simulation Design Template. ⁸ We implemented a multi-component escape room game and unfolding simulation involving standardized patients for 29 pre-licensure nursing students within a population health/community health nursing course, within a private university in the southeastern region of the United States. To prepare the students for the experience, in the week preceding the escape room game and unfolding simulation, students received classroom content in a lecture format covering key topics such as public health preparedness, principles of disaster triage, and the nursing responsibilities in disaster response. Students were also required to complete online modules on the principles of epidemiology, notifiable diseases, and the nurse’s role in outbreak investigation.

On the day of the escape room and unfolding simulation, students attended a 30-minute pre-brief where faculty reviewed the simulation objectives, clarified role expectations, and provided an overview of the scenario. Students were then divided into 6 groups of 4 and 1 group of 5. Each student was assigned a role with its just-in-time description: Team leader, Assistant/Runner, Bedside Nurse, and Communicator. Two faculty were present during the escape room/simulation to facilitate the students and assure that students with challenges solving the escape room clues could receive adequate assistance.

In their groups, students first completed an escape room challenge to solve a tuberculosis (TB) outbreak in a nursing home using 6 clues related to epidemiology concepts, infection control, and disease testing. Students completed 6 tasks: completing a crossword puzzle (see Figure 1), calculating an incident rate quiz, answering a reportable disease quiz, interpreting a message written with invisible ink, finding a clue hidden in a wall clock, and creating a TB testing station set up. Each correctly executed task yielded a clue or key to open the next task. If the students wrongly completed a task, they could use a clue card to obtain assistance from the faculty. Students had up to 45 minutes to complete the escape room. After completing the escape room, students participated in a 30-minute standardized debrief where they were prompted to discuss their reactions and lessons learned, and to clarify information from faculty.

Figure 1.

Crossword puzzle.

Table 1.

Evaluation data for escape room (n = 29) and disaster simulation (n = 11)

Students next participated in a second pre-brief (20 minutes duration) to receive background information regarding the unfolding simulation. While in their previously assigned groups, students completed a “rapid-response” (15 minutes duration) disaster simulation related to a tornado at the same nursing home as in the earlier escape room game. To support the simulation being as realistic as possible, the room was set-up with little to no light, a smoke machine to mimic poor air quality and visibility, the presence of debris and downed electrical wires, and 3 expired or injured nursing home residents played by trained standardized patients. The realistic simulation required students to demonstrate disaster triage, evacuation of residents, and disaster communication with the media. Upon the simulation’s conclusion, students received feedback from standardized patients well-trained in giving general and scenario-specific feedback (10 minutes duration).

Students then repeated the scenario, incorporating this feedback for another 45 minutes. During the repeated scenario, students provided the rationale for their interventions and discussed actions/decisions with their teammates. The unfolding simulation concluded with a 45-minute standardized debrief, during which faculty trained in the scenarios and the standardized debriefing content discussed concepts related to the simulation objectives and lessons learned. The time frame from the initial pre-brief to the final debrief was 4 hours.

The implementation and evaluation of this educational approach was deemed as non-human subjects research by the University’s Institutional Review Board (IRB) and consequently, informed consent to participate in the evaluation was not required, although the evaluation survey included a statement to confirm consent. After participating in the escape room, students completed a 24-item investigator-developed questionnaire consisting of Likert-scale items, select-all-that-apply items, and open-ended questions designed to measure the escape room’s effectiveness in improving students’ knowledge of epidemiological concepts and improving students’ confidence in applying the concepts to a disease outbreak investigation. The survey also measured students’ perceptions of the appropriateness of the escape room format for learning epidemiological concepts and disease outbreak investigation, and students’ recommendations for improving the escape room game.

After participating in the unfolding simulation, students completed a 13-item, validated questionnaire,Reference Phan, Geller and Broughton ⁹ designed to measure the simulation’s effectiveness in improving students’ confidence in participating in disaster response and knowledge of disaster preparedness. The post-simulation survey also measured students’ perceptions of the appropriateness of the simulation for learning disaster response and students’ recommendations for improving the simulation.