Escape Room Methodology for the Assessment of Basic Operational Skills of Undergraduate Nursing Students: A Qualitative Study

doi:10.21203/rs.3.rs-3767549/v1

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Escape Room Methodology for the Assessment of Basic Operational Skills of Undergraduate Nursing Students: A Qualitative Study

https://doi.org/10.21203/rs.3.rs-3767549/v1

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Objective: The study analysed the learning experience of undergraduate nursing students in basic nursing operations using escape room teaching method.

Methods: Using descriptive phenomenology, we conducted semi-structured in-depth interviews with 12 undergraduate nursing students whose basic nursing skills were assessed using the escape room method. The Colaizzi seven-step analysis was used to organise and analyse the data.

Results: Two themes including learning effect and learning feedback were identified. Six sub-themes also emerged including novel assessment to stimulate learning interest and increase learning commitment; assessment under relaxed conditions, and weakened role of the invigilator; group cooperation for improved communication and collaboration; enhanced clinical thinking via combination of theory and practice; improved classification mechanism; and the need for optimal process.

Conclusion: The escape room teaching method should be combined with the training needs of nursing personnel, and further improve the training programme.

Nursing students

escape room

basic nursing

Learning experience

Qualitative research

Basic nursing is the most fundamental aspect of nursing curriculum. The learning content includes basic nursing knowledge and skills. The traditional teaching and assessment system for basic nursing often emphasizes the inculcation of of operational skills. However, it does not motivate students to practise, analyse, or resolve clinical challenges. Due to restricted thought patterns, the students' vocational ability is hindered. Experts in nursing education at home and abroad generally believe that the cultivation of professional core competence and clinical thinking by nursing undergraduates is important in higher education. Therefore, nursing teachers should focus on the introduction of new teaching methods to impart basic knowledge in order to improve students' comprehension and nursing skills.

International experts have introduced the concept of serious game (serious game, SU) into medical teaching with good results^[1]. SU integrates teaching and gaming concepts to ensure easy and efficient acquisition of theoretical knowledge and practical ability via integration of immersive contextual game and teaching skills, which not only stimulate learning interest, but also improve the learning efficiency ^[2]. An escape room (ER) is a real-life immersive game, which stimulates interest and challenges players to rely on accurate clues, colourful reasoning, and smooth collaboration, to complete the task within the specified time. The ER teaching method is based on the combination of medical theory, professional skills, and logical reasoning to crack the puzzle, and ultimately find the solution to meet the teaching goal, that is, the success of the "escape"^[3]. Accordingly, this study designed an ER nursing operation assessment programme for oral care, wearing and taking off isolation gowns and related basic nursing skills. The study used descriptive phenomenology to conduct semi-structured interviews with 12 nursing students. The participating students’ real-life experience and feelings were assessed. The study provides a reference for the subsequent design and implementation of a more optimised assessment programme.

1.1 Study subjects

This qualitative study was conducted in November 2023 at a university in Zhejiang. Purposive sampling method was used to select and interview sophomore nursing students of our university who participated in the assessment of basic nursing operations via ER. The sample size was based on the saturation of the interviews and no new themes were introduced ^[4]. The inclusion criteria were: (1) informed consent and willingness to participate in this interview; (2) sophomore nursing students who participated in the assessment of basic nursing operations via ER method; and (3) the ability to clearly and accurately express thoughts. Nursing students who never participated in the assessment of routine basic nursing skills were excluded. Combined with the criteria, 12 undergraduate nursing sophomores from our university were finally selected as the study subjects. The alphabets A-L were used instead of names to mask the identity of the subjects. The number of participants was determined after information saturation was reached during the interview collection period, i.e., no new themes were identified or repetitive information had emerged. The 10th interview was saturated with information and two additional interviews were conducted for confirmation based on the qualitative research methodology described previously ^[5]. All the participants agreed to be interviewed and none of them dropped out.

1.2 Methodology

1.2.1 Interview outline

Based on the study objective, literature review, and the semi-structured interview defined by descriptive phenomenology ^[6], the interview outline was generated. The interview questions included: (1) Have you experienced the ER game before? (2) What are your feelings about this assessment? (3) What is your opinion regarding the ER method compared with the regular assessment? (4) What do you think are the advantages and disadvantages of the ER teaching method? (5) Do you have any comments or suggestions about the ER teaching method?

1.2.2 Data collection methods

Semi-structured in-depth interviews were used for data collection. The purpose and content of the study were explained to the interviewees before the formal interviews were conducted. The subjects were promised strict confidentiality. Participants’ informed consent was obtained. Audio-records of the interviews, which lasted for 20 to 30 minutes, were also obtained. Data were collected until no new themes emerged.

1.2.3 Analysis of information

Records were completed within 24 hours after the transcription of the interview. The data were checked twice. Statements related to the purpose of the study were extracted. Similar points of view were identified. Interviewees were questioned again for confirmation. The interview data were collated and analysed using the Colaizzi seven-step method ^[7]. The researcher read the interview data repeatedly by reading the transcripts several times to completely familiarise with the interview content. Meaningful statements were identified. Following initial coding, units of significance were identified. The coding was repeated and described in detail after clustering similar themes into a single category. A final theme was developed after the information obtained was verified with the interviewees.

2.1 Learning experience

2.1.1 Novel forms of assessment stimulate learning interest and increase learning engagement

The ER style of assessment was presented in the form of a game. Most of the interviewees reported a feeling of anticipation regarding the ER method of assessment. The fun and novelty of the assessment format motivated the nursing students. Respondent E commented that "the ER is a little bit more fun and newer than the regular assessment, and there is a certain degree of challenge." Respondent B expressed that "I like it more because it is full of unknowns, and I like games that are challenging." Respondents said that they would also spend additional time on prior review because the ER format aroused the desire to win. Respondent C: "If you want to win, you drive yourself to solidify some of your knowledge and be more prepared."

2.1.2 The new assessment format provides a relaxed atmosphere and diminishes the role of the invigilator

Most of the interviewees stated that the ER teaching method to evaluate the basic skills of nursing ensured a relaxed atmosphere. Thereby, it reduced the psychological pressure, which not only led to efficient use of the knowledge acquired, but also improved the students' motivation to review and consolidate their knowledge at the end of the examination. Respondent F stated that "participating in this is a little bit more relaxing than taking the regular examination. It is a little less tense and promotes the feeling and desire to participate more."

On the other hand, although the teacher was still involved in this assessment, the teacher's role changed. Thus, it weakened the role of the teacher as an invigilator during regular examinations, which also relieved the students' stress and tension. Respondent D remarked that "this way, you won't be so nervous that you forget all thee memorised knowledge."

2.1.3 Group work improves communication skills and collaboration

Narrating their experience, all 12 interviewees mentioned that the ER assessment format amplified teamwork and strongly tested students’ coordination and cooperation. Respondent H observed that "the members in a group need to work closely with each other during the assessment process." Some interviewees said that compared with the conventional assessment, the ER teaching method emphasised cooperation among group members, and this cooperation lasted from the pre-preparative phase to the assessment process. According to respondent D, "perhaps each of our group members has a different focus, and we may divide the work when reviewing and preparing."

2.1.4 Integration of theory and practice to enhance clinical thinking

When talking about the advantages of the ER teaching method, some interviewees reported that, compared with the conventional assessment method, applying the ER teaching method to the nursing operation assessment is flexible due to the combination of theoretical knowledge with practical application, which also led to a more comprehensive assessment. Respondent B expressed that "I think that the ER format promoted better combination." The ER style integrates theoretical knowledge with operational skills into cases, which simulated clinical scenarios and inculcated clinical thinking. According to respondent B, "I think that this format is quite good, and the assessment content is also richer; in addition to operational skills, it also involves a lot of theoretical knowledge. A few complete cases test our clinical judgment and resilience."

2.3 Learning feedback

2.3.1 Improvement of the clustering mechanism

The grouping method of this assessment was based on free combination. Some interviewees mentioned that such a grouping method was somewhat unreasonable, which failed to guarantee randomness of the groups and potentially affected the subsequent assessment of performance. In addition, some interviewees thought that the number of participants (4-6) in each group was more reasonable, and that too many or too few people might make it impossible to analyse individual performance fairly. Respondent H expressed that "in the groups, the number of participants might be higher, which prevented analysis of everyone's performance, and perhaps everyone's tasks would be distributed unevenly."

2.3.2 Process needs to be improved

The interviews revealed that most students had experienced ER games before, while some students never played them or understand the process. Students who lacked gaming experience spent longer to familiarise themselves with the game and process after the assessment started, which not only weakened the sense of participation of some students, but also dampened their motivation, and ultimately affected the results and learning outcomes. As respondent D stated, "because I haven't experienced it before, I was a little bit confused when I went in. "

3.1 ER teaching method mobilisede nursing students' learning motivation

The interview results showed that the nursing students were strongly motivated by the ER style of assessment compared with the traditional format, which is consistent with the findings of Roman et al.^[8] Nursing students who participated in this ER assessment were all millennials, whose growth and educational experience have been strongly influenced by the rapid development of the Internet. Thus, they were willing to try and accept new ideas. In the ER test, facing different levels and clues, nursing students can only find the path to the next step by actively exploring new clues. Nursing students were motivated to discover, think, and solve problems. They took the initiative to improve their participation.

3.2 ER pedagogy helps to build core competencies of nursing students

During the interview, the nursing students indicated that under the influence of the ER teaching method, the individual nursing professional core competencies, such as teamwork, clinical thinking, emergency care and humanistic care, were strengthened to different degrees. Nursing professional core competencies are based on the concept of outcome-based education (OBE), which is a pre-requisite for clinical engagement by the nursing staff. It is a comprehensive reflection of their knowledge, operational skills, and character. The ability to work as a team has been a long-term goal of nursing education. The application of ER method to nursing teaching reduces the pressure on the learners. Compared with the traditional clinical skill assessment, the ER environment is more relaxed ^[9], which is consistent with the views of the interviewees in this study. Meanwhile, the relaxed environment promotes communication and cooperation between teams. The ER game setting provides the team additional space to play, and the teaching game inculcates shared learning and goal setting. Different learners share resources and interact with each other for the common learning goal, thereby establishing a learning community. Further, as a valuable learning mode, the ER methods ensures that learners enjoy group participation and promote a sense of belonging. Thus, the sharing of resources and different perspectives of individuals improves the learning efficiency ^[10]. In the ER method, nursing students no longer repeat the practical skills. Instead, based on different case scenarios, analysis of various types of information, constant assessment of the condition, the patient is managed accurately. Thus, the exercise promotes the ability to think clearly, which is in line with the study of Morrell et al.^[11]

3.3 Improved curriculum design

During the practice of ER teaching method, some interviewees stated that they had never experienced ER games before, and were unfamiliar with the game play and process. Some interviewees also reported that it was their first time to participate in the ER games, and they did not know what to do. Therefore, an introduction to the ER game should be provided before the assessment. The introduction should also briefly explain the rules to ensure that the learners can be integrated promptly into the teaching game in order to ensure optimal learning experience. The OBE concept suggests that the curriculum design should be based on a clear blueprint of learning outcomes. The ER teaching method, which combines theory and practice, is ultimately intended to develop the comprehensive competence of nursing students for clinical practice. Other countries have successfully applied the ER teaching method in their nursing curriculum^[12], obstetric skills training^[13], and paediatric asthma care^[14]. Currently, the ER teaching method is successfully utilised in nursing education in China. The ER method is also used in cardiovascular medicine in China^[15]. Friedrich et al.^[16] suggested that learners should be involved in puzzle design to ensure that the puzzles meet the developmental needs of learners at their age. Rouse^[17] suggested that the puzzles should be made more difficult in order to help students accept the challenge and develop self-confidence.

3.4 Prospects for the Application of ER Teaching Methodology

Traditional ER games rely on the excitement and tension introduced by physical environment, such as confined spaces. Accordingly, different teaching modes can be combined with the ER teaching method to improve the learning experience. Taking basic nursing as an example, virtual simulation technology can be introduced to assess operational skills. Virtual simulation ensures real-time evaluation, which can quantify the operational performance. It also provides a systematic review, which allows the teacher to identify the students’ challenges after the completion of the assessment. The virtual simulation system also has the advantages of high simulability, adjustability, and repeatability^[18]. Shen Xiaozen ^[19] proposed a combination of video case studies and comprehensive practical training for nurses. A variety of media can be used intuitively and vividly to mobilise students' enthusiasm, enhance students' perceptual understanding of the practical operation, and facilitate nursing students to enter the clinic as soon as possible. In the ER, videos can be used to introduce different real-world cases to promote learning.

Based on in-depth interviews with nursing undergraduates who participated in ER style nursing assessment of basic skills, we found that the use of the ER teaching mode stimulated the learning interest of nursing students. The strategy contributed to building the core competence of nursing students and improved comprehensive literacy. However, the gaming process and design need to be further improved to align with the teaching objectives. Qualitative research may also be subjective, suggesting the need to expand the scope of practice in the future. Scientific and rigorous, context-rich, and diverse programmes of appropriate difficulty, which meet the needs of modern nursing students should be developed.

Acknowledgements: The authors thank the nursing students participating in this study who shared their experiences with us.

Funding: There was no funding for this study.

Availability of data and materials: The datasets generated and/or analysed during the current study are not publicly available but are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate: Ethics approval was obtained from the Medical Ethics Committee of Zhejiang Chinese Medical University (code: AF-20231110-1). The authors confirmed that written informed consent was obtained from all the study participants before the interview. All methods were performed in accordance with the relevant guidelines and regulations.

Competing Interest: All authors declare that there are no conflicts of interest.

Consent for publication: Not applicable.

Author's contributions: Xinyi Feng: performed the data collection and analyses, wrote the manuscript;

Chunqing Zhou: helped perform the analysis with constructive discussions;

Yazhuo Gao: contributed significantly to manuscript preparation;

Xiaoqin Ma: Thesis guidance, revision.

Authors' Information:

Xinyi Feng, School of Nursing, Zhejiang Chinese Medical University, E-mail: [email protected]; Hangzhou 310053, Zhejiang;

Chunqing Zhou, School of Nursing, Zhejiang Chinese Medical University, E-mail: [email protected]; Hangzhou 310053, Zhejiang;

Yazhuo Gao, School of Nursing, Zhejiang Chinese Medical University, E-mail: [email protected]; Hangzhou 310053, Zhejiang;

Xiaoqin Ma, corresponding author, School of Nursing, Zhejiang Chinese Medical University, E-mail: [email protected]; Hangzhou 310053, Zhejiang.

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No competing interests reported.

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Escape Room Methodology for the Assessment of Basic Operational Skills of Undergraduate Nursing Students: A Qualitative Study

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