The Effect of escape room clinical evaluation method on satisfaction, learning, and preparedness to practice as interns of nursing students: a quasi-experimental quantitative study

doi:10.21203/rs.3.rs-2337457/v1

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The Effect of escape room clinical evaluation method on satisfaction, learning, and preparedness to practice as interns of nursing students: a quasi-experimental quantitative study

https://doi.org/10.21203/rs.3.rs-2337457/v1

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Background

Clinical evaluation utilizing the escape room game is recognized as a novel method for assessing the team-oriented performance of learners. It is a tool for evaluating teamwork skills in clinical settings, which can boost student motivation and learning. This study aimed to investigate the effect of clinical evaluation through escape rooms and feedback provision through the PEARLS approach on pre-internship nursing students’ satisfaction, learning, and preparedness to practice as interns in the Faculty of Nursing and Midwifery, Zahedan University of Medical Sciences.

Method

The current research is a quasi-experimental quantitative study conducted with a census sample of 42 sixth-semester undergraduate nursing students at Zahedan University of Medical Sciences in 2022. The escape room method was utilized to evaluate entry preparedness into the clinical field. Reliable and valid researcher-made questionnaires were administered to assess the impact of the intervention on learning, satisfaction, and preparedness. The data were analyzed in SPSS version 26 using descriptive and inferential tests. The significance level was considered to be less than 0.05.

Results

26 males and 16 females constituted the 42 participants (mean age: 23.46 years). The clinical evaluation method of the escape room game was deemed satisfactory or highly satisfactory by 80% of students. From their perspective, escape rooms were definitely or highly effective in shaping their preparedness to enter the clinical field. Comparing the students’ mean learning scores (self-assessment of clinical skills) before and after the test revealed that their post-test scores were significantly higher than their pre-test scores (p < 0.001).

Conclusions

Considering the satisfaction of nursing students with the clinical evaluation using the escape room game and its impact on student learning, it is recommended that this method be implemented in all medical education departments.

escape room

clinical evaluation

nursing student

satisfaction

It is the responsibility of nursing schools to equip students with the knowledge and clinical skills required to provide the highest quality of care. Clinical education is an essential component of nursing education for the development of professional competence and skill. In addition to clinical skills, nursing students must acquire communication and cognitive skills (1). However, problems with evaluation are among the most significant obstacles to clinical education. Clinical evaluation is also highly crucial for determining the success of clinical education. Evaluation is, in fact, one of the integral components of learning in every educational program and the basis for decision-making in scientific and operational activities (2).

The evaluation process is conducive to student motivation. Specifically, it can affect the willingness of learners to accept responsibility for their learning and independent progress, as well as their capacity for sustained motivation in learning (3). The Objective Structured Clinical Examination (OSCE) is an accepted assessment method for measuring nursing students’ clinical skills. As the OSCE evaluates students individually, fundamental aspects of clinical performance, such as communication and teamwork, remain unevaluated. This approach is costly, time-consuming, and anxiety-inducing for students, among other disadvantages (4). Exam anxiety is the unpleasant experience of worry and excitement students feel in evaluation situations and a hindrance to their academic progress. Exam anxiety impairs students’ performance and causes a decline in self-confidence, a negative attitude toward university, and a fear of failure (5). Since clinical evaluation in nursing, as one of the most important pillars of education, should measure the nurse’s competency and abilities, it is imperative to use new and innovative evaluation methods to assess various facets of nursing performance (6).

In recent years, game-based learning and gamification have become increasingly popular in the medical curriculum. In medical science education, gamification involves incorporating game elements into educational contexts. Gamification’s worth is contingent on its capacity to engage students and improve learning. The purpose of game-based learning is to increase student motivation and aid in the acquisition and evaluation of knowledge and skills. According to Chen and Hwang, games can stimulate motivation, one of the fundamental principles of learning, thereby enhancing students’ interest, active participation, critical thinking, and problem-solving skills (7).

The educational escape room game is recognized as a novel game-based educational method. Escape rooms are interactive and engaging games in which players are placed in a locked room and must collaborate to solve a series of puzzles within a set amount of time in order to obtain the codes and solutions necessary to escape. The vast majority of escape rooms are purely recreational. However, educational escape rooms with professional programs are gaining popularity as a means of involving students in their learning environment, fostering cooperation, and encouraging the development of social and team skills (8).

According to Brown et al., the escape room game is a highly effective and efficient method of learning that enables students to retain and apply the knowledge gained in class. Furthermore, it motivates the players to study because it is enjoyable and improves teamwork (9). In the study by López-Pernas et al., it is also noted that the escape room game enables students to engage in an appealing, enjoyable, non-threatening, and non-clinical activity that fosters teamwork and effective leadership (10).

The escape room game is a form of active learning strategy that transforms the participant from a passive observer into an active participant. It has been demonstrated that escape rooms have positive effects on students across the educational program, including a rise in the grade point average (GPA) for each course, a rise in conceptual comprehension, an increase in students’ positive perceptions of learning material, and a decrease in student anxiety and dropout rates (12). Students use problem-solving, clinical skills, communication skills, teamwork, and critical thinking to solve puzzles in the educational escape room. These qualities are indeed crucial for nursing students (13). In conducting clinical evaluation, it must be ensured that students use critical thinking in clinical settings, exhibit appropriate professional behavior, interact with patients appropriately, prioritize problems, have a fundamental understanding of clinical procedures, and adopt proper care procedures (14).

Students are evaluated inconsistently and individually by traditional evaluation methods such as the OSCE. These new methods, such as escape rooms, evaluate the development and reinforcement of students’ problem-solving, rethinking, coordination, and group communication skills. Among the advantages of escape rooms as an evaluation technique compared to traditional methods of clinical evaluation, such as the OSCE, are reduced stress, enhanced motivation, the identification of strengths and weaknesses, the ability to make better clinical decisions, and the induction of motivation to improve professional performance. According to studies, students’ performance may be impaired if they experience stress, anxiety, or fear, which may result in a negative attitude toward assessment. In addition, the manner in which students interact and communicate with the examiner significantly impacts the evaluation outcome.

Clinical education evaluations focusing on problem-solving have multiple dimensions and cover a range of skills such as self-directed learning, group cooperation, and communication. Self-evaluation is a crucial component of self-directed and performance-based learning, which yields more realistic and reliable outcomes than teacher evaluations. In evaluating escape room games, it is possible to evaluate areas such as communication skills, self-learning, and respect for others that are difficult to evaluate using conventional methods. This adds a new dimension to learner evaluation, where the traditional goal is to describe the nursing student’s abilities and skills required for a clinical case. In light of the benefits of the escape room game and problem-solving in clinical evaluation, the present study is the first attempt in Iran to investigate the effect of clinical evaluation using the escape room method and PEARLS-based (Promoting Excellence and Reflective Learning in Simulation) feedback provision on pre-internship nursing students’ satisfaction, learning, and preparedness to practice as interns at Zahedan University of Medical Sciences.

This research is a quasi-experimental quantitative study conducted in 2022 at the Faculty of Nursing and Midwifery of Zahedan University of Medical Sciences. The aim was to examine the satisfaction, learning, and preparedness to practice as interns of pre-internship nursing students upon participating in escape room-based clinical evaluations.

Ethical considerations

This research was conducted in accordance with the Declaration of Helsinki and with the approval of the ethics committee at Zahedan University of Medical Sciences (ethics code: IR.ZAUMS.REC.1401.291). In all phases of the study, the researchers adhered to the Helsinki Convention’s ethical principles, which included explaining the objectives to the research units and obtaining their informed written consent to participate in the research, allowing participants to enter or withdraw from the study at any time, maintaining the confidentiality of information, and upholding integrity in participant selection, data collection, and data analysis. Other ethical considerations included presenting research results to research units and research setting officials upon request, expressing gratitude to all research units and all relevant officials who cooperated, observing the publication and ethics in research principles, and publishing study results per the principles of COPE: International Committee on Publication Ethics.

Participants

The research population comprised all sixth-semester nursing students at Zahedan University of Medical Sciences. The inclusion criterion was enrollment in the sixth semester of nursing at Zahedan University of Medical Sciences; exclusion criteria comprised having incomplete grades, not enrolling in the internship course, and not taking the test due to absence or illness, among others. Considering the small number of students, we recruited a census sample of 42 individuals.

Data Collection

In order to hold the test, the escape room test committee was formed in the first step, followed by an examination of the clinical skills learning objectives for nursing students and the determination and confirmation of the final evaluation objectives. Certain clinical skills were identified as must-learn skills, and a blueprint of educational content was developed. Clinical functions that students must master include hand hygiene, communication with the patient, control and monitoring of vital signs, gavage and lavage, venipuncture and fluid therapy, injections, vaccinations, oxygen therapy, cardiopulmonary resuscitation, teamwork, and wound care and dressing. Afterward, the escape room scenario was designed based on the evaluation of the mentioned skills. A list of sixth-semester nursing students, along with their GPAs, was requested. In accordance with their six-semester GPA, 42 sixth-semester nursing students were divided into five groups of 8–9 individuals, and a group leader was appointed for each group.

The evaluators were selected from the academic staff of the nursing department who had previously served as evaluators of the OSCE (of nursing principles and techniques) and nursing final exams. Three rooms resembling a hospital ward with visual effects served as escape rooms. Located in the Faculty of Nursing and Midwifery’s skills lab, the rooms were designed similarly to hospital ward rooms and were equipped with a sink, glove box, patient bed, telephone, and monitor, among other things. The list of evaluated skills was presented to the office of the clinical skills center so as to provide the necessary resources and facilities. A manikin serving as the simulated patient was placed on the bed, and a speaker was installed in each room. A person spoke in place of the simulated patient in the room (manikin).

The evaluators visited the escape rooms in person and were given ample time to ask questions and receive explanations about the game. They were briefed on the game scenario and instructed on how to provide PEARLS-based feedback. Immediately prior to the commencement of the escape room game, all the students participated in a 10-minute introductory meeting in which they were presented with the necessary rules and explanations. The students subsequently entered the quarantine room. Three groups of students were evaluated simultaneously using three escape rooms, and each group was given 45 minutes to solve the escape rooms’ puzzles.

The evaluator used a camera to observe how the students in each team performed their skills, and the learners’ performance was evaluated as a team. After solving the escape room puzzles, the results of the students’ skills were evaluated, and the evaluator reviewed the students’ performance in person. Using the PEARLS model, faculty members provided each group with feedback during a sixty-minute session.

Simulation programs use the PEARLS model for feedback provision, which includes five steps:

1- Presenting the program schedule (the operational program of the feedback session) to the students to foster a secure learning environment

2- Obtaining students’ initial reactions/emotions with the intent of exploring and investigating students’ emotions regarding the evaluation

Participants are asked about their emotions.

3- Description: The purpose of the description is to provide information and clarify the facts, including posing questions such as what happened and what actions were taken. The evaluators must determine whether or not the reason for poor student performance is obvious, whether the student is using the equipment properly, or whether the student does not know what to do.

4- Analysis: In this stage, the learners are required to identify their successful interventions and those they would change if they could go back in time, explaining why they would do so. The evaluator will present the knowledge/information necessary for eliminating student performance gaps.

5- Summary of applications/lessons learned. Students are asked to identify two points they can apply in the future.

Students were given a full explanation of the scenario, the study procedures, and the nursing skills assessed in the escape room. In order to better answer the students’ questions about the evaluated equipment and clinical skills, a feedback presentation session was held in the escape room so that, if necessary, the students’ troublesome clinical skills could be applied to a simulated patient. The protocol’s effectiveness was evaluated using the Kirkpatrick model. In addition, the researcher-developed questionnaires of test satisfaction, feedback satisfaction based on the PEARLS model, and the test impact on students’ preparedness for practicing as interns were administered as post-tests. Moreover, the researcher-made questionnaire of the participants’ learning level was administered as both a pre-test and a post-test. The questionnaires were given to ten nursing and medical education faculty members to assess their face validity. The test objectives and operational definitions pertaining to the content of the questions were explained to the experts. Face validity was evaluated based on a tool’s appearance and the writing and readability of the items. The reliability of the questionnaires was also evaluated using the internal consistency method.

The six-item student satisfaction questionnaire was scored on a five-point Likert scale ranging from strongly agree (5 points) to strongly disagree (1 point). It was completed by participants in person after playing the escape room game as a post-test. The minimum and maximum possible scores are 6 and 30, respectively. A score of 1–10 suggests undesirable satisfaction, a score of 10–20 is indicative of relatively favorable satisfaction, and a score of 20–30 indicates desirable satisfaction. The Cronbach’s alpha for this survey was 0.88.

The clinical skills self-assessment questionnaire contained 12 questions, each of which was scored on a five-point scale from very certain (5 points) to very uncertain (1 point). It was administered in person as both a pre- and post-test. The minimum and maximum possible scores on this survey are 12 and 60, respectively. A score between 1 and 20 indicates an undesirable clinical skill status, a score between 20 and 40 indicates a relatively desirable status, and a score between 40 and 60 is regarded as desirable. The Cronbach’s alpha for this survey was 0.82.

The PEARLS-based feedback questionnaire consisted of five questions, each of which was scored on a five-point Likert scale ranging from strongly agree (5 points) to strongly disagree (1 point). The participants completed it as a post-test in person after playing the escape room game. This questionnaire has a minimum score of 5 and a maximum score of 25. Scores between 1 and 8 indicate undesirable satisfaction, scores between 8 and 16 indicate somewhat satisfactory satisfaction, and scores between 16 and 25 are regarded as satisfactory. Its Cronbach’s alpha coefficient was 0.85.

The preparedness assessment questionnaire contains seven items that are scored on a five-point Likert scale ranging from definitely effective (5 points) to definitely ineffective (5 points) (1 point). The participants completed the questionnaire after playing the escape room game as a post-test and in person. The minimum and maximum possible scores on this survey are 7 and 35, respectively. A score between 1 and 12 indicates undesirable preparedness, a score between 12 and 24 indicates relatively desirable preparedness, and a score between 24 and 35 indicates desirable preparedness. The Cronbach’s alpha for this survey was 0.87.

Data analysis

The data were analyzed using SPSS version 26. Descriptive statistical tests were employed to screen for missing data, including frequencies, percent, mean, and standard deviation. The paired t-test (two series of scores from the same group of students) was utilized to compare the mean scores of clinical skills self-assessment among students. Cronbach’s alpha coefficient was calculated to confirm the questionnaires’ reliability. The acceptable range for Cronbach’s alpha in this study was above 0.80. The majority of questions regarding missing data were answered, and any missing data were omitted from the analysis.

This study examined 42 students. The results indicated that the mean age of students was 23.46 ± 2.46 years. Regarding gender, 61.9% and 38.1% of the students were female and male, respectively, and their mean GPA was 15.44 out of 20. The mean and standard deviation of the students’ satisfaction with the test was 24.38 ± 3.4, which was desirable. Indeed, 45% of the students strongly agreed that holding the escape room test could meet the students’ clinical education requirements.

Table 1

Students’ satisfaction with the test (n = 42)
Item	Strongly agree		Agree		Somewhat agree		Disagree		Strongly disagree
Item	Percent	Frequency	Percent	Frequency	Percent	Frequency	Percent	Frequency	Percent	Frequency
Appropriate notifications regarding the escape room were provided.	57.1	24	40.5	17	2.4	1	-	-	-	-
The execution procedure for the escape room test was clearly defined.	31.0	13	50.0	21	16.7	7	2.4	1	-	-
The length of the escape room test was sufficient.	33.3	14	42.9	18	21.4	9	2.4	1	-	-
The physical setting of the escape room test was appropriate.	33.3	14	42.9	18	16.7	7	7.1	3	-	-
The escape room test motivated me to learn.	28.8	12	40.8	17	24.0	10	7.1	3	-	-
The escape room test can help students meet their clinical training requirements.	45.6	19	48.0	20	7.1	3	-	-	-	-

The mean and standard deviation of participant satisfaction with the test feedback was 21.64 ± 2.27, which was favorable according to the Likert scale. The nursing students’ highest levels of satisfaction with the test feedback were associated with the following statements: “The facilitator assisted me in recognizing how to improve my performance or how to sustain it if it was good” and “The facilitator provided me with specific feedback about my or my team’s performance based on an honest and accurate perspective.” The statement that generated the least satisfaction was, “The facilitator prompted in-depth conversations that stimulated me to reflect on my own or my team’s performance.”

Table 2

Feedback satisfaction with the PEARLS model (n = 42)
Item	Definitely agree		Agree		Somewhat agree		Disagree		Definitely disagree
Item	Percentage	Frequency	Percentage	Frequency	Percentage	Frequency	Percentage	Frequency	Percentage	Frequency
The facilitator conducted briefing in an organized manner.	38.1	16	54.8	23	7.1	3	-	-	-	-
The facilitator prioritized learning over making people feel bad about making mistakes.	42.9	18	45.2	19	11.9	5		-	-	-
The presenter prompted in-depth conversations that stimulated me to reflect on my or my team’s performance.	28.6	12	47.6	20	14.3	6	2.4	1	-	-
The facilitator provided me with specific feedback about my or my team’s performance based on an honest and accurate perspective.	40.5	17	42.9	18	14.3	6	2.4	1	-	-
The facilitator assisted me in recognizing how to improve my performance or how to sustain it if it was good	40.5	17	50	21	9.5	4		-	-	-

According to the Likert scale, the mean preparedness to practice as an intern was 28.45 ± 5.7, which was desirable. In addition, 38% of students believed that the escape room game test effectively prepared them for the internship.

Table 3

Preparedness of students to practice as interns (n = 42)
Item	Definitely effective		Very effective		Effective		Not effective		Definitely ineffective
Item	Percentage	Frequency	Percentage	Frequency	Percentage	Frequency	Percentage	Frequency	Percentage	Frequency
Has the escape room game evaluation prepared you adequately for the internship?	38.1	16	33.3	14	21.4	9	4.8	2	2.4	1
Has the evaluation of the escape room game increased your confidence to enter the internship?	38.1	16	31.0	13	26.2	11	2.4	1	2.4	1
Has the evaluation of the escape room game improved your critical thinking skills?	26.2	11	47.6	20	21.4	9	2.4	1	2.4	1
Has the evaluation of the escape room game improved your problem-solving skills?	47.6	20	26.2	11	23.8	10	-	-	2.4	1
Has the evaluation of the escape room game decreased your anxiety about the internship?	40.5	17	40.5	17	14.3	6	2.4	1	2.4	1
Has the feedback session following the escape room game enhanced your internship preparedness?	38.1	16	38.1	16	19.0	8	2.4	1	2.4	1
Has the escape room’s open-ended evaluation and subsequent feedback session served to familiarize you with aspects of teamwork?	42.9	18	38.1	16	14.3	6	-	-	4.8	2

The average score of students’ clinical skills in the post-test was significantly higher than in the pre-test.

Table 4

Mean scores of clinical skills (n = 42)
Self-assessment score	Mean and standard deviation	P-value
Pre-test	40.26 ±4.04	0.000
Post-test	51.69 ± 3.51	0.000

The purpose of the present study was to investigate the impact of clinical evaluation utilizing the escape room method and PEARLS-based feedback provision on the satisfaction, learning, and field preparedness of pre-internship nursing students.

The results of the current study demonstrated that the implementation of the test had a positive impact on student satisfaction, field preparedness, and the improvement of clinical skills among nursing students compared to the baseline. This new evaluation method was well-received by most students. The majority of studies evaluating the effect of the escape room test on student satisfaction have confirmed this result.

Gutiérrez-Puertas et al. conducted a study with nursing students titled “Escape rooms as a clinical evaluation method for nursing students”. Analysis of the data revealed that students were, on average, more satisfied with this new clinical evaluation method than with traditional tests. Many students preferred the escape room test over conventional evaluation methods. The highest level of satisfaction was associated with the test’s ability to meet students’ educational needs. In line with the present study, they viewed this experience as valuable because it helped students identify knowledge and skill gaps and share them with group members (15). This may suggest that the escape room method reduces students’ stress levels by fostering a relaxed environment, teamwork, knowledge and skill sharing, and peer learning. On the other hand, it enhances student satisfaction by assisting them in identifying their weaknesses.

The literature did not show a study to have measured student satisfaction with the PEARLS model feedback following the escape room test. There was, however, a similar study regarding students’ satisfaction with providing feedback after an escape room-based educational intervention.

Martin et al. utilized the PEARLS model to provide students with feedback in an educational intervention designed to orient medical students from a preclinical setting to a clinical environment using an escape room game. The results of this study indicated that providing feedback increases student satisfaction, which was consistent with our findings (13).

The purpose of an evaluation is to monitor the learning process throughout education and to inform students and instructors of learning successes and failures. Feedback to students reinforces successful learning, identifies and corrects learning errors, provides teachers with information to improve education, and recommends individual or group remedial measures for learners. In case this feedback is provided as group feedback, it can improve the students’ working group and boost their motivation and learning level (16). In the present study, students received feedback using the PEARLS model after completing the escape room test, with the results indicating that the escape room test increased the students’ learning level. On the other hand, clinical work is an essential component of medical education, and it is necessary to provide learners with regular performance feedback to yield optimal clinical experiences. Unfortunately, doing this vital issue in clinical learning environments is challenging, and clinical educators tend to shy away from this important responsibility. Students typically complain about the lack of feedback (17). Therefore, using the escape room test in clinical settings can be useful for providing students with effective feedback.

Beheshtifar et al. sought to determine the effect of escape room game-based training on the preparedness of undergraduate nursing students for bioterrorism. Their results revealed that the training affected the participants’ preparation (18). While this study employed the escape room to teach bioterrorism, the current project used the escape room game as a new student-centered educational method for evaluation. Furthermore, in the study by Martin et al., the escape room game improved medical students’ preparation for the clinical environment (13). The escape room test allows students to collaborate with their peers and helps novices gain experience. Moreover, it helps novices reflect on their actions and contributes to teamwork and problem-solving skills. The present study also demonstrated that the escape room test could improve clinical skill acquisition and student preparation to enter the field.

Research limitations

Among the limitations of the current study is the inability to measure effectiveness at the upper levels of the Kirkpatrick pyramid. In addition, the prolonged time of the evaluation is one of the other limitations of the current research; instead, a greater number of escape rooms can be used concurrently for evaluation to save time.

In conclusion, it appears that using the escape room evaluation method in conjunction with other student evaluation methods has helped improve students’ interpersonal communication, problem-solving skills, critical thinking, and teamwork. The experience of working in a group not only improves these skills and is enjoyable to students but can also enhance their learning. Clinical education is dependent on teamwork. The escape room test can be viewed as a valuable tool for encouraging students to collaborate as a team. Therefore, it is suggested that students in all medical education groups be evaluated clinically using this test.

Acknowledgements

The authors would like to express their gratitude to the participants as well as esteemed authorities of Zahedan university of medical sciences

Authors contributions

Najmeh ghiamikeshtgar, fereshteh ghaljaei designed and supervised the study and wrote the main manuscript text . mahnaz ghaljeh, Zahra Pishkar involved in data interpretations , Bentolhoda Taherizad participated in data analyses,. Narjeskhatoun Sadeghi Googhary, nasrin mahmoodi, simin sharifi did Data analyses and were responsible for editing and critical revisions of the paper.The authors read and approved the final manuscript.

Funding

None

Availability of data and materials

The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The Ethics Committee of Zahedan University of Medical Sciences, Zahedan , Iran (IR.ZAUMS.REC.1401.291) approved the study. All participants signed informed consent form. This research was conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no confict of interes

Author details

¹Department of Operating Room, School of Nursing and Midwifery Zahedan University of Medical Sciences , Zahedan ,Iran

²Department of Nursing ,School of Nursing and Midwifery Zahedan University of Medical Sciences , Zahedan ,Iran

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The Effect of escape room clinical evaluation method on satisfaction, learning, and preparedness to practice as interns of nursing students: a quasi-experimental quantitative study

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