Setting and context
This Escape room training program was conducted in a tertiary hospital in Yunnan Province, Southwest China.
Study design
The study utilised a one-group pretest–posttest design in 2023 and 2024. An escape room training program was implemented for new nurses who met the inclusion criteria. Before and after the training program, nurses were required to complete tests and questionnaires.
Population and sample
The inclusion criteria were new nurses who had less than two years of work experience and who were willing to participate in the study. Nurses who could not attend games for any reason, such as sick leave or vacation, were excluded, and nurses who did not complete the online questionnaire or participate in an examination of intensive care knowledge were excluded from the study due to data deficiency. The new nurses were made to be clearly aware that taking part in the study was voluntary, and their written consent was acquired. A convenience sampling method was used to recruit participants who met the inclusion criteria. Ultimately, 84 new nurses were involved in this study.
Project design and intervention
Three external professionals were game masters of escape room games. The first game master A had ten years of working experience, including six years of intensive care unit work experience. Another two professionals, B and C, had more than four years of experience in the hospital, including two years of intensive care unit work experience. Game masters designed the playful escape rooms and were mainly responsible for the training program to ensure the smooth implementation of the training program.
The rooms were decorated in a thematic way like a mini ICU, which included four rooms, a patient room, a nursing station, a storage room, and a therapy room. These rooms were decorated with patient beds, electrocardiogram monitors, office desks, stretchers, documents, mobile phones and other materials associated with the challenges of the escape room. New nurses participated in this escape room training program as a group, and each group had 5 to 7 nurses.
Before starting the activity, game masters asked players to complete the TeamSTEPPS teamwork attitudes questionnaire (T-TAQ) and an online intensive care nursing test. After the questionnaire and test, players were covered with eye packs to ensure the mystery of the game and which kept players focusing on key points of the game context. Game master B played the audio, which expounded the rules essential to carry out the game, similar to telling a story. The rules were straightforward: the players were nurses in the intensive care unit, and their tasks were to care for and maintain the safety of the new patient. All of the clues were within the players' reach, it was not necessary to employ force or break anything, and the clues and tasks had only one application; for instance, a code would only unlock a lock and would not be used to open others; it would not serve to open others. There were 30 minutes for each group, three chances to ask for help, and 100 points of energy for each group. The energy would be reduced if they rescued the patient over time, asked for help and answered the question incorrectly. After the introduction of the game rules, new nurses entered the room. Finally, the audio ended with the situation of the patient, and then players were required to take off the eye pack.
Afterwards, the countdown emerged, and each team, in a cooperative manner, needed to address the four challenges of the escape room. The challenges were evaluating intensive patients, administering mannitol infusion, transferring patients with spinal injury, and observing complications. Players were obliged to hunt for clues in the room related to the four challenges. For example, the audio played the doctor giving medical advice, but the prescription was locked in the box. Then, players needed to find a four-digit password to open the box. To obtain four digital passwords, the player should have the right assessment of the patient, including the pupil, consciousness and muscle strength of both sides. Game master C acted as a standard patient to cooperate with key training points, such as evaluating consciousness and muscle strength, as well as transferring patients with spinal injury.
Game masters A and B inspired players to operate as a team and make the best use of the time to seek out clues around the room. Whenever they noticed that the new nurses were frustrated or requested a clue, they provided assistance to ensure that the game had the proper pace of challenge and difficulty. It is important to note that the majority of the new nurses had no prior experience in an escape room. Once one group finished the game, it took 20 minutes for game masters B and C to rearrange the clues on the stage between the diverse groups.
Outcome measures
Primary outcome
The T-TAQ created by the Department of Defense and the Agency for Healthcare Research and Quality was employed to assess the attitudes of new nurses toward teamwork. The T-TAQ encompasses 30 items and includes five dimensions: team structure, leadership, situation monitoring, mutual support, and communication. Every dimension has six items along with five response options ranging from 1, meaning strongly disagree, to 5, meaning strongly agree, on a Likert scale. Four items are negatively related, including three items in the mutual support dimension and one item in the communication dimension. The scores of the total scale, as well as for each dimension, are determined by combining all items and dividing the score by the number of items in each dimension. The questionnaire was translated and cross-culturally adapted by Ye Xuechen et al. in 2018 [30]. The Chinese version of the T-TAQ has a good Cronbach's alpha value of 0.864, which is greater than the 0.70 for each subfactor. New nurses were required to finish the T-TAQ before starting and at the conclusion of the escape room.
Secondary outcomes
The initial and secondary levels of Kirkpatrick's four-level model, which are the reaction level and learning level, respectively, were applied to evaluate the effectiveness of this training. At the reaction level, participants' feelings and satisfaction after the escape room training program were evaluated, including the question "Are you willing to participate in a similar training program?" and a single item of satisfaction evaluation, varying from 0 to 10, in which 0 represents entirely dissatisfied and 10 stands for entirely satisfied. Learning level was evaluated using online scenario-based multiple and single-choice question tests. This form included six multiple-choice questions and ten single-choice questions based on the escape room training program and the textbooks. Three experienced nurses who worked in the intensive care unit evaluated the face and content validity of the questions. They were requested to offer their viewpoint concerning the grammar, the employment of suitable words, the lucidity and simplicity, and the pertinence of the questions. They reflected that the questions could evaluate trainees’ ICU-related knowledge. Players were required to complete the intensive care knowledge test before and after the game, and a willingness investigate after the game.
Statistical analysis
The data were analysed using SPSS v26.0. The Kolmogorov‒Smirnov test was used to assess the normality of the distribution of intensive care knowledge (n = 61), and the Shapiro‒Wilk test was used to assess the normality of the distributions of the total T-TAQ score and scores on the five dimensions (n = 43). Descriptive statistics (mean and standard deviation) and the paired samples test were used for normally distributed data, while for nonnormally distributed data, descriptive statistics (median and interquartile range) and the Wilcoxon signed-rank test were utilised for analysis. A P value less than 0.05 was considered to indicate statistical significance.
Ethical consideration
This project was approved by the research committee of the First Affiliated Hospital of Kunming Medical University.