Moderate benefit of escape room game on learning outcome in medicine

Moderate benefit of escape room game on learning outcome in medicine | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Moderate benefit of escape room game on learning outcome in medicine Peter Fedorcsak This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4764235/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Nov, 2024 Read the published version in BMC Medical Education → Version 1 posted 4 You are reading this latest preprint version Abstract Background Well-designed escape room games engage students with complex problems and challenge clinical and teamwork skills, but their impact on learning has been uncertain. This study aimed to estimate the effect size of escape room game on performance in a broad knowledge test. Methods During clinical rotation in reproductive endocrinology and infertility (REI), medical students participated in a 3-hour small-group class. For 2 semesters, groups had traditional patient visits and case discussions, and for 3 semesters, patient visits and an escape room game including debrief. The game was set up in the outpatient clinic, the puzzles were taken from clinical problems in REI, and challenges included operating an ultrasound scanner on a mannequin. Mid-semester, students completed a test of general knowledge in REI. To estimate the effect of small group class on declarative knowledge, test scores of students who had already had the class (exposed) were compared to scores of those who had not yet had the class (control). Results Students were highly satisfied with gamified teaching. Those who attended the small group class without the escape room game achieved similar scores on knowledge test than control students (Cohen's d = 0.05, 95%CI -0.58 to 0.68, n = 71). Students who played the escape room game achieved marginally higher score than respective controls (Cohen's d = 0.22, 95%CI -0.1 to 0.53, n = 182). Conclusions Escape room game may improve learning outcome of a traditional small group class, but the effect of a single game on declarative knowledge is modest and is unlikely to exceed related instructional methods like simulation. gamification escape room game learning outcome Figures Figure 1 Figure 2 Background Clinical teachers have preference for small group formats, such as ward rounds, which can effectively present clinical scenarios to the students, give explanation, and facilitate discussion [ 1 ]. Some clinical settings like emergency rooms or gynecology outpatient clinics, however, are not ideal for small groups [ 2 ]. To train problem-solving in such high-intensity or sensitive environments, group-based simulations and serious games, in particular escape room games, can be effective by letting learners to practice teamwork skills, to discuss, present ideas, and persuade peers [ 3 , 4 ]. Escape room is a live-action team-based game that stems from the point-and-click genre of adventure computer games, like the Maniac Mansion , The Secret of the Monkey Island , or the Day of the Tentacle (LucasArts). In an escape room, a team of players is locked in a physical room where they are presented to a captivating story and a challenging task. By interacting with the environment under time pressure, discovering hidden clues and solving puzzles and riddles, the team must find a key to escape the room. The most successful game designs have been described by scholarly surveys [ 5 ]: Before the game, a mystical story is presented to the players to create anticipation and tension. Once in the room, most teams start with slow and careful discovery of the surroundings, but soon excitement will take over as the team members call out discoveries or hunch over puzzles in groups. Most groups will leave the game with excitement and may continue to discuss the activity online, also known as froth. Nicholson [ 5 ] distinguishes four basic game formats depending on the presence of a specific theme and narrative, and whether the puzzles are stand-alone or integrated into the narrative. In the more elaborate games, the puzzles are part of the storytelling, and immersive experience comes from games designed with attention to player motivations, physical environment, intellectual challenges, and emotions [ 6 ]. The puzzle design is either path-based or sequential. In path-based designs, the team is presented with several different puzzles at the same time and each of the paths are needed to solve a meta-puzzle, which will unlock the next stage or victory. The team can split into smaller groups to solve path-based puzzles. The sequential game design presents the players with one puzzle at a time that will unlock the next puzzle in sequence. The sequential design requires the entire team work together. The most frequent types of puzzles are searching hidden objects; using light; counting; noticing something obvious in the room; symbol substitution with a key; using something in an unusual way; searching images; assembly of an object. Escape room facilities usually provide a gamemaster to ensure fair player experience. The gamemaster may monitor the players via video, help the players if stuck or frustrated, and ensure safety. Gamemasters may also give hints, either on request or at timed intervals. Nicholson’s survey [ 5 ] indicates that the average player’s success rate is 41%. Escape rooms have become remarkably popular, with over 2200 event facilities established in the USA alone in 2020, where only a dozen existed in 2014 [ 7 ]. Educational use of escape rooms is also increasing [ 8 ], and specific tutorials are available for implementation in higher education [ 9 ], including undergraduate medical teaching [ 10 , 11 ]. The escape room class designed by Friedrich et al. [ 10 ] aims to improve team skills of interprofessional health care students. After a plenary introduction, the students are divided into small groups (6–8) for the escape room experience. According to the storyline, the players must plan discharge from the hospital of a patient with diabetes and mental disease. The game design by Friedrich et al. [ 10 ] is supported by a small collection of physical props (e.g. code-labelled balls hidden in the room), but most content is delivered to the players in online spreadsheets and text documents. The puzzles are elaborate but non-medical, including matching color to music tone, finding hidden objects, riddles, and an online maze, but the puzzles are not integrated in story of the game. The escape room session is followed by a plenary debriefing to ascertain that the educational aims of the game had been met. The escape room game designed by Rosenkrantz et al. [ 11 ] aims to train collaboration and communication skills using a fictious game narrative (countering a zombie-like virus attack). Their game applies clinical props from emergency wards (ECG monitor, nebulizer mask), as well as toys (remote controlled car), and the riddles are aligned with the fictious narrative, i.e. triaging zombies [ 11 ]. The efficacy of escape room games in teaching and learning remains nonetheless uncertain. I developed and implemented a serious escape room game in small group teaching in reproductive endocrinology and infertility (REI). I aimed to achieve specific educational objectives with focusing on immersive game design, clinically relevant riddles, and hands-on experience for students. Consecutive groups of students played the game during the semester, and the performance of students who played the game was compared to those who had not yet played the game on a mid-semester test of broad knowledge in REI, which allowed estimating the effect of escape room game on declarative knowledge. Methods Context and design of study The obligatory small group class in REI was part of the undergraduate curriculum for 5th year medical students at the Faculty of Medicine, University of Oslo. This was a non-randomized, retrospective, two group, posttest-only study assessing the effect of small group teaching or small group teaching combined with escape room as interventions during this class. Statistical power was not calculated in advance. Small group class Ahead of the class, the students were asked to browse the REI website for customized educational sources including texts, videos, podcast, and textbook chapters specifically relevant for the planned activities. The class started with clinical rounds, when each student shadowed a gynecologist for 2 hours at the outpatient clinic. All students had had the opportunity to observe transvaginal ultrasound examinations, and most students could also participate in consultations on early pregnancy. After the clinical rounds, the group was convened for either traditional case discussion (2 semesters) or escape room game and de-brief (3 semesters). The educational objectives of the escape room game were: 1. Describe the process of spontaneous human conception, assisted reproduction treatment, the signs of intrauterine pregnancy (IUP) and extrauterine gestation. 2. Review clinical records and perform ultrasound examination of the pelvic organs on the mannequin, including assessment of the fetal crown-rump length (CRL). 3. Recognize clinical, biochemical, and ultrasonographic signs of early IUP and calculate the gestational age using multiple cues. 4. Demonstrate professional attitude during clinical examination. 5. Demonstrate efficient teamwork under time pressure. Implementation of the escape room game Supplemental online material gives detailed instructions for setting up the game, including list and sourcing of props, gamemaster’s script, and fictious patient journals. Briefly, the game was set up in a gynecological outpatient room. Gynecological examination chair, ultrasound scanner with transvaginal transducer, and gestational wheel were borrowed from the clinic. Props specifically purchased for the game included a medical dictionary, intrauterine pregnancy transvaginal ultrasound training mannequin, a document safe with digital lock, countdown timer with large LED display, and a baby monitor with camera. Additional items were an envelope with the welcome letter and the safe code puzzle, a tear-off calendar, three fictious patient journals, and an address book with the telephone number puzzle. The gestational wheel and the address book were locked in the document safe, the other items were inconspicuously arranged in the room (Fig. 1 ). After arranging the props in the room, the gamemaster came out to the corridor to greet the waiting students, read out the introductory script, gave the students the envelope with the game quest, and let the group enter the room. The group was also informed that the gameplay will be observed on the baby monitor but no recordings will be made. The countdown timer in the room was set to 30 min. The objective of the players was to examine the mannequin using the ultrasound scanner, select the patient journal that matched ultrasound findings on the mannequin, unlock the safe, decode the telephone number in the address book, and call the number to tell the fictious patient about follow-up investigations. Groups making the phone call within 30 min and giving appropriate instructions won the game. The game contained 8 interconnected puzzles of varying complexity and difficulty (Fig. 2 A). The date puzzle required finding the desktop calendar and recognizing the fictious date of the game. The blastocyst puzzle required finding the page number for entry ‘blastocyst’ in the medical dictionary by identifying drawing of a blastocyst. To solve the IUP puzzle, the group needed to operate the ultrasound scanner, examine the mannequin, and identify 8 weeks old intrauterine pregnancy. The journals puzzle required solution of the calendar puzzle, as well as correct interpretation of three fictious patient histories, which were extrauterine pregnancy, first trimester pregnancy conceived by IVF, and second trimester pregnancy conceived spontaneously. The journals puzzle and the blastocyst puzzle unlocked the safe. When opening the safe, the group needed to solve the CRL puzzle, which required either measuring the approximate fetal length on the mannequin or use the gestational wheel found in the safe. Solution of the CRL puzzle gave the missing digit in the telephone number, allowing the group to make the call. (The phone number belonged to the gamemaster.) The correct instruction to the patient was that she was pregnant and advised to book appointment for prenatal visits week 12 of gestation at her GP, as it is recommended in Norway. Unless the group finished earlier, the game was ended after 30 min on the chime of the countdown timer. Throughout the game, the gamemaster watched the players through the baby monitor and noted game progress, misunderstandings, errors, and other discussion points for the debriefing. Hints were given through the baby monitor if requested or if the group was stuck in the game. The game was always followed by 30–45 min structured debriefing. Student evaluation The students were invited to give feedback by answering a 14-item questionnaire on the satisfaction with the class, teamwork quality using the Jefferson Teamwork Observation Guide [ 12 ], new knowledge learned, and suggestions for improvement using a secure anonymous webform service operated by the University of Oslo. The link to the questionnaire was distributed 1–4 days after the class to 4 groups simultaneously to further ascertain the anonymity of respondents. Quantitative data were evaluated using descriptive statistics, open text responses were summarized after thematic analysis in Nvivo (version 12, QSR International), including gamemaster’s notes of gameplays. Test of knowledge Students participated in one plenary non-obligatory team-based learning (TBL) session during the semester. At the start of TBL, students filled out an individual readiness assessment test, consisting of 20 multiple choice questions. The questions addressed broad knowledge in REI and were not targeted to specific topics of the small group class and the escape room game. As the TBL was held mid-semester, some students had already had the small group class in REI by the time of TBL session while others had not. To estimate the effect of small group class on declarative knowledge, test scores of students who had already had the class (exposed) were compared to scores of those who had not yet had the class (control). The effect size was expressed as Cohen’s d . Results During 5 semesters in 2017 to 2019, small groups of 2–5 students attended the outpatient class in reproductive endocrinology and infertility (REI). The class started with patient visits followed by either traditional case discussion for 2 semesters (56 groups, 213 students) or the escape room game for 3 semesters (84 groups, 324 students). Most groups (51%) completed the game within median 27 min (range 15–30 min) after receiving one or more hints, usually after 17 min into the game (Fig. 2 B). Student evaluation Students evaluated the class 1–4 days later, rating satisfaction with the teaching, teamwork quality, and learning outcome. During the 2 semesters without escape room game, 36 (54%) of 67 students (31% response rate) reported high overall satisfaction with teaching (grade 1 on scale 1–5). During the 3 semesters with escape room game, 63 (66%) of 95 respondents (29% response rate) expressed high overall satisfaction with the class. Mean student satisfaction during the two periods was comparable (1.41 and 1.49 for the respective periods; mean difference = 0.08, z = 0.13, P = 0.98). Open text responses from 95 students participating in the escape room game included 163 positive and 68 negative comments. Students most often commended the escape room (n = 63) and organization of the class (n = 57), whereas organization (n = 46) and escape room (n = 10) were also often criticized. The students were also asked to self-evaluate the quality of teamwork during the escape room game. The respondents (n = 56) characterized the teamwork as friendly and respectful, but lacking leadership (Fig. 2 C). Friendliness without leadership was a recurring theme of the open text responses: « A bit chaotic because there was no teamleader. » «It's nice to be able to discuss findings and ideas with one another and together find the right answer.» «Although I wasn't sure about everything, I trusted my team-mates and together we got the solution of the game.» «It is possible to come to the right conclusion, and then in plenary discuss ourselves away from it, never to end up in the right place again.» The students most often reported learning new clinical skills (n = 20), like using the gestational wheel, operating the ultrasound scanner, and measuring CRL, new knowledge about treatment (n = 9), like IVF, as well as new knowledge in physiology (n = 8), like gonadotropin action or early pregnancy physiology (Table 1 ). Table 1 Distribution of self-reported learning outcome (n = 49) by 95 students participating in a clinical class including the escape room game Learning outcome Selected responses Practiced clinical skills (n = 20; 41%) “A taste of how ultrasound works.” “To properly use the [pregnancy] wheel.” Knowledge on treatment (n = 9; 18%) “What missed abortion is, and what we should measure when we do an ultrasound scan.” “Details of IVF treatment.” Knowledge on physiology (n = 8; 16%) “Learned that we have to stimulate the follicles with FSH.” Anatomy (n = 6; 12%) “Learned about the fornices of the vagina and more about orientation on the screen.” “Location and significance of the cul de sac.” “Anteverted vs retroverted uterus.” Theory of clinical examination (n = 6; 12%) “How to use the ultrasound probe to get an appropriate picture of the uterus and adnexa.” Test of knowledge Students who attended the small group class without the escape room game achieved similar scores on broad knowledge test in REI than control students (Cohen's d = 0.05, 95%CI -0.58 to 0.68, n = 71). Students who played the escape room game achieved marginally higher score than respective controls (Cohen's d = 0.22, 95%CI -0.1 to 0.53, n = 182, Fig. 2 D). Discussion This paper reports implementation of a serious escape room game in clinical small group teaching. The game is moderately difficult for undergraduate medical students, while it is highly engaging, gives a satisfactory learning experience, and invokes persistent task-focused team effort. Feedback from students suggests that the game was able to engage with intended learning content, including practicing examination and diagnostic skills, and retention of subject-specific knowledge. The game has also revealed weaknesses of students’ teamwork skills. The effect of gameplay on acquisition and recall of broad declarative knowledge was moderate (effect size 0.22), and may be inferior to related teaching methods, such as simulation [ 13 ]. Indeed, technology-enhanced simulation was shown to have large effect size on many learning outcomes, including knowledge (1.20), skills (1.09 to 1.18), behavior (0.79), and patient care (0.50). In this study, declarative knowledge in the broad field of REI was tested, not limiting the questions to topics that were encountered during the small group class or the escape room game. Therefore, the effect size on more focused learning may be underestimated. Furthermore, the study was unable to detect improvement in other relevant learning outcomes, including skills, behaviors or patient care. Notably, games may promote learning by increasing engagement, motivation and awareness of a subject, which may not be assessed by a MCQ test addressing broad declarative knowledge in a field. Furthermore, a single gamified class lasting 1 hour including debrief may be too short to improve learning. Indeed, extending simulation trainings over 1 day was shown to be associated with better learning outcomes [ 13 ]. While watching many groups during the game, I made some reflections about gameplay and optimal implementation. To exploit surprise and maximize initial excitement, I found it useful to wait revealing the game right until it started. The students showed sustained intense involvement, and I have invariably seen task-focused persistent effort during the whole the game. The groups worked even more ferociously towards the end, which they were constantly reminded by the large-display countdown timer. Nonetheless, some groups found the riddles overtly challenging. Being able to give timely hints to struggling groups, most often warning about wrong track may have reduced frustration, improved game experience, and kept motivation sustained. Visible countdown timer and baby monitor with high quality audio are therefore crucial tools of the gamemaster. I also observed various problem-solving strategies, including reliance on shortcut cues. Few groups attempted trial-and-error, however, as the safe locked out for 30 sec after repeated incorrect attempts. Students showed professional conduct while alone in the room, for example all followed required procedures for using gloves, transducer sheath, waste disposal, etc. In agreement with students’ self-reports, I often observed inefficient teamwork, lack of self-management, and non-emergence of leader, which were persistent sources of frustration and inefficiency. Indeed, some groups struggled to recall from transactive memory even the most recent knowledge, for example diagnosis of intrauterine pregnancy, even though they had just participated in early pregnancy consultations and could watch training videos before class. I have only occasionally noted emergence of a leader who assigned tasks, summarized status, or prevented the group going off the track. Location, props, and puzzles were carefully selected for immersive game experience. A gynecological outpatient room was chosen as location, as the authenticity might improve the players’ identification with the story of the game. Pilot versions of the game were vetted for clinical relevance, and distracting items, riddles, or story elements were removed from the final game. Indeed, meta-analysis of serious games suggests that distractive narratives can reduce learning effect [ 14 ]. In the extent it aspired to represent reality, this escape room was more a simulation than a game [ 15 ]. The gameplay required a broad set of knowledge and skills, including basic physiology and clinical examination, and implied a workload that could not be solved by a single player within the allocated time, thus forcing teamwork. Riddles and activities also challenged boldness and resolution of the group, for example by needing to operate an unfamiliar ultrasound scanner for the first time. Serious games promote learning by allowing repeated active engagement with the game environment coupled with appropriate instructional support, like learning content, scaffolding and debriefing [ 15 ]. The present game allowed free roaming in the game and unhindered interaction with riddles, medical instruments and game props, which were all linked to defined educational objectives. Furthermore, the learning content was also scaffolded multiple ways for the students, including website, videos for advance viewing, and one-to-one clinical teaching. After the game, the students went through a debriefing, which is thought to provide a link between the game experience and real-world educational outcome [ 15 ]. The debriefing discussion usually touched on the group’s experience during the game, solution strategies, mistakes and errors, which were sometimes only uncovered by watching the gameplay with baby monitor. To reinforce the educational aims of the class, the debriefing often ended by demonstration of proper examination technique on the mannequin, pelvic ultrasound anatomy, early pregnancy signs, calculation of gestational age, and interpretation of the menstrual calendar. Self-evaluation by the students a few days after class suggests that some learned facts were retained. Wider implementation of the escape room activity may be limited by requirements of time, space, and high costs. Indeed, the gamemaster must allocate 10–15 min ahead of the activity to find a vacant room and arrange the props while keeping eye on student safety. Further 30 min are needed for the gameplay, 30–45 min for debriefing, and 5–10 min for packing down. A suitable clinical room with ultrasound scanner should be assigned for this class, which can be challenging in a busy clinical environment. Furthermore, some props, especially the mannequin, are expensive. The game can be optimally played by a group of 3–5 medical students, which may limit its versatility. In my experience, two students could be overwhelmed by the workload, while some students in a group of 6 or more may idle. One gamemaster can hardly monitor more than two games at the same time, and it may be impractical to run several parallel games because of multiplication of costs. For large groups, I created a boxed version of the game replacing the ultrasound scanner and mannequin with a pre-recorded video. The boxed version can be played simultaneously by several groups of students, but the valuable challenges and experiences of a real clinical environment are lost for the players. Conclusions In summary, escape room is an engaging and popular activity that can be implemented in small group clinical teaching. The concept is flexible, allows many iterations, and can be easily modified or adjusted for the target learners. For clinical teaching, it may be appropriate to design games with relevant narrative and non-distracting clinical puzzles. However, escape rooms are time intensive to create and supervise, and optimal experience may require expensive props and resources. The effect of escape room games on learning outcomes may be narrow and modest. Declarations Ethics approval and consent to participate Approval from research ethics committee was not sought and individual consent of students was not obtained, as it was not mandated by research authorities in Norway in case of analysis of anonymous data. Data on student satisfaction and teamwork quality were collected with a secure webform service operated by the University of Oslo using settings for anonymous recording. Individual MCQ test results during TBL class were anonymized, and students were only identified by whether they had the TBL class before or after the small group class during the semester. Availability of data and materials Supplemental online material gives comprehensive description of the escape room game allowing replication and free adaptation. Competing interests The author reports there are no competing interests to declare. Funding No external funding was sought for this study. Author’s contributions PF conceived and designed the study, collected, analyzed and interpreted the data, and wrote the manuscript. Acknowledgement I thank my co-teacher in team-based learning associate professor Atle Klovning MD. References Spencer J: Learning and teaching in the clinical environment. BMJ 2003, 326(7389):591-594. Gordon J: One to one teaching and feedback. BMJ 2003, 326(7388):543. Steinert Y: Twelve tips for effective small-group teaching in the health professions. Medical Teacher 2009, 18(3):203-207. Jaques D: Teaching small groups. BMJ 2003, 326(7387):492. Nicholson S: The State of Escape: Escape Room Design and Facilities. In: Meaningful Play 2016. Lansing, Michigan; 2016. Heikkinen O, Shumeyko J: Designing an escape room with the Experience Pyramid model. Helsinki, Finland: Haaga-Helia University of Applied Sciences; 2016. Year US Escape Room Industry Report (August 2020) [https://roomescapeartist.com/2020/08/24/escape-room-industry-report-2020/] Stone Z: The rise of educational escape rooms. The Atlantic 2016. Clarke S, J. Peel D, Arnab S, Morini L, Keegan H, Wood O: EscapED: A Framework for Creating Educational Escape Rooms and Interactive Games to For Higher/Further Education, vol. 4; 2017. Friedrich CL, Teaford H, Taubenheim A, Boland P, Sick B: Healthcare escape room design guidebooks. . In: Technology #20180272-20180273. University of Minnesota; 2018. Rosenkrantz O, Jensen TW, Sarmasoglu S, Madsen S, Eberhard K, Ersbøll AK, Dieckmann P: Priming healthcare students on the importance of non-technical skills in healthcare: How to set up a medical escape room game experience. Medical Teacher 2019, 41(11):1285-1292. Lyons KJ, Giordano C, Speakman E, Smith K, Horowitz JA: Jefferson Teamwork Observation Guide (JTOG): An Instrument to Observe Teamwork Behaviors. J Allied Health 2016, 45(1):49-53. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ: Technology-Enhanced Simulation for Health Professions Education: A Systematic Review and Meta-analysis. JAMA 2011, 306(9):978-988. Wouters P, van Nimwegen C, van Oostendorp H, van der Spek ED: A meta-analysis of the cognitive and motivational effects of serious games. Journal of Educational Psychology 2013, 105(2):249-265. Garris R, Ahlers R, Driskell JE: Games, Motivation, and Learning: A Research and Practice Model. Simulation & Gaming 2002, 33(4):441-467. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Nov, 2024 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 30 Jul, 2024 Editor assigned by journal 29 Jul, 2024 Submission checks completed at journal 29 Jul, 2024 First submitted to journal 18 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4764235","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":333568525,"identity":"922164d4-807a-470d-a50d-1bcbe8a0d225","order_by":0,"name":"Peter Fedorcsak","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIie2RsWrDMBCGLxiq5eqsFgT3FRQMNsZDXyWhg5cMHT0EqhJIljyAA6XPkCyeZQTxYuhctFj4CUKnLqV2WjoJl2wZ9HHoQKdP8EsAFsu1koFz7iOedasEEF3DQaX+U+qLlec1/JwfIgLSgMgSP9pU+rR7LXy3Ilo+gpyM4bZsDErMYQaiToNJvQjooVABlchkDhIpdx+YQWEChHNay3nuIVBdqPleIpyLCQw9ozLiUH71Cmk/9Yt62kvS/KN0yUveKxDSA1czJoENKvHqBoQ4poGHizDOj2q667MgS5GuMDBlichGN2KZ+B6p2vftUt25b1X7gVlyPybbqenFmGP+iP56x7D/O7JYLBbLMN+6H2Q+nSOmzAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Oslo","correspondingAuthor":true,"prefix":"","firstName":"Peter","middleName":"","lastName":"Fedorcsak","suffix":""}],"badges":[],"createdAt":"2024-07-18 17:17:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4764235/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4764235/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-024-06352-8","type":"published","date":"2024-11-23T15:57:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63288499,"identity":"77645cdd-f2c4-4dbe-907e-a3e558d7612f","added_by":"auto","created_at":"2024-08-26 13:58:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2502550,"visible":true,"origin":"","legend":"\u003cp\u003eArrangement of game items in the outpatient room. Before starting the escape room game, the gamemaster arranges all props and clinical items in the room (left to right): the medical dictionary, tear-off calendar showing the game’s date and fictious journals on the desk; document safe with the gestational wheel and address book locked inside; mannequin on the examination chair; ultrasound scanner; baby monitor to view the examination area; large-display countdown timer set to 30 min.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4764235/v1/82f41b5551da481b29d74e45.png"},{"id":63288498,"identity":"0ff459f3-89dd-45f1-a375-8b328351e0fd","added_by":"auto","created_at":"2024-08-26 13:58:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":345839,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic chart of the puzzles, students’ performance during the game and test of knowledge. \u003cem\u003eA\u003c/em\u003e, the game comprised 6 puzzles that all needed to be solved for successfully exiting the game. For discovery puzzles, players needed to locate objects, e.g. find the calendar for the date puzzle. Meta-puzzles used solution of one or more other puzzles. \u003cem\u003eB\u003c/em\u003e, progress chart of 39 gameplays with hints indicated as red dots. \u003cem\u003eC\u003c/em\u003e, students self-rated their teamwork using 11 items from the Jefferson Teamwork Observation Guide [12]. Average frequency of responses from 56 students is illustrated with a color density scale. \u003cem\u003eD\u003c/em\u003e, distribution of knowledge test score in students after small group teaching with or without escape room game (exposed) versus students who had not had small group teaching (control).\u003c/p\u003e","description":"","filename":"Figure2mounted.png","url":"https://assets-eu.researchsquare.com/files/rs-4764235/v1/1c416d38d15142e15836f8d4.png"},{"id":69835601,"identity":"e3a0afe8-2a6c-406b-a908-9f150c4ffe13","added_by":"auto","created_at":"2024-11-25 16:13:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4396812,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4764235/v1/1b0d0f02-0c57-4492-9b3f-b9d6b6bc387d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Moderate benefit of escape room game on learning outcome in medicine","fulltext":[{"header":"Background","content":"\u003cp\u003eClinical teachers have preference for small group formats, such as ward rounds, which can effectively present clinical scenarios to the students, give explanation, and facilitate discussion [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Some clinical settings like emergency rooms or gynecology outpatient clinics, however, are not ideal for small groups [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. To train problem-solving in such high-intensity or sensitive environments, group-based simulations and serious games, in particular escape room games, can be effective by letting learners to practice teamwork skills, to discuss, present ideas, and persuade peers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEscape room is a live-action team-based game that stems from the point-and-click genre of adventure computer games, like the \u003cem\u003eManiac Mansion\u003c/em\u003e, \u003cem\u003eThe Secret of the Monkey Island\u003c/em\u003e, or the \u003cem\u003eDay of the Tentacle\u003c/em\u003e (LucasArts). In an escape room, a team of players is locked in a physical room where they are presented to a captivating story and a challenging task. By interacting with the environment under time pressure, discovering hidden clues and solving puzzles and riddles, the team must find a key to escape the room. The most successful game designs have been described by scholarly surveys [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]: Before the game, a mystical story is presented to the players to create anticipation and tension. Once in the room, most teams start with slow and careful discovery of the surroundings, but soon excitement will take over as the team members call out discoveries or hunch over puzzles in groups. Most groups will leave the game with excitement and may continue to discuss the activity online, also known as froth.\u003c/p\u003e \u003cp\u003eNicholson [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] distinguishes four basic game formats depending on the presence of a specific theme and narrative, and whether the puzzles are stand-alone or integrated into the narrative. In the more elaborate games, the puzzles are part of the storytelling, and immersive experience comes from games designed with attention to player motivations, physical environment, intellectual challenges, and emotions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe puzzle design is either path-based or sequential. In path-based designs, the team is presented with several different puzzles at the same time and each of the paths are needed to solve a meta-puzzle, which will unlock the next stage or victory. The team can split into smaller groups to solve path-based puzzles. The sequential game design presents the players with one puzzle at a time that will unlock the next puzzle in sequence. The sequential design requires the entire team work together. The most frequent types of puzzles are searching hidden objects; using light; counting; noticing something obvious in the room; symbol substitution with a key; using something in an unusual way; searching images; assembly of an object.\u003c/p\u003e \u003cp\u003eEscape room facilities usually provide a gamemaster to ensure fair player experience. The gamemaster may monitor the players via video, help the players if stuck or frustrated, and ensure safety. Gamemasters may also give hints, either on request or at timed intervals. Nicholson\u0026rsquo;s survey [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] indicates that the average player\u0026rsquo;s success rate is 41%.\u003c/p\u003e \u003cp\u003eEscape rooms have become remarkably popular, with over 2200 event facilities established in the USA alone in 2020, where only a dozen existed in 2014 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Educational use of escape rooms is also increasing [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and specific tutorials are available for implementation in higher education [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], including undergraduate medical teaching [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The escape room class designed by Friedrich et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] aims to improve team skills of interprofessional health care students. After a plenary introduction, the students are divided into small groups (6\u0026ndash;8) for the escape room experience. According to the storyline, the players must plan discharge from the hospital of a patient with diabetes and mental disease. The game design by Friedrich et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] is supported by a small collection of physical props (e.g. code-labelled balls hidden in the room), but most content is delivered to the players in online spreadsheets and text documents. The puzzles are elaborate but non-medical, including matching color to music tone, finding hidden objects, riddles, and an online maze, but the puzzles are not integrated in story of the game. The escape room session is followed by a plenary debriefing to ascertain that the educational aims of the game had been met. The escape room game designed by Rosenkrantz et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] aims to train collaboration and communication skills using a fictious game narrative (countering a zombie-like virus attack). Their game applies clinical props from emergency wards (ECG monitor, nebulizer mask), as well as toys (remote controlled car), and the riddles are aligned with the fictious narrative, i.e. triaging zombies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe efficacy of escape room games in teaching and learning remains nonetheless uncertain.\u003c/p\u003e \u003cp\u003eI developed and implemented a serious escape room game in small group teaching in reproductive endocrinology and infertility (REI). I aimed to achieve specific educational objectives with focusing on immersive game design, clinically relevant riddles, and hands-on experience for students. Consecutive groups of students played the game during the semester, and the performance of students who played the game was compared to those who had not yet played the game on a mid-semester test of broad knowledge in REI, which allowed estimating the effect of escape room game on declarative knowledge.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eContext and design of study\u003c/h2\u003e\n \u003cp\u003eThe obligatory small group class in REI was part of the undergraduate curriculum for 5th year medical students at the Faculty of Medicine, University of Oslo. This was a non-randomized, retrospective, two group, posttest-only study assessing the effect of small group teaching or small group teaching combined with escape room as interventions during this class. Statistical power was not calculated in advance.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eSmall group class\u003c/h2\u003e\n \u003cp\u003eAhead of the class, the students were asked to browse the REI website for customized educational sources including texts, videos, podcast, and textbook chapters specifically relevant for the planned activities. The class started with clinical rounds, when each student shadowed a gynecologist for 2 hours at the outpatient clinic. All students had had the opportunity to observe transvaginal ultrasound examinations, and most students could also participate in consultations on early pregnancy. After the clinical rounds, the group was convened for either traditional case discussion (2 semesters) or escape room game and de-brief (3 semesters).\u003c/p\u003e\n \u003cp\u003eThe educational objectives of the escape room game were:\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e1. Describe the process of spontaneous human conception, assisted reproduction treatment, the signs of intrauterine pregnancy (IUP) and extrauterine gestation.\u003cbr\u003e\u003c/span\u003e \u003cspan\u003e2. Review clinical records and perform ultrasound examination of the pelvic organs on the mannequin, including assessment of the fetal crown-rump length (CRL).\u003cbr\u003e\u003c/span\u003e \u003cspan\u003e3. Recognize clinical, biochemical, and ultrasonographic signs of early IUP and calculate the gestational age using multiple cues.\u003cbr\u003e\u003c/span\u003e \u003cspan\u003e4. Demonstrate professional attitude during clinical examination.\u003cbr\u003e\u003c/span\u003e \u003cspan\u003e5. Demonstrate efficient teamwork under time pressure.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eImplementation of the escape room game\u003c/h2\u003e\n \u003cp\u003eSupplemental online material gives detailed instructions for setting up the game, including list and sourcing of props, gamemaster\u0026rsquo;s script, and fictious patient journals. Briefly, the game was set up in a gynecological outpatient room. Gynecological examination chair, ultrasound scanner with transvaginal transducer, and gestational wheel were borrowed from the clinic. Props specifically purchased for the game included a medical dictionary, intrauterine pregnancy transvaginal ultrasound training mannequin, a document safe with digital lock, countdown timer with large LED display, and a baby monitor with camera. Additional items were an envelope with the welcome letter and the safe code puzzle, a tear-off calendar, three fictious patient journals, and an address book with the telephone number puzzle. The gestational wheel and the address book were locked in the document safe, the other items were inconspicuously arranged in the room (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eAfter arranging the props in the room, the gamemaster came out to the corridor to greet the waiting students, read out the introductory script, gave the students the envelope with the game quest, and let the group enter the room. The group was also informed that the gameplay will be observed on the baby monitor but no recordings will be made. The countdown timer in the room was set to 30 min.\u003c/p\u003e\n \u003cp\u003eThe objective of the players was to examine the mannequin using the ultrasound scanner, select the patient journal that matched ultrasound findings on the mannequin, unlock the safe, decode the telephone number in the address book, and call the number to tell the fictious patient about follow-up investigations. Groups making the phone call within 30 min and giving appropriate instructions won the game.\u003c/p\u003e\n \u003cp\u003eThe game contained 8 interconnected puzzles of varying complexity and difficulty (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA). The date puzzle required finding the desktop calendar and recognizing the fictious date of the game. The blastocyst puzzle required finding the page number for entry \u0026lsquo;blastocyst\u0026rsquo; in the medical dictionary by identifying drawing of a blastocyst. To solve the IUP puzzle, the group needed to operate the ultrasound scanner, examine the mannequin, and identify 8 weeks old intrauterine pregnancy. The journals puzzle required solution of the calendar puzzle, as well as correct interpretation of three fictious patient histories, which were extrauterine pregnancy, first trimester pregnancy conceived by IVF, and second trimester pregnancy conceived spontaneously. The journals puzzle and the blastocyst puzzle unlocked the safe. When opening the safe, the group needed to solve the CRL puzzle, which required either measuring the approximate fetal length on the mannequin or use the gestational wheel found in the safe. Solution of the CRL puzzle gave the missing digit in the telephone number, allowing the group to make the call. (The phone number belonged to the gamemaster.) The correct instruction to the patient was that she was pregnant and advised to book appointment for prenatal visits week 12 of gestation at her GP, as it is recommended in Norway. Unless the group finished earlier, the game was ended after 30 min on the chime of the countdown timer.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eThroughout the game, the gamemaster watched the players through the baby monitor and noted game progress, misunderstandings, errors, and other discussion points for the debriefing. Hints were given through the baby monitor if requested or if the group was stuck in the game. The game was always followed by 30\u0026ndash;45 min structured debriefing.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eStudent evaluation\u003c/h2\u003e\n \u003cp\u003eThe students were invited to give feedback by answering a 14-item questionnaire on the satisfaction with the class, teamwork quality using the Jefferson Teamwork Observation Guide [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e], new knowledge learned, and suggestions for improvement using a secure anonymous webform service operated by the University of Oslo. The link to the questionnaire was distributed 1\u0026ndash;4 days after the class to 4 groups simultaneously to further ascertain the anonymity of respondents. Quantitative data were evaluated using descriptive statistics, open text responses were summarized after thematic analysis in Nvivo (version 12, QSR International), including gamemaster\u0026rsquo;s notes of gameplays.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eTest of knowledge\u003c/h2\u003e\n \u003cp\u003eStudents participated in one plenary non-obligatory team-based learning (TBL) session during the semester. At the start of TBL, students filled out an individual readiness assessment test, consisting of 20 multiple choice questions. The questions addressed broad knowledge in REI and were not targeted to specific topics of the small group class and the escape room game. As the TBL was held mid-semester, some students had already had the small group class in REI by the time of TBL session while others had not. To estimate the effect of small group class on declarative knowledge, test scores of students who had already had the class (exposed) were compared to scores of those who had not yet had the class (control). The effect size was expressed as Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring 5 semesters in 2017 to 2019, small groups of 2\u0026ndash;5 students attended the outpatient class in reproductive endocrinology and infertility (REI). The class started with patient visits followed by either traditional case discussion for 2 semesters (56 groups, 213 students) or the escape room game for 3 semesters (84 groups, 324 students). Most groups (51%) completed the game within median 27 min (range 15\u0026ndash;30 min) after receiving one or more hints, usually after 17 min into the game (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStudent evaluation\u003c/h2\u003e \u003cp\u003eStudents evaluated the class 1\u0026ndash;4 days later, rating satisfaction with the teaching, teamwork quality, and learning outcome. During the 2 semesters without escape room game, 36 (54%) of 67 students (31% response rate) reported high overall satisfaction with teaching (grade 1 on scale 1\u0026ndash;5). During the 3 semesters with escape room game, 63 (66%) of 95 respondents (29% response rate) expressed high overall satisfaction with the class. Mean student satisfaction during the two periods was comparable (1.41 and 1.49 for the respective periods; mean difference\u0026thinsp;=\u0026thinsp;0.08, z\u0026thinsp;=\u0026thinsp;0.13, P\u0026thinsp;=\u0026thinsp;0.98).\u003c/p\u003e \u003cp\u003eOpen text responses from 95 students participating in the escape room game included 163 positive and 68 negative comments. Students most often commended the escape room (n\u0026thinsp;=\u0026thinsp;63) and organization of the class (n\u0026thinsp;=\u0026thinsp;57), whereas organization (n\u0026thinsp;=\u0026thinsp;46) and escape room (n\u0026thinsp;=\u0026thinsp;10) were also often criticized.\u003c/p\u003e \u003cp\u003eThe students were also asked to self-evaluate the quality of teamwork during the escape room game. The respondents (n\u0026thinsp;=\u0026thinsp;56) characterized the teamwork as friendly and respectful, but lacking leadership (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). Friendliness without leadership was a recurring theme of the open text responses:\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e\u0026laquo; A bit chaotic because there was no teamleader. \u0026raquo;\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026laquo;It's nice to be able to discuss findings and ideas with one another and together find the right answer.\u0026raquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026laquo;Although I wasn't sure about everything, I trusted my team-mates and together we got the solution of the game.\u0026raquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026laquo;It is possible to come to the right conclusion, and then in plenary discuss ourselves away from it, never to end up in the right place again.\u0026raquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe students most often reported learning new clinical skills (n\u0026thinsp;=\u0026thinsp;20), like using the gestational wheel, operating the ultrasound scanner, and measuring CRL, new knowledge about treatment (n\u0026thinsp;=\u0026thinsp;9), like IVF, as well as new knowledge in physiology (n\u0026thinsp;=\u0026thinsp;8), like gonadotropin action or early pregnancy physiology (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of self-reported learning outcome (n\u0026thinsp;=\u0026thinsp;49) by 95 students participating in a clinical class including the escape room game\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelected responses\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePracticed clinical skills\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20; 41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;A taste of how ultrasound works.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;To properly use the [pregnancy] wheel.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge on treatment\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9; 18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;What missed abortion is, and what we should measure when we do an ultrasound scan.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Details of IVF treatment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge on physiology\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8; 16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Learned that we have to stimulate the follicles with FSH.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnatomy\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6; 12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Learned about the fornices of the vagina and more about orientation on the screen.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Location and significance of the cul de sac.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Anteverted vs retroverted uterus.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheory of clinical examination\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6; 12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;How to use the ultrasound probe to get an appropriate picture of the uterus and adnexa.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTest of knowledge\u003c/h2\u003e \u003cp\u003eStudents who attended the small group class without the escape room game achieved similar scores on broad knowledge test in REI than control students (Cohen's \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05, 95%CI -0.58 to 0.68, n\u0026thinsp;=\u0026thinsp;71). Students who played the escape room game achieved marginally higher score than respective controls (Cohen's \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.22, 95%CI -0.1 to 0.53, n\u0026thinsp;=\u0026thinsp;182, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper reports implementation of a serious escape room game in clinical small group teaching. The game is moderately difficult for undergraduate medical students, while it is highly engaging, gives a satisfactory learning experience, and invokes persistent task-focused team effort. Feedback from students suggests that the game was able to engage with intended learning content, including practicing examination and diagnostic skills, and retention of subject-specific knowledge. The game has also revealed weaknesses of students\u0026rsquo; teamwork skills.\u003c/p\u003e \u003cp\u003eThe effect of gameplay on acquisition and recall of broad declarative knowledge was moderate (effect size 0.22), and may be inferior to related teaching methods, such as simulation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Indeed, technology-enhanced simulation was shown to have large effect size on many learning outcomes, including knowledge (1.20), skills (1.09 to 1.18), behavior (0.79), and patient care (0.50).\u003c/p\u003e \u003cp\u003eIn this study, declarative knowledge in the broad field of REI was tested, not limiting the questions to topics that were encountered during the small group class or the escape room game. Therefore, the effect size on more focused learning may be underestimated. Furthermore, the study was unable to detect improvement in other relevant learning outcomes, including skills, behaviors or patient care. Notably, games may promote learning by increasing engagement, motivation and awareness of a subject, which may not be assessed by a MCQ test addressing broad declarative knowledge in a field. Furthermore, a single gamified class lasting 1 hour including debrief may be too short to improve learning. Indeed, extending simulation trainings over 1 day was shown to be associated with better learning outcomes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile watching many groups during the game, I made some reflections about gameplay and optimal implementation. To exploit surprise and maximize initial excitement, I found it useful to wait revealing the game right until it started. The students showed sustained intense involvement, and I have invariably seen task-focused persistent effort during the whole the game. The groups worked even more ferociously towards the end, which they were constantly reminded by the large-display countdown timer. Nonetheless, some groups found the riddles overtly challenging. Being able to give timely hints to struggling groups, most often warning about wrong track may have reduced frustration, improved game experience, and kept motivation sustained. Visible countdown timer and baby monitor with high quality audio are therefore crucial tools of the gamemaster.\u003c/p\u003e \u003cp\u003eI also observed various problem-solving strategies, including reliance on shortcut cues. Few groups attempted trial-and-error, however, as the safe locked out for 30 sec after repeated incorrect attempts. Students showed professional conduct while alone in the room, for example all followed required procedures for using gloves, transducer sheath, waste disposal, etc.\u003c/p\u003e \u003cp\u003eIn agreement with students\u0026rsquo; self-reports, I often observed inefficient teamwork, lack of self-management, and non-emergence of leader, which were persistent sources of frustration and inefficiency. Indeed, some groups struggled to recall from transactive memory even the most recent knowledge, for example diagnosis of intrauterine pregnancy, even though they had just participated in early pregnancy consultations and could watch training videos before class. I have only occasionally noted emergence of a leader who assigned tasks, summarized status, or prevented the group going off the track.\u003c/p\u003e \u003cp\u003eLocation, props, and puzzles were carefully selected for immersive game experience. A gynecological outpatient room was chosen as location, as the authenticity might improve the players\u0026rsquo; identification with the story of the game. Pilot versions of the game were vetted for clinical relevance, and distracting items, riddles, or story elements were removed from the final game. Indeed, meta-analysis of serious games suggests that distractive narratives can reduce learning effect [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In the extent it aspired to represent reality, this escape room was more a simulation than a game [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The gameplay required a broad set of knowledge and skills, including basic physiology and clinical examination, and implied a workload that could not be solved by a single player within the allocated time, thus forcing teamwork. Riddles and activities also challenged boldness and resolution of the group, for example by needing to operate an unfamiliar ultrasound scanner for the first time.\u003c/p\u003e \u003cp\u003eSerious games promote learning by allowing repeated active engagement with the game environment coupled with appropriate instructional support, like learning content, scaffolding and debriefing [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The present game allowed free roaming in the game and unhindered interaction with riddles, medical instruments and game props, which were all linked to defined educational objectives. Furthermore, the learning content was also scaffolded multiple ways for the students, including website, videos for advance viewing, and one-to-one clinical teaching. After the game, the students went through a debriefing, which is thought to provide a link between the game experience and real-world educational outcome [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The debriefing discussion usually touched on the group\u0026rsquo;s experience during the game, solution strategies, mistakes and errors, which were sometimes only uncovered by watching the gameplay with baby monitor. To reinforce the educational aims of the class, the debriefing often ended by demonstration of proper examination technique on the mannequin, pelvic ultrasound anatomy, early pregnancy signs, calculation of gestational age, and interpretation of the menstrual calendar. Self-evaluation by the students a few days after class suggests that some learned facts were retained.\u003c/p\u003e \u003cp\u003eWider implementation of the escape room activity may be limited by requirements of time, space, and high costs. Indeed, the gamemaster must allocate 10\u0026ndash;15 min ahead of the activity to find a vacant room and arrange the props while keeping eye on student safety. Further 30 min are needed for the gameplay, 30\u0026ndash;45 min for debriefing, and 5\u0026ndash;10 min for packing down. A suitable clinical room with ultrasound scanner should be assigned for this class, which can be challenging in a busy clinical environment. Furthermore, some props, especially the mannequin, are expensive.\u003c/p\u003e \u003cp\u003eThe game can be optimally played by a group of 3\u0026ndash;5 medical students, which may limit its versatility. In my experience, two students could be overwhelmed by the workload, while some students in a group of 6 or more may idle. One gamemaster can hardly monitor more than two games at the same time, and it may be impractical to run several parallel games because of multiplication of costs. For large groups, I created a boxed version of the game replacing the ultrasound scanner and mannequin with a pre-recorded video. The boxed version can be played simultaneously by several groups of students, but the valuable challenges and experiences of a real clinical environment are lost for the players.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, escape room is an engaging and popular activity that can be implemented in small group clinical teaching. The concept is flexible, allows many iterations, and can be easily modified or adjusted for the target learners. For clinical teaching, it may be appropriate to design games with relevant narrative and non-distracting clinical puzzles. However, escape rooms are time intensive to create and supervise, and optimal experience may require expensive props and resources. The effect of escape room games on learning outcomes may be narrow and modest.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval from research ethics committee was not sought and individual consent of students was not obtained, as it was not mandated by research authorities in Norway in case of analysis of anonymous data. Data on student satisfaction and teamwork quality were collected with a\u0026nbsp;secure webform service operated by the University of Oslo using settings for anonymous recording. Individual\u0026nbsp;MCQ test results during TBL class were anonymized, and students were only identified by whether they had the TBL class before or after the small group class during the semester.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupplemental online material gives comprehensive description of the escape room game allowing replication and free adaptation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author reports there are no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was sought for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePF conceived and designed the study, collected, analyzed and interpreted the data, and wrote the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI thank my co-teacher in team-based learning associate professor Atle Klovning MD.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSpencer J: Learning and teaching in the clinical environment. BMJ 2003, 326(7389):591-594.\u003c/li\u003e\n\u003cli\u003eGordon J: One to one teaching and feedback. BMJ 2003, 326(7388):543.\u003c/li\u003e\n\u003cli\u003eSteinert Y: Twelve tips for effective small-group teaching in the health professions. Medical Teacher 2009, 18(3):203-207.\u003c/li\u003e\n\u003cli\u003eJaques D: Teaching small groups. BMJ 2003, 326(7387):492.\u003c/li\u003e\n\u003cli\u003eNicholson S: The State of Escape: Escape Room Design and Facilities. In: Meaningful Play 2016. Lansing, Michigan; 2016.\u003c/li\u003e\n\u003cli\u003eHeikkinen O, Shumeyko J: Designing an escape room with the Experience Pyramid model. Helsinki, Finland: Haaga-Helia University of Applied Sciences; 2016.\u003c/li\u003e\n\u003cli\u003eYear US Escape Room Industry Report (August 2020) [https://roomescapeartist.com/2020/08/24/escape-room-industry-report-2020/]\u003c/li\u003e\n\u003cli\u003eStone Z: The rise of educational escape rooms. The Atlantic 2016.\u003c/li\u003e\n\u003cli\u003eClarke S, J. Peel D, Arnab S, Morini L, Keegan H, Wood O: EscapED: A Framework for Creating Educational Escape Rooms and Interactive Games to For Higher/Further Education, vol. 4; 2017.\u003c/li\u003e\n\u003cli\u003eFriedrich CL, Teaford H, Taubenheim A, Boland P, Sick B: Healthcare escape room design guidebooks. . In: Technology #20180272-20180273. University of Minnesota; 2018.\u003c/li\u003e\n\u003cli\u003eRosenkrantz O, Jensen TW, Sarmasoglu S, Madsen S, Eberhard K, Ersb\u0026oslash;ll AK, Dieckmann P: Priming healthcare students on the importance of non-technical skills in healthcare: How to set up a medical escape room game experience. Medical Teacher 2019, 41(11):1285-1292.\u003c/li\u003e\n\u003cli\u003eLyons KJ, Giordano C, Speakman E, Smith K, Horowitz JA: Jefferson Teamwork Observation Guide (JTOG): An Instrument to Observe Teamwork Behaviors. J Allied Health 2016, 45(1):49-53.\u003c/li\u003e\n\u003cli\u003eCook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ: Technology-Enhanced Simulation for Health Professions Education: A Systematic Review and Meta-analysis. JAMA 2011, 306(9):978-988.\u003c/li\u003e\n\u003cli\u003eWouters P, van Nimwegen C, van Oostendorp H, van der Spek ED: A meta-analysis of the cognitive and motivational effects of serious games. Journal of Educational Psychology 2013, 105(2):249-265.\u003c/li\u003e\n\u003cli\u003eGarris R, Ahlers R, Driskell JE: Games, Motivation, and Learning: A Research and Practice Model. Simulation \u0026amp; Gaming 2002, 33(4):441-467.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"gamification, escape room game, learning outcome","lastPublishedDoi":"10.21203/rs.3.rs-4764235/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4764235/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWell-designed escape room games engage students with complex problems and challenge clinical and teamwork skills, but their impact on learning has been uncertain. This study aimed to estimate the effect size of escape room game on performance in a broad\u003c/p\u003e\n\u003cp\u003eknowledge test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring clinical rotation in reproductive endocrinology and infertility (REI), medical students participated in a 3-hour small-group class. For 2 semesters, groups had traditional patient visits and case discussions, and for 3 semesters, patient visits and an escape room game including debrief. The game was set up in the outpatient clinic, the puzzles were taken from clinical problems in REI, and challenges included operating an ultrasound scanner on a mannequin. Mid-semester, students completed a test of general knowledge in REI. To estimate the effect of small group class on declarative knowledge, test scores of students who had already had the class (exposed) were compared to scores of those who had not yet had the class (control).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents were highly satisfied with gamified teaching. Those who attended the small group class without the escape room game achieved similar scores on knowledge test than control students (Cohen's \u003cem\u003ed\u003c/em\u003e = 0.05, 95%CI -0.58 to 0.68, n = 71). Students who played the escape room game achieved marginally higher score than respective controls (Cohen's \u003cem\u003ed\u003c/em\u003e = 0.22, 95%CI -0.1 to 0.53, n = 182).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEscape room game may improve learning outcome of a traditional small group class, but the effect of a single game on declarative knowledge is modest and is unlikely to exceed related instructional methods like simulation.\u003c/p\u003e","manuscriptTitle":"Moderate benefit of escape room game on learning outcome in medicine","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 13:58:12","doi":"10.21203/rs.3.rs-4764235/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-30T07:09:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-29T14:08:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-29T14:06:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-07-18T17:16:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4a4588cc-2814-419a-9ce3-845989f2fc4a","owner":[],"postedDate":"August 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-25T16:09:05+00:00","versionOfRecord":{"articleIdentity":"rs-4764235","link":"https://doi.org/10.1186/s12909-024-06352-8","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2024-11-23 15:57:20","publishedOnDateReadable":"November 23rd, 2024"},"versionCreatedAt":"2024-08-26 13:58:12","video":"","vorDoi":"10.1186/s12909-024-06352-8","vorDoiUrl":"https://doi.org/10.1186/s12909-024-06352-8","workflowStages":[]},"version":"v1","identity":"rs-4764235","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4764235","identity":"rs-4764235","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}