Disease-state-themed Escape Room Simulations in Undergraduate Pharmacy Education: A Systematic Review

Disease-state-themed Escape Room Simulations in Undergraduate Pharmacy Education: A Systematic Review | 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 Disease-state-themed Escape Room Simulations in Undergraduate Pharmacy Education: A Systematic Review Chinonyelum Emmanuel Agbo, Olumide Ademola Noah, Ikponmwosa Jude Ogieuhi, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6636552/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Traditional lecture-based approaches are usually inadequate in enhancing applicability, clinical skills, and engaging students. Escape rooms have been increasingly studied due to their ability to facilitate critical thinking, collaborative learning, and immersive learning. Since pharmacists are an integral part of healthcare, their extensive clinical knowledge of communicable and non-communicable disease states is crucial to adequate patient care. Therefore, we systematically evaluated the effectiveness of disease-state-themed escape rooms among pharmacy students, who are future pharmacists. Method We carried out an extensive search across PubMed, Google Scholar, and Cochrane using appropriate keywords and Boolean operators. We screened articles for eligibility, ensuring that only escape room studies themed on disease states among pharmacy undergraduates were included. Quality assessment was done using the MERSQI tool. Results Of the 1,146 studies screened, 6 studies published between 2017 to 2023 met the eligibility criteria. The study participants ranged from 36 to 418. The escape rooms assessed disease states such as diabetes, heart failure, cancer, and hepatitis. There was a significant improvement in the knowledge assessment score on the disease topics across most studies after participating in the disease-state-themed escape room activity. The studies also showed a positive students’ perception and satisfaction levels about the escape room activity, with the majority of the students expressing willingness to recommend the activity to other students. Additionally, improvements in critical thinking and collaborative learning were reported among the students. Conclusion Disease-state-themed escape rooms show promising effectiveness in learning disease topics among pharmacy undergraduates. However, the limited number of studies included in this review restricts its generalizability and calls for further research, particularly randomized controlled trials, to establish a comparison and determine their true impact on learning outcomes and long-term knowledge retention. Escape Room Gamified learning Disease States Pharmacy Students Pharmacy Education Figures Figure 1 1.0 Introduction The landscape of pharmacy education is rapidly and continually evolving, with a growing emphasis on innovative and interactive teaching methods that foster active learning, critical thinking, and problem-solving skills [ 1 ]. Traditional lecture-based approaches, although foundational, are frequently inadequate in engaging students [ 1 ] and promoting deep understanding and retention of complex pharmaceutical concepts [ 2 ]. In response, educators have increasingly turned to simulation-based training, recognizing its potential to bridge the gap between theoretical knowledge and practical application [ 3 ]. Escape rooms are engrossing, interactive simulations that challenge participants to solve problems, decipher clues, and collaborate to "escape" within a set timeframe [ 4 – 6 ]. They are usually filled with a series of puzzles which players must solve in order to escape. Each puzzle unlocks a key or code, progressing players toward the final lock and ultimate escape [ 7 ]. Virtual escape rooms often mirror this set-up, digitally integrating locks and challenges. The puzzles encourage teamwork [ 2 ] and the development of problem-solving skills. Disease-state-themed escape rooms are among the novel approaches picking up steam in pharmacy education. By integrating pharmaceutical concepts into an engaging and riveting narrative, escape rooms offer a unique opportunity for pharmacy students to apply their knowledge in a dynamic, real-world context. Here, participants are immersed in a simulation of a medical scenario, which may involve communicable or non-communicable diseases. In this simulation, the participants decode clues and crack puzzles related to the disease state in focus. They navigate through the room, unraveling diagnostic hints, interpreting lab reports, and developing therapy plans, all while racing against time to escape. By simulating real-world medical challenges, these escape rooms help students cultivate a deeper understanding of complex diseases and promote collaborative learning [ 2 ]. Research suggests that escape rooms can effectively enhance learning outcomes, especially in healthcare and STEM education, by increasing engagement, motivation, and knowledge-retention [ 2 , 5 , 6 ]. Studies have shown that students who participated in educational escape rooms demonstrate superior knowledge acquisition, outperforming those who learn through conventional lecture means [ 8 ]. By capitalizing on the students’ natural affinity for puzzle-solving and competition, escape rooms can create a memorable learning experience that resonates with students. In pharmacy education, disease-state-themed escape rooms can simulate real-world scenarios, forcing students to employ critical thinking about disease pathology, pharmacotherapy, and patient care. Educators have learnt to theme puzzles around topics they want the players to explore [ 9 ], which involves solving a sequence of clues, puzzles, and tasks under time pressure to reach an ultimate goal [ 5 ]. Pharmacy students, who are future pharmacists, play essential roles in healthcare [ 10 ] as pharmacists may serve as the first point of contact, in some countries like those in Asia [ 11 ], and especially in some low and middle-income countries like Nigeria [ 12 ]. Hence, an appropriate teaching style complemented with traditional lecture-based teaching will enhance their clinical skills, disease management, and patient care. Escape rooms have been studied extensively in Pharmacy education in the areas of good manufacturing practices [ 13 ], disaster preparedness [ 14 ], first-year orientation [ 15 ], diabetes [ 16 , 17 ], heart failure [ 18 ], to mention but a few. Other systematic reviews have evaluated the effectiveness and impact of escape rooms among healthcare and medical students [ 19 , 20 ], and among pharmacy students [ 2 ]. However, to the best of our knowledge, this is the first systematic review on escape rooms in pharmacy education focusing on specific disease states. With a growing interest in the role of pharmacists in disease management, there is a need for a systematic evaluation of the effectiveness of disease-state-themed escape rooms in pharmacy curricula. This study aims to analyze existing research to provide clarity on the potential benefits, limitations, and potential applications of disease-state-themed escape room simulations in pharmacy education curricula. Our findings aim to inform educators, researchers, and policymakers, supporting the development of innovative, evidence-based teaching methods that prepare students for the complexities of real-world practice. 2.0 Methodology This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. The protocol was registered on PROSPERO with registration number CRD420251050200. 2.1 Search Strategies The literature search was conducted on Thursday 17th April 2025 in PubMed, Google Scholar (using Harzing’s Publish or Perish app), and Cochrane using the following terms: (Escape Room OR Simulation OR Gamification) AND (Pharmacy OR Pharmacy Students OR Pharmacy Education OR Pharmacy Undergraduates). These databases were selected as they index literature relevant to disease-state-themed escape rooms. Conference proceedings; institutional reports; preprints; and non-peer reviewed articles were excluded in order to ensure that all included studies met rigorous peer-review standards. No limit was set for the year of publication. Satisfactory articles were imported into EndNote to remove duplicates and then screened using Rayyan software. See Fig. 1 2.2 Eligibility Criteria Studies were selected only if they met the following conditions: Focused on disease states only (Communicable or non-communicable). Participants were pharmacy undergraduates only. The escape rooms were educational in nature. Studies were published in English. Outcomes involved one of the following: Learning outcomes (Knowledge, Critical Thinking, Student engagement etc); Perception; Acceptability. 2.2.1 Exclusion Criteria Studies were excluded if: They did not involve pharmacy undergraduates. They involved pharmacy as well as other health professionals. Escape room not themed or focused on certain disease states. The studies were reviews. 2.3 Study Selection Two reviewers (O.A.N and C.E.A) independently screened titles and abstracts for relevance, and conflicts were resolved by I.J.O. All included studies were assessed for ethical compliance, and only studies that reported adherence to ethical research guidelines, including obtaining informed consent and approval from appropriate ethics committees, were included. As a result, ethical approval was not required for this systematic review. The studies that did not meet the eligibility criteria were excluded. 2.4 Data Extraction and Analysis Data was extracted under the following columns: Author and year, Disease theme, Study objectives, Sample size, Sample characteristics, Grouping, Max. time of escape, Mode of escape room, Escape room delivery, Key findings, Conclusion. 2.5 Quality Assessment The studies that were included were assessed for their methodological quality using the 10-item Medical Education Research Study Quality Instrument (MERSQI). Study design, sampling, type of data, validity, data analysis, and outcomes were assessed [ 21 ]. The MERSQI instrument has 10 individually scored items varying on scales ranging from 0.5-3, with a total score of 18 [ 22 ]. A MERSQI score of 9 or below is generally considered to indicate low-quality or rejected studies. In our assessment, the total MERSQI scores of the included studies ranged from 9.5 to 11.0, suggesting that while none of the studies fell below the rejection threshold, several were only marginally above it and may still be considered of moderate quality [ 23 ]. 3.0 Results The initial search yielded 1,146 articles, and 288 articles remained after duplicate removal. Title and abstract screening were done, after which 17 articles were identified for full text screening. Finally, six (6) articles were included for systematic review. MERSQI scores ranged from 9.5 to 10.5, with an average score of 10.2. Two (2) studies scored a summative score of 9.5 [ 3 , 5 ] while the study by Kavanaugh et al. scored 11 [ 17 ]. 3.1 Characteristics of Included Studies The included studies were published between 2017 and 2023, where half of the included studies (n = 3, 50%) were published in 2020 [ 17 , 18 , 24 ] with participants ranging from 36 to 418 students. While two (2) of the studies were diabetes-themed [ 16 , 17 ] and cancer-themed [ 24 , 25 ], other disease-specific themes were handled in two other studies: hepatitis [ 26 ] and heart failure [ 18 ]. Five of the included studies were pilot studies where the learning objectives were based on knowledge improvement [ 16 – 18 , 25 , 26 ] while the study by Wilby et al. [ 24 ] was a feasibility study with SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis of the disease-themed escape room. 3.2 Characteristics of the Disease-themed Escape Rooms The characteristics of the disease-themed escape rooms as identified in the included articles were summarized in Table 1 : Table 1 Participants' Details and Maximum Time of Escape Author & Year Disease theme Study Objectives Sample size Sample Characteristics Grouping Max. Time of Escape Eukel et al., 2017 [ 16 ] Diabetes-themed Escape Room To design an educational game that will increase third-year professional pharmacy students’ knowledge of diabetes mellitus disease management and to evaluate their perceived value of the game. 83 Third-year professional pharmacy students Students were divided into teams of five 75 minutes Krishnan et al., 2023 [ 26 ] Hepatitis-themed virtual escape room To assess students' knowledge gained on Hepatitis through pre- and post-intervention assessments. To evaluate students' perceptions of the game's educational value. 418 Third-year pharmacy students Each team consisted of five to six members, with one member assuming the role of the ‘player’. 60 minutes Plakogiannis et al., 2020 [ 18 ] Heart failure-themed escape room To design, pilot, and evaluate the efficacy of an educational game to enhance knowledge of heart failure, as well as students' perceptions of the game. 193 Second-year Doctor of Pharmacy students Randomized into teams of approximately eight students​ 60 minutes Kavanaugh et al., 2020 [ 17 ] Diabetes-themed escape room To evaluate the transferability of a diabetes-themed escape room educational activity from a traditional four-year pharmacy program to an accelerated three-year program. To assess the impact of diabetes themed escape rooms on students' knowledge of diabetes management and their perceptions of the learning experience.​ 127 84 students from North Dakota State University (NDSU) in their third year who had been taught diabetes management. 43 students from Medical College of Wisconsin (MCW) in their second year of an accelerated 3-year program Specific number not stated Specific time not stated Wilby et al., 2020 [ 24 ] Cancer-themed escape room To evaluate the feasibility of a cancer-themed escape room as a learning activity for pharmacy students. 130 Undergraduate pharmacy students at the University of New Zealand Each group consisted of six students 30 minutes Norville et al., 2021 [ 25 ] Cancer-themed escape room To evaluate the effectiveness of integrating a hybrid cancer clinic simulation into the curricula for third-year pharmacy students. 36 Third-year pharmacy students Students were randomized to teams of 6 students 30 minutes 3.2.1 Mode of Delivery The escape rooms were conducted in three forms: physically in-person, virtually, or hybrid format. Physical escape room format was used in four studies [ 16 , 17 , 24 , 25 ] while virtual escape room was used in the study by Krishnan et al. [ 26 ]. Plakogiannis et al. [ 18 ] implemented a hybrid approach, conducting five challenges in virtual settings and concluding with an in-person final challenge. 3.2.2 Team Size All the interventions were team-based, consisting of a range of three to eight students and a total sample size ranging from 36 to 418. The escape room consisted of third-year pharmacy students in three out of six studies, while one study used second-year Pharm.D students [ 18 ]. 3.3.3 Escape Time Limit A time-bound format was used across all escape rooms. The duration for completing the escape rooms ranged from 30 to 75 minutes. The most frequently allocated duration for participants was 30 [ 24 , 25 ] and 60 minutes [ 18 , 26 ] as seen in two studies each. 3.3.4 Use of Digital Technologies Various digital technologies were utilized in some studies either as part of the game challenge or as a communication/interaction medium. A live video stream run through Google Hangout connections was used to observe the group interactions in Eukel et al.’s study [ 16 ]; web-based game named Hepatitiscape© was used in Krishnan’s study [ 26 ]; escape room activity was designed and administered using Google Forms in Plakogiannis et al.’s study [ 18 ] while all the communication in Kavanaugh et al.’s study was done via email and telephone, with pre- and post-knowledge assessments administered using the Blackboard learning management system for North Dakota State University (NDSU) students and the ExamSoft examination platform for Medical College of Wisconsin (MSW) students [ 17 ]. 3.3.5 Role of facilitators/faculty The role of the facilitators/faculty varied across the included studies. In Norville et al.’s study [ 25 ], the faculty member played the role of the physician in the clinic simulations while in Eukel et al.’s study [ 16 ], the faculty members observed the student demonstration of monofilament foot exam, explanations of medication administration devices, and patient consultation skills via the live feed as well as the group interactions. In Krishnan’s study [ 26 ], facilitators assisted with technical issues during gameplay and offered hints to students who were unable to solve certain puzzles. Facilitator’s roles in other studies were not mentioned. 3.4 Outcome Evaluation of Disease-themed Escape Room A summary of the outcome evaluation of disease-themed escape room is presented in Table 2 . Table 2 Escape Room Details and Key Findings Author & Year Mode of Escape room (Virtual or Physical) Escape room delivery Key findings Conclusion Eukel et al., 2017 [ 16 ] Physical The game took place in a simulated child’s bedroom, which was filled with clues to help teams escape. It simulated a child with type 1 diabetes facing severe hypoglycemia and comprised four puzzles, all centered on diabetes management Students' average pre-knowledge assessment scores were a significant predictor of their post-knowledge scores, F(1,71) = 18.8, p < 0.01, accounting for 21% of the variance (r² = 0.21). The mean post-assessment score of 81% was significantly higher than the pre-assessment average of 56%, t(72) = -18.1, p < 0.01. Additionally, the game had a strong positive influence on students' perceptions, highlighting its potential as an effective teaching tool. The game enhanced students' understanding of diabetes management and was perceived by them as a valuable and effective learning experience. Krishnan et al., 2023 [ 26 ] Virtual Hepatitiscape© was designed as an alternative to the traditional workshop on hepatitis B. Before participating in the game, students received written instructions on how to play the virtual escape room, along with a step-by-step setup guide to ensure their computers were properly configured for the online platform. Hepatitiscape© boosted students' immediate retention of hepatitis-related concepts, with a statistically significant increase of 13.39% in their average scores on the post-intervention assessment (58.66% pre-intervention vs. 72.05% post-intervention; p < 0.05). Students described the game as engaging, educational, and valuable in reinforcing pharmacotherapy concepts The digital game-based learning activity was effective in enhancing students' knowledge of hepatitis. Students found the virtual educational game both engaging and enjoyable. Additionally, the escape room game helped improve their teamwork, critical thinking, and problem-solving abilities. Plakogiannis et al., 2020 [ 18 ] Physical and virtual escape rooms It consisted of six connected virtual rooms, with the final room requiring students to solve a puzzle that revealed a specific room number on campus. The group leader then had to go to this location to finish the game. The heart failure-themed escape room proved to be a potent tool for reinforcing course material and underlined its value in pharmacy education. Students reported high satisfaction with the experience, noting that its interactive and collaborative approach provided a welcome alternative to standard lecture-based instruction. Interestingly, a negative correlation was found between satisfaction and grade point average (r = -0.20, p = 0.05), indicating that students with lower GPAs tended to enjoy the escape room format more. Students had a positive perception of the escape room activity, which helped enhance their understanding of heart failure pharmacology, medicinal chemistry, and pharmacotherapeutics. Kavanaugh et al., 2020 [ 17 ] Physical Students worked together to solve diabetes-themed puzzles. Students completed pre- and post-game knowledge tests, as well as a perception survey. There was significant immediate knowledge improvement in participants from both NDSU and MCW ( p < 0.001 and p < 0.05, respectively). Also, there was knowledge retention in over time in MCW students. The students had positive perceptions about the game The diabetes escape room led to significant improvements in knowledge and positive student feedback. The diabetes escape room is a transferable activity that can be used by other colleges or schools of pharmacy. Wilby et al., 2020 [ 24 ] Physical Four puzzles, linked to patient assessment, communication, therapeutics and calculations were created. Two escape rooms were created to run simultaneously and the activity took place over the course of one full day. Two offices were set up to run duplicate sessions, enabling two tracks to operate simultaneously. 20 out of 26 groups successfully escaped the room where the average escape time was 22 minutes. The findings suggest that while the escape room is a feasible learning activity, it demands a high level of staff involvement. The results indicate that the escape room could be an effective platform for students to apply their cancer knowledge in a practical environment. The cancer-themed escape room is an effective and engaging educational tool for pharmacy students, providing an innovative way to learn about oncology-related topics. Norville et al., 2021 [ 25 ] Physical To simulate real-life clinical situations, standardized patient actors portrayed the cancer patient, while a pharmacy faculty member took on the role of the physician. Teams were tasked with completing a series of interactive activities, including uncovering hidden messages, solving drug-based calculations to unlock codes, and providing counseling. Average student quiz scores significantly increased from 61.4–81.7% after the first simulation and from 52.6–81.8% following the second (p < 0.0001 for both). Students strongly agreed that the cancer clinic simulations helped reinforce their knowledge, supported the Pharmacists’ Patient Care Process, improved their ability to make chemotherapy recommendations, strengthened their problem-solving skills, and promoted teamwork. This innovative hybrid simulation boosted oncology-related knowledge and fostered an interactive environment that enhanced student confidence and teamwork. Students found the simulations enjoyable and suggested that they be continued for future cohorts. Table 3 Study risk of bias assessment with MERSQI instruments MERSQI Authors and year of publication Eukel et al., 2017 [ 16 ] Krishnan et al., 2023 [ 26 ] Plakogiannis et al., 2020 [ 18 ] Kavanaugh et al., 2020 [ 17 ] Wilby et al., 2020 [ 24 ] Norville et al., 2021 [ 25 ] Study design 1 1.5 1 2 1 1.5 Sampling: institutions 0.5 1 0.5 1 0.5 0.5 Sampling: response rate 1.5 1.5 1.5 1.5 1.5 1.5 Type of data 3 1 1 1 3 1 Validity: content 0 0 0 0 0 0 Validity: internal structure 1 1 1 1 1 1 Validity: relationships 0 0 0 0 0 0 Data: sophistication 1 2 2 2 1 2 Data: appropriate 1 1 1 1 0 1 outcome 1.5 1.5 1.5 1.5 1.5 1.5 Summation score 10.5 10.5 9.5 11 9.5 10 3.4.1 Cognitive skills learning (Knowledge assessment) There was a significant improvement in the knowledge assessment scores following the implementation of the escape room game activity for the four studies where pre- and post-knowledge were assessed. Particularly, in Eukel et al.’s study [ 16 ], students showed a statistically significant improvement in knowledge, with their average post-assessment score (81%) notably higher than their pre-assessment score (56%), t(72) = -18.1, p < 0.01. Likewise, a significant improvement (13.39%, p < 0.05) was observed in the average score, which rose from 58.66% after completing Hepatitiscape© as seen in Krishnan et al.’s study [ 26 ]. Also, in Kavanaugh et al.’s study [ 17 ], students' diabetes knowledge scores showed a significant improvement from the pre-game average of 56% to the post-game average of 77.6%, t(83) = − 15.38, p < 0.001. For students in NDSU and likewise for MCW students, a significant difference between pre- and post-game mean diabetes knowledge scores, increasing from 79.6–84.4%, t(39) = − 2.37, p < 0.05 was recorded. However, for MCW students where delayed post-game knowledge was assessed, no significant differences were observed between the pre-game and delayed post-game mean scores, t(39) = − 1.23, p = 0.23, or between the post-game and delayed post-game mean scores, t(42) = 0.93, p = 0.36. In Norville et al.’s study [ 25 ] where the students were presented with two cancer clinic simulations, a notable improvement was recorded in quiz scores in both simulations; the quiz scores significantly improved in the first clinic from 61.4–81.7% ( p < 0.0001), with the second clinic mirroring this trend, moving from 52.6–81.8% ( p < 0.0001). 3.4.2 Perceived Value of the Escape Room Activity Five studies measured pharmacy students’ perception and satisfaction levels regarding the escape room experience. Escape room activity was well perceived by the students in all the five studies with pharmacy students showing high satisfaction levels. Overall, students’ mean perception value was significantly higher than the mean value (neutral point) of the evaluation scale (3.00 on a five-point Likert scale) [ 16 , 17 ]. In all the five studies, pharmacy students stated that they would recommend the activity to other students [ 16 – 18 , 25 , 26 ]. The escape room activity was an effective way to learn new information related to the disease as agreed by majority of the students in four studies [ 16 – 18 , 26 ]. Beyond the positive effects on cognitive skills, escape room participation also helped improve the students’ non-technical skills such as critical thinking [ 26 ] and problem-solving [ 25 , 26 ]. Escape room participation also helped the students to learn from their peers [ 16 – 18 ]. The escape room activity helped the students to collaborate and practice the components of the Pharmacists’ Patient Care Process (PPCP) – Collect, Assess, Plan, Implement, Monitor/Follow-up [ 25 ]. Students’ positive perceptions and high satisfaction towards escape room participation did not alter over time [ 18 ]. Also, a correlation analysis between sociodemographic characteristics and satisfaction levels showed that students with lower GPA scores expressed higher levels of satisfaction toward the escape room activity (r = -0.20, p = 0.05) [ 18 ]. 3.4.3 Feasibility of a Disease-themed Escape Room Only one study evaluated the feasibility of a disease-themed escape room. Majority of the groups (20 out of 26), representing 77%, successfully escaped the room. The average escape time was 22 minutes with a fastest escape time of 12 minutes 9 seconds [ 24 ]. The results of the SWOT analysis highlighted student engagement, collaboration, enjoyment, learning outcome mapping among others as the strengths of a disease-themed escape room; limited depth to content, time required for resetting the room, student preparedness as the weaknesses; collaboration competency development, potential for interprofessional learning activities among others as the opportunities; and staff contact time, space, potential for contamination between group (for physical escape room), assessment of learning activities among others as threats against the adoption of disease-themed escape room [ 24 ]. 4.0 Discussion Escape rooms have become increasingly popular in healthcare education, as demonstrated by the significant number of studies emerging since 2020 (n = 3). Escape rooms represent an engaging and enjoyable method for delivering educational content and are now a commonly used tool in medical [ 27 , 28 ] and pharmacy training [ 16 , 29 , 30 ]. They have become a popular and interactive teaching approach aimed at enhancing student learning and engagement in higher education [ 4 ]. Escape room activity is designed to help students simulate real-life professional scenarios, enabling them to put theoretical knowledge into practical use. Escape rooms were typically delivered physically as shown in the majority of the studies in this review. However, the growing use of virtual technology during the COVID-19 pandemic has contributed to a shift from face-to-face to virtual escape rooms, leading to their expanded use in healthcare education, particularly in pharmacy education. Following the COVID-19 pandemic, in-person escape rooms were transitioned to virtual formats, demonstrating the adaptability of digital escape rooms in delivering effective learning experiences online. This shift was facilitated by accessible digital tools like video conferencing platforms and Google Forms, which enabled online collaboration and team-based gamified activities. Several digital tools, such as Google Forms, Google Hangouts, Email, and other learning management systems, were commonly adopted in some of the reviewed studies to supplement the physical escape rooms. Particularly, incorporating digital tools into in-person escape rooms has been shown to support instructors by organizing activities more efficiently. In the reviewed studies, these digital tools were used as either part of the game challenge or as a communication or interaction medium. In this era of artificial intelligence, developing more hybrid escape rooms that incorporate virtual and augmented reality technologies could offer a more immersive educational experience [ 31 ]. The primary learning goals of escape rooms in healthcare education often center on deepening knowledge of pharmacist-led patient care, followed by the development of procedural competencies. This focus may be attributed to the puzzle-based nature of escape rooms, which typically demand the application of theoretical understanding as seen in the majority of the reviewed studies. Evidence from five studies showed significant knowledge improvement on disease topics, highlighting the effectiveness of escape rooms in pharmacy training. Furthermore, disease-themed escape rooms have shown potential for broad applicability, as evidenced by statistically significant knowledge gains regardless of student group, curriculum structure, or instructional content [ 17 ]. The demonstrated effectiveness of disease-themed escape rooms—evident in significant knowledge gains across diverse student groups and educational settings—supports their adoption in various instructional formats. These escape rooms can be implemented as co-curricular activities, integrated into pharmacotherapy courses, used as capstone projects in chronic disease management, or designed to include students from multiple health professions to foster interprofessional collaboration and learning. While a recent review of escape rooms emphasized the enhancement of non-technical skills like teamwork and communication [ 32 ], these skills were not the primary focus in most of the studies examined in this review. Because escape rooms are team-based and centered on problem-solving, they naturally encourage discussion and reflection on teamwork and leadership [ 33 ]. The collaborative effort required to achieve shared goals can help learners build non-technical skills such as communication and teamwork [ 28 ]. Team-based activities in escape rooms can highlight and leverage individual strengths within a group, and students have expressed appreciation for seeing these diverse abilities applied through practical, hands-on learning [ 33 ]. The development of these non-technical skills, such as critical thinking and problem-solving skills, is considered crucial across all healthcare fields and is vital for maintaining patient safety. As such, further research is needed to assess how effectively escape rooms support the development of these skills, especially in interprofessional education settings [ 20 ]. This review highlighted key design elements in the use of disease-themed escape rooms within pharmacy education. Most studies featured teams of 3 to 8 participants, a size that typically encourages active involvement from all members [ 4 ]. Additionally, the most frequently used time limits for completing the escape rooms were 30 and 60 minutes. While specific reasons for these time constraints were not always provided, completing tasks within a set timeframe is considered important to help learners meet objectives without becoming discouraged or disengaged [ 34 ]. Implementing disease-themed escape rooms can present logistical difficulties, particularly related to physical space and group size. Since standard escape rooms usually hold only 8 to 12 participants, they can be challenging to use with larger classes unless the activity is repeated multiple times [ 30 ]. Research by Eukel et al. and Adams in the health professions has demonstrated that serious games like these can be effectively implemented in educational settings with small groups of fewer than 20 participants [ 16 , 35 ]. To address the logistical challenges posed by large class sizes, particularly in terms of space and resources, escape rooms can adopt a hybrid format, which combines traditional in-person elements with online components, as shown in one of the studies [ 18 ]. Also, evaluating how long it takes to complete the learning activities is essential for establishing a suitable time limit for the escape room, as identified in one study [ 24 ]. The studies reviewed emphasized the important roles facilitators play during gameplay, including providing hints, acting as physicians in simulations, and monitoring group interactions. Common challenges with escape rooms, such as students' negative feedback about the lack of guidance and lack of meaningful hints, emphasize the vital roles of facilitators [ 31 ]. However, it is recommended that facilitators intervene only when essential, to encourage greater learner independence. Considering the crucial role facilitators play in the gameplay, future research could focus on exploring their viewpoints and finding strategies to optimize their involvement in order to improve student learning outcomes. Majority of the reviewed studies aimed to assess learners' responses to disease-state-themed escape rooms, with most reporting positive perceptions, including a sense of enjoyment derived from the gaming experience. One study conducted a longitudinal evaluation of student satisfaction and found no statistically significant difference between immediate feedback and responses collected four weeks later, reinforcing the sustained positive perceptions students had toward the escape room activity [ 18 ]. Particularly, students agreed that they will recommend the activity to other students and also identified the escape room activity as an effective way to learn new information related to the disease [ 16 – 18 , 26 ]. Nevertheless, earlier research has highlighted the negative impact of student stress experienced during traditional simulations or objective structured clinical examination (OSCE) assessments [ 36 ]. Escape room activity does pose some challenges such as staff contact time, space, potential for contamination between group (for physical escape room), and assessment of learning activities as identified in one of the studies [ 24 ]. Regardless, the strengths and opportunities identified in the study supports the adoption of disease-themed escape room in pharmacy education. 4.1 Limitations This review has several limitations. With only six studies analyzed, it is difficult to draw firm conclusions about the effectiveness of disease-themed escape rooms in undergraduate pharmacy education. The limited number of studies also restricts the generalizability of the findings, particularly regarding broader implementation. Nonetheless, the review offers promising insights for targeted applications in specific chronic disease management contexts. Secondly, all the included studies were conducted in the USA, Malaysia, and New Zealand, which limits the geographical diversity of the findings and may affect their applicability to other educational systems or cultural contexts. However, there is evidence of transferability of disease-themed escape room to other educational settings. Additionally, this review included only articles published in English, which may have led to the unintentional exclusion of relevant studies available in other languages, potentially limiting the comprehensiveness of the findings. Finally, an important limitation was the absence of a control group, which made it difficult to compare student performance in achieving the learning objectives. 5.0 Conclusion Disease-state-themed escape rooms show promising effectiveness in learning disease topics among pharmacy undergraduates. The significant improvement in knowledge, students’ satisfaction levels, and critical thinking skills among students who undertook the escape room activity supports their adoption in other disease states across different regions. However, the limited number of studies included in this review restricts its generalizability and calls for further research, particularly randomized controlled trials, to establish a comparison between the disease-state-themed escape room arm and control arm. Declarations Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analysed during the current study Competing interests: The authors declare that they have no competing interests Funding: No funding was received for this study Clinical trial number: not applicable Code availability: Not Applicable Authors' contributions : CEA conceptualized the study; All authors were involved in the literature review; CEA & OAN extracted the data from the reviewed studies; CEA prepared Figure 1. OAN prepared Tables 1 & 2; OA prepared Table 3. All authors (CEA, OAN, IJO, UEC, CKN, OA, CSA, VOA, KEN, CSN) wrote the final and first drafts. All authors (CEA, OAN, IJO, UEC, CKN, OA, CSA, VOA, KEN, CSN) read and approved the final manuscript. Acknowledgments: None References Helena Manojlovic. Escape room as a teaching method. OpEE [Internet]. 2022 [cited 2025 May 10];9. Available from: https://journals.bme.hu/oee/article/view/39279 Hintze TD, Samuel N, Braaten B. A Systematic Review of Escape Room Gaming in Pharmacy Education. Am J Pharm Educ. 2023;87:100048. Sanchez E, Plumettaz-Sieber M. Teaching and Learning with Escape Games from Debriefing to Institutionalization of Knowledge. In: Gentile M, Allegra M, Söbke H, editors. Games and Learning Alliance [Internet]. Cham: Springer International Publishing; 2019 [cited 2025 May 10]. pp. 242–53. Available from: http://link.springer.com/ 10.1007/978-3-030-11548-7_23 Veldkamp A, Van De Grint L, Knippels M-CPJ, Van Joolingen WR. Escape education: A systematic review on escape rooms in education. Educational Res Rev. 2020;31:100364. Manzano-León A, Rodríguez-Ferrer JM, Aguilar-Parra JM, Martínez Martínez AM, Luque, De La Rosa A, Salguero García D et al. Escape Rooms as a Learning Strategy for Special Education Master’s Degree Students. IJERPH. 2021;18:7304. MacKenzie I, Parsons K, Lee YP. Escape rooms in pharmacy education: More than just a game. Currents Pharm Teach Learn. 2024;16:102201. Nicholson S. Creating Engaging Escape Rooms for the Classroom. Child Educ. 2018;94:44–9. Gordillo A, López-Fernández D. Are Educational Escape Rooms More Effective Than Traditional Lectures for Teaching Software Engineering? A Randomized Controlled Trial. IEEE Trans Educ. 2024;67:660–8. Grepperud P. Educational escape games in primary and secondary education: a framework synthesis review. Educ Inq. 2025;1–17. Rathbone AP, Richardson CL, Mundell A, Lau WM, Nazar H. Exploring the role of pharmacy students using entrustable professional activities to complete medication histories and deliver patient counselling services in secondary care. Exploratory Res Clin Social Pharm. 2021;4:100079. Alenezi S, Alanazi M, Aljazaeri R, Almuzaini M, Alrasheidi S, Shamlan WB, et al. Community Pharmacies in the Asian Countries of Developing Health System: Formation, Regulation, and Implication. Pharmacy. 2023;11:127. Chukwu OA. Beyond medicines provision: community pharmacists roles in meeting patient needs through value-added pharmacy services. J Pharm Health Serv Res. 2020;11:299–301. Berthod F, Bouchoud L, Grossrieder F, Falaschi L, Senhaji S, Bonnabry P. Learning good manufacturing practices in an escape room: Validation of a new pedagogical tool. J Oncol Pharm Pract. 2020;26:853–60. Nybo SE, Klepser SA, Klepser M. Design of a disaster preparedness escape room for first and second-year pharmacy students. Currents Pharm Teach Learn. 2020;12:716–23. Eric Nybo S, Sahr M, Young M, Axford K, Sohn M, Lyons M, et al. Design of a large-scale escape room for first-year pharmacy student orientation. Currents Pharm Teach Learn. 2020;12:1340–7. Eukel HN, Frenzel JE, Cernusca D. Educational Gaming for Pharmacy Students – Design and Evaluation of a Diabetes-themed Escape Room. Am J Pharm Educ. 2017;81:6265. Kavanaugh R, George S, Lamberton N, Frenzel JE, Cernusca D, Eukel HN. Transferability of a diabetes escape room into an accelerated pharmacy program. Currents Pharm Teach Learn. 2020;12:709–15. Plakogiannis R, Stefanidis A, Hernandez N, Nogid A. A heart failure themed escape room approach to enhance pharmacy student learning. Currents Pharm Teach Learn. 2020;12:940–4. He Y, Chen X, Ma H, Zhao R, Zhou H, Yang Y. Effectiveness of Escape Room in Medical Education: A Systematic Review and Meta-Analysis. Games Health J. 2024;13:419–27. Quek LH, Tan AJQ, Sim MJJ, Ignacio J, Harder N, Lamb A, et al. Educational escape rooms for healthcare students: A systematic review. Nurse Educ Today. 2024;132:106004. Reed DA, Cook DA, Beckman TJ, Levine RB, Kern DE, Wright SM. Association Between Funding and Quality of Published Medical Education Research. JAMA. 2007;298:1002. Taylor M, Hoch J, Porter K. Educational interventions to improve emotional intelligence in nursing and medical students: A systematic review. JNEP. 2022;13:19. Reed DA, Beckman TJ, Wright SM, Levine RB, Kern DE, Cook DA. Predictive Validity Evidence for Medical Education Research Study Quality Instrument Scores: Quality of Submissions to JGIM’s Medical Education Special Issue. J GEN INTERN MED. 2008;23:903–7. Wilby KJ, Kremer LJ. Development of a cancer-themed escape room learning activity for undergraduate pharmacy students. Int J Pharm Pract. 2020;28:541–3. Norville K, Philip A, Halford Z. The design, implementation and evaluation of hybrid cancer clinic simulations: Escaping the norm. J Oncol Pharm Pract. 2023;29:162–9. Krishnan S, Blebil AQ, Dujaili JA, Chuang S, Lim A. Implementation of a hepatitis-themed virtual escape room in pharmacy education: A pilot study. Educ Inf Technol. 2023;28:14347–59. Backhouse A, Malik M. Escape into patient safety: bringing human factors to life for medical students. BMJ Open Qual. 2019;8:e000548. Guckian J, Eveson L, May H. The great escape? The rise of the escape room in medical education. Future Healthc J. 2020;7:112–5. Badr AF. The Geriatric Virtual Escape Room in Pharmacy Education: Female Students Escape Significantly Faster than Male Students. Pharmacy. 2022;10:36. Cain J. Exploratory implementation of a blended format escape room in a large enrollment pharmacy management class. Currents Pharm Teach Learn. 2019;11:44–50. Makri A, Vlachopoulos D, Martina RA. Digital Escape Rooms as Innovative Pedagogical Tools in Education: A Systematic Literature Review. Sustainability. 2021;13:4587. Lathwesen C, Belova N. Escape Rooms in STEM Teaching and Learning—Prospective Field or Declining Trend? A Literature Review. Educ Sci. 2021;11:308. Baker CM, Crabtree G, Anderson K. Student pharmacist perceptions of learning after strengths-based leadership skills lab and escape room in pharmacy practice skills laboratory. Currents Pharm Teach Learn. 2020;12:724–7. Hermanns M, Deal B, Campbell AM, Hillhouse S, Opella JB, Faigle C, et al. Using an Escape Room toolbox approach to enhance pharmacology education. JNEP. 2017;8:89. Adams V, Burger S, Crawford K, Setter R. Can You Escape? Creating an Escape Room to Facilitate Active Learning. J Nurses Prof Dev. 2018;34:E1–5. Ignacio J, Dolmans D, Scherpbier A, Rethans J-J, Chan S, Liaw SY. Stress and anxiety management strategies in health professions’ simulation training: a review of the literature. BMJ STEL. 2016;2:42–6. Additional Declarations No competing interests reported. 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Lagos","correspondingAuthor":false,"prefix":"","firstName":"Olumide","middleName":"Ademola","lastName":"Noah","suffix":""},{"id":481194735,"identity":"19e3cbda-e6f2-4e7d-8dcc-23fed64aee64","order_by":2,"name":"Ikponmwosa Jude Ogieuhi","email":"","orcid":"","institution":"Siberian State Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ikponmwosa","middleName":"Jude","lastName":"Ogieuhi","suffix":""},{"id":481194736,"identity":"40ddc7a3-c7d4-4d74-84e2-73a17e2489a7","order_by":3,"name":"Uzochukwu Emmanuel Chima","email":"","orcid":"","institution":"University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Uzochukwu","middleName":"Emmanuel","lastName":"Chima","suffix":""},{"id":481194737,"identity":"dc802564-98e5-4fc5-b12d-365b69ac5279","order_by":4,"name":"Chinemelum Kingsley Nwankwo","email":"","orcid":"","institution":"University of 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Technology","correspondingAuthor":false,"prefix":"","firstName":"Victor","middleName":"Oluwatomiwa","lastName":"Ajekiigbe","suffix":""},{"id":481194743,"identity":"f71bd4b0-2918-447c-9048-e02db7398eea","order_by":8,"name":"Kosisochukwu Emmanuel Ngwu","email":"","orcid":"","institution":"University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Kosisochukwu","middleName":"Emmanuel","lastName":"Ngwu","suffix":""},{"id":481194745,"identity":"d61cd6fa-9550-4ba7-9501-7ea6d440e835","order_by":9,"name":"Chukwuemeka Sylvester Nworu","email":"","orcid":"","institution":"University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Chukwuemeka","middleName":"Sylvester","lastName":"Nworu","suffix":""}],"badges":[],"createdAt":"2025-05-10 19:38:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6636552/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6636552/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86149219,"identity":"f8d74556-9c57-4cdf-a6b3-7b3794c48221","added_by":"auto","created_at":"2025-07-07 09:43:27","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":435072,"visible":true,"origin":"","legend":"\u003cp\u003eProvides a PRISMA flowchart and summary of the selection process.\u003c/p\u003e","description":"","filename":"DiseaseStateThemedPRISMA.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6636552/v1/c394679deca98032ad55386a.jpg"},{"id":102904617,"identity":"14e3c517-b19c-4a2b-8dd1-3fc0b9d7d9a5","added_by":"auto","created_at":"2026-02-18 08:57:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1685214,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6636552/v1/e0eac228-6a79-41f6-b5da-59d2fa13fc0d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Disease-state-themed Escape Room Simulations in Undergraduate Pharmacy Education: A Systematic Review","fulltext":[{"header":"1.0 Introduction","content":"\u003cp\u003eThe landscape of pharmacy education is rapidly and continually evolving, with a growing emphasis on innovative and interactive teaching methods that foster active learning, critical thinking, and problem-solving skills [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Traditional lecture-based approaches, although foundational, are frequently inadequate in engaging students [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and promoting deep understanding and retention of complex pharmaceutical concepts [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In response, educators have increasingly turned to simulation-based training, recognizing its potential to bridge the gap between theoretical knowledge and practical application [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEscape rooms are engrossing, interactive simulations that challenge participants to solve problems, decipher clues, and collaborate to \"escape\" within a set timeframe [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. They are usually filled with a series of puzzles which players must solve in order to escape. Each puzzle unlocks a key or code, progressing players toward the final lock and ultimate escape [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Virtual escape rooms often mirror this set-up, digitally integrating locks and challenges. The puzzles encourage teamwork [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and the development of problem-solving skills.\u003c/p\u003e \u003cp\u003eDisease-state-themed escape rooms are among the novel approaches picking up steam in pharmacy education. By integrating pharmaceutical concepts into an engaging and riveting narrative, escape rooms offer a unique opportunity for pharmacy students to apply their knowledge in a dynamic, real-world context. Here, participants are immersed in a simulation of a medical scenario, which may involve communicable or non-communicable diseases. In this simulation, the participants decode clues and crack puzzles related to the disease state in focus. They navigate through the room, unraveling diagnostic hints, interpreting lab reports, and developing therapy plans, all while racing against time to escape. By simulating real-world medical challenges, these escape rooms help students cultivate a deeper understanding of complex diseases and promote collaborative learning [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch suggests that escape rooms can effectively enhance learning outcomes, especially in healthcare and STEM education, by increasing engagement, motivation, and knowledge-retention [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Studies have shown that students who participated in educational escape rooms demonstrate superior knowledge acquisition, outperforming those who learn through conventional lecture means [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. By capitalizing on the students\u0026rsquo; natural affinity for puzzle-solving and competition, escape rooms can create a memorable learning experience that resonates with students. In pharmacy education, disease-state-themed escape rooms can simulate real-world scenarios, forcing students to employ critical thinking about disease pathology, pharmacotherapy, and patient care. Educators have learnt to theme puzzles around topics they want the players to explore [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], which involves solving a sequence of clues, puzzles, and tasks under time pressure to reach an ultimate goal [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePharmacy students, who are future pharmacists, play essential roles in healthcare [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] as pharmacists may serve as the first point of contact, in some countries like those in Asia [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and especially in some low and middle-income countries like Nigeria [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Hence, an appropriate teaching style complemented with traditional lecture-based teaching will enhance their clinical skills, disease management, and patient care.\u003c/p\u003e \u003cp\u003eEscape rooms have been studied extensively in Pharmacy education in the areas of good manufacturing practices [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], disaster preparedness [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], first-year orientation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], diabetes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], heart failure [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], to mention but a few. Other systematic reviews have evaluated the effectiveness and impact of escape rooms among healthcare and medical students [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and among pharmacy students [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, to the best of our knowledge, this is the first systematic review on escape rooms in pharmacy education focusing on specific disease states. With a growing interest in the role of pharmacists in disease management, there is a need for a systematic evaluation of the effectiveness of disease-state-themed escape rooms in pharmacy curricula. This study aims to analyze existing research to provide clarity on the potential benefits, limitations, and potential applications of disease-state-themed escape room simulations in pharmacy education curricula. Our findings aim to inform educators, researchers, and policymakers, supporting the development of innovative, evidence-based teaching methods that prepare students for the complexities of real-world practice.\u003c/p\u003e"},{"header":"2.0 Methodology","content":"\u003cp\u003e This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. The protocol was registered on PROSPERO with registration number CRD420251050200.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Search Strategies\u003c/h2\u003e \u003cp\u003eThe literature search was conducted on Thursday 17th April 2025 in PubMed, Google Scholar (using Harzing\u0026rsquo;s Publish or Perish app), and Cochrane using the following terms: (Escape Room OR Simulation OR Gamification) AND (Pharmacy OR Pharmacy Students OR Pharmacy Education OR Pharmacy Undergraduates). These databases were selected as they index literature relevant to disease-state-themed escape rooms. Conference proceedings; institutional reports; preprints; and non-peer reviewed articles were excluded in order to ensure that all included studies met rigorous peer-review standards. No limit was set for the year of publication. Satisfactory articles were imported into EndNote to remove duplicates and then screened using Rayyan software. \u003cb\u003eSee Fig.\u0026nbsp;1\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Eligibility Criteria\u003c/h2\u003e \u003cp\u003eStudies were selected only if they met the following conditions:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eFocused on disease states only (Communicable or non-communicable).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eParticipants were pharmacy undergraduates only.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe escape rooms were educational in nature.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStudies were published in English.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOutcomes involved one of the following: Learning outcomes (Knowledge, Critical Thinking, Student engagement etc); Perception; Acceptability.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Exclusion Criteria\u003c/h2\u003e \u003cp\u003eStudies were excluded if:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThey did not involve pharmacy undergraduates.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThey involved pharmacy as well as other health professionals.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEscape room not themed or focused on certain disease states.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe studies were reviews.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study Selection\u003c/h2\u003e \u003cp\u003eTwo reviewers (O.A.N and C.E.A) independently screened titles and abstracts for relevance, and conflicts were resolved by I.J.O. All included studies were assessed for ethical compliance, and only studies that reported adherence to ethical research guidelines, including obtaining informed consent and approval from appropriate ethics committees, were included. As a result, ethical approval was not required for this systematic review. The studies that did not meet the eligibility criteria were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Extraction and Analysis\u003c/h2\u003e \u003cp\u003eData was extracted under the following columns: Author and year, Disease theme, Study objectives, Sample size, Sample characteristics, Grouping, Max. time of escape, Mode of escape room, Escape room delivery, Key findings, Conclusion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Quality Assessment\u003c/h2\u003e \u003cp\u003eThe studies that were included were assessed for their methodological quality using the 10-item Medical Education Research Study Quality Instrument (MERSQI). Study design, sampling, type of data, validity, data analysis, and outcomes were assessed [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The MERSQI instrument has 10 individually scored items varying on scales ranging from 0.5-3, with a total score of 18 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A MERSQI score of 9 or below is generally considered to indicate low-quality or rejected studies. In our assessment, the total MERSQI scores of the included studies ranged from 9.5 to 11.0, suggesting that while none of the studies fell below the rejection threshold, several were only marginally above it and may still be considered of moderate quality [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"3.0 Results","content":"\u003cp\u003eThe initial search yielded 1,146 articles, and 288 articles remained after duplicate removal. Title and abstract screening were done, after which 17 articles were identified for full text screening. Finally, six (6) articles were included for systematic review. MERSQI scores ranged from 9.5 to 10.5, with an average score of 10.2. Two (2) studies scored a summative score of 9.5 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] while the study by Kavanaugh et al. scored 11 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Characteristics of Included Studies\u003c/h2\u003e \u003cp\u003eThe included studies were published between 2017 and 2023, where half of the included studies (n\u0026thinsp;=\u0026thinsp;3, 50%) were published in 2020 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] with participants ranging from 36 to 418 students. While two (2) of the studies were diabetes-themed [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and cancer-themed [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], other disease-specific themes were handled in two other studies: hepatitis [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and heart failure [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Five of the included studies were pilot studies where the learning objectives were based on knowledge improvement [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] while the study by Wilby et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] was a feasibility study with SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis of the disease-themed escape room.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Characteristics of the Disease-themed Escape Rooms\u003c/h2\u003e \u003cp\u003eThe characteristics of the disease-themed escape rooms as identified in the included articles were summarized in 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\u003eParticipants' Details and Maximum Time of Escape\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor \u0026amp; Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisease theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy Objectives\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSample Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrouping\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMax. Time of Escape\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEukel et al., 2017 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes-themed Escape Room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo design an educational game that will increase third-year professional pharmacy students\u0026rsquo; knowledge of diabetes mellitus disease management and to evaluate their perceived value of the game.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThird-year professional pharmacy students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStudents were divided into teams of five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e75 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKrishnan et al., 2023\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHepatitis-themed virtual escape room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo assess students' knowledge gained on Hepatitis through pre- and post-intervention assessments.\u003c/p\u003e \u003cp\u003eTo evaluate students' perceptions of the game's educational value.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThird-year pharmacy students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEach team consisted of five to six members, with one member assuming the role of the \u0026lsquo;player\u0026rsquo;.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e60 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlakogiannis et al., 2020 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeart failure-themed escape room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo design, pilot, and evaluate the efficacy of an educational game to enhance\u003c/p\u003e \u003cp\u003eknowledge of heart failure, as well as students' perceptions of the game.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecond-year Doctor of Pharmacy students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRandomized into teams of approximately eight students​\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e60 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKavanaugh et al., 2020 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes-themed escape room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo evaluate the transferability of a diabetes-themed escape room educational activity from a traditional four-year pharmacy program to an accelerated three-year program.\u003c/p\u003e \u003cp\u003eTo assess the impact of diabetes themed escape rooms on students' knowledge of diabetes management and their perceptions of the learning experience.​\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84 students from North Dakota State University (NDSU) in their third year who had been taught diabetes management.\u003c/p\u003e \u003cp\u003e43 students from Medical College of Wisconsin (MCW) in their second year of an accelerated 3-year program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpecific number not stated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSpecific time not stated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilby et al., 2020 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer-themed escape room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo evaluate the feasibility of a cancer-themed escape room as a learning activity for pharmacy students.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUndergraduate pharmacy students at the University of New Zealand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEach group consisted of six students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorville et al., 2021 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer-themed escape room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo evaluate the effectiveness of integrating a hybrid cancer clinic simulation into the curricula for third-year pharmacy students.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThird-year pharmacy students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStudents were randomized to teams of 6 students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Mode of Delivery\u003c/h2\u003e \u003cp\u003eThe escape rooms were conducted in three forms: physically in-person, virtually, or hybrid format. Physical escape room format was used in four studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] while virtual escape room was used in the study by Krishnan et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Plakogiannis et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] implemented a hybrid approach, conducting five challenges in virtual settings and concluding with an in-person final challenge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Team Size\u003c/h2\u003e \u003cp\u003eAll the interventions were team-based, consisting of a range of three to eight students and a total sample size ranging from 36 to 418. The escape room consisted of third-year pharmacy students in three out of six studies, while one study used second-year Pharm.D students [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Escape Time Limit\u003c/h2\u003e \u003cp\u003eA time-bound format was used across all escape rooms. The duration for completing the escape rooms ranged from 30 to 75 minutes. The most frequently allocated duration for participants was 30 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and 60 minutes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] as seen in two studies each.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.3.4 Use of Digital Technologies\u003c/h2\u003e \u003cp\u003eVarious digital technologies were utilized in some studies either as part of the game challenge or as a communication/interaction medium. A live video stream run through Google Hangout connections was used to observe the group interactions in Eukel et al.\u0026rsquo;s study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]; web-based game named Hepatitiscape\u0026copy; was used in Krishnan\u0026rsquo;s study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]; escape room activity was designed and administered using Google Forms in Plakogiannis et al.\u0026rsquo;s study [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] while all the communication in Kavanaugh et al.\u0026rsquo;s study was done via email and telephone, with pre- and post-knowledge assessments administered using the Blackboard learning management system for North Dakota State University (NDSU) students and the ExamSoft examination platform for Medical College of Wisconsin (MSW) students [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.3.5 Role of facilitators/faculty\u003c/h2\u003e \u003cp\u003eThe role of the facilitators/faculty varied across the included studies. In Norville et al.\u0026rsquo;s study [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], the faculty member played the role of the physician in the clinic simulations while in Eukel et al.\u0026rsquo;s study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], the faculty members observed the student demonstration of monofilament foot exam, explanations of medication administration devices, and patient consultation skills via the live feed as well as the group interactions. In Krishnan\u0026rsquo;s study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], facilitators assisted with technical issues during gameplay and offered hints to students who were unable to solve certain puzzles. Facilitator\u0026rsquo;s roles in other studies were not mentioned.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Outcome Evaluation of Disease-themed Escape Room\u003c/h2\u003e \u003cp\u003eA summary of the outcome evaluation of disease-themed escape room is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEscape Room Details and Key Findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor \u0026amp; Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMode of Escape room (Virtual or Physical)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEscape room delivery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKey findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEukel et al., 2017 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe game took place in a simulated child\u0026rsquo;s bedroom, which was filled with clues to help teams escape. It simulated a child with type 1 diabetes facing severe hypoglycemia and comprised four puzzles, all centered on diabetes management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents' average pre-knowledge assessment scores were a significant predictor of their post-knowledge scores, F(1,71)\u0026thinsp;=\u0026thinsp;18.8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, accounting for 21% of the variance (r\u0026sup2; = 0.21). The mean post-assessment score of 81% was significantly higher than the pre-assessment average of 56%, t(72) = -18.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01. Additionally, the game had a strong positive influence on students' perceptions, highlighting its potential as an effective teaching tool.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe game enhanced students' understanding of diabetes management and was perceived by them as a valuable and effective learning experience.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKrishnan et al., 2023\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVirtual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHepatitiscape\u0026copy; was designed as an alternative to the traditional workshop on hepatitis B. Before participating in the game, students received written instructions on how to play the virtual escape room, along with a step-by-step setup guide to ensure their computers were properly configured for the online platform.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHepatitiscape\u0026copy; boosted students' immediate retention of hepatitis-related concepts, with a statistically significant increase of 13.39% in their average scores on the post-intervention assessment (58.66% pre-intervention vs. 72.05% post-intervention; \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eStudents described the game as engaging, educational, and valuable in reinforcing pharmacotherapy concepts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe digital game-based learning activity was effective in enhancing students' knowledge of hepatitis. Students found the virtual educational game both engaging and enjoyable. Additionally, the escape room game helped improve their teamwork, critical thinking, and problem-solving abilities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlakogiannis et al., 2020 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical and virtual escape rooms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIt consisted of six connected virtual rooms, with the final room requiring students to solve a puzzle that revealed a specific room number on campus. The group leader then had to go to this location to finish the game.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe heart failure-themed escape room proved to be a potent tool for reinforcing course material and underlined its value in pharmacy education. Students reported high satisfaction with the experience, noting that its interactive and collaborative approach provided a welcome alternative to standard lecture-based instruction. Interestingly, a negative correlation was found between satisfaction and grade point average (r = -0.20, p\u0026thinsp;=\u0026thinsp;0.05), indicating that students with lower GPAs tended to enjoy the escape room format more.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStudents had a positive perception of the escape room activity, which helped enhance their understanding of heart failure pharmacology, medicinal chemistry, and pharmacotherapeutics.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKavanaugh et al., 2020 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudents worked together to solve diabetes-themed puzzles. Students completed pre- and post-game knowledge tests, as well as a perception survey.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThere was significant immediate knowledge improvement in participants from both NDSU and MCW (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.05, respectively).\u003c/p\u003e \u003cp\u003eAlso, there was knowledge retention in over time in MCW students.\u003c/p\u003e \u003cp\u003eThe students had positive perceptions about the game\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe diabetes escape room led to significant improvements in knowledge and positive student feedback. The diabetes escape room is a transferable activity that can be used by other colleges or schools of pharmacy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilby et al., 2020 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFour puzzles, linked\u003c/p\u003e \u003cp\u003eto patient assessment, communication, therapeutics and calculations were created. Two escape rooms were created to run simultaneously and the activity took place over the course of one full day. Two offices were set up to run duplicate sessions, enabling two tracks to operate simultaneously.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 out of 26 groups successfully escaped the room where the average escape time was 22 minutes. The findings suggest that while the escape room is a feasible learning activity, it demands a high level of staff involvement. The results indicate that the escape room could be an effective platform for students to apply their cancer knowledge in a practical environment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe cancer-themed escape room is an effective and engaging educational tool for pharmacy students, providing an innovative way to learn about oncology-related topics.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorville et al., 2021 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo simulate real-life clinical situations, standardized patient actors portrayed the cancer patient, while a pharmacy faculty member took on the role of the physician. Teams were tasked with completing a series of interactive activities, including uncovering hidden messages, solving drug-based calculations to unlock codes, and providing counseling.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAverage student quiz scores significantly increased from 61.4\u0026ndash;81.7% after the first simulation and from 52.6\u0026ndash;81.8% following the second (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 for both). Students strongly agreed that the cancer clinic simulations helped reinforce their knowledge, supported the Pharmacists\u0026rsquo; Patient Care Process, improved their ability to make chemotherapy recommendations, strengthened their problem-solving skills, and promoted teamwork.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThis innovative hybrid simulation boosted oncology-related knowledge and fostered an interactive environment that enhanced student confidence and teamwork. Students found the simulations enjoyable and suggested that they be continued for future cohorts.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy risk of bias assessment with MERSQI instruments\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMERSQI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eAuthors and year of publication\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEukel et al., 2017 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKrishnan et al., 2023 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePlakogiannis et al., 2020 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKavanaugh et al., 2020 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWilby et al., 2020 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNorville et al., 2021 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSampling: institutions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSampling: response rate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of data\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eValidity: content\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eValidity: internal structure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eValidity: relationships\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eData: sophistication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eData: appropriate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eoutcome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSummation score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Cognitive skills learning (Knowledge assessment)\u003c/h2\u003e \u003cp\u003eThere was a significant improvement in the knowledge assessment scores following the implementation of the escape room game activity for the four studies where pre- and post-knowledge were assessed. Particularly, in Eukel et al.\u0026rsquo;s study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], students showed a statistically significant improvement in knowledge, with their average post-assessment score (81%) notably higher than their pre-assessment score (56%), t(72) = -18.1, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01. Likewise, a significant improvement (13.39%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) was observed in the average score, which rose from 58.66% after completing Hepatitiscape\u0026copy; as seen in Krishnan et al.\u0026rsquo;s study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Also, in Kavanaugh et al.\u0026rsquo;s study [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], students' diabetes knowledge scores showed a significant improvement from the pre-game average of 56% to the post-game average of 77.6%, t(83) = \u0026minus;\u0026thinsp;15.38, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001. For students in NDSU and likewise for MCW students, a significant difference between pre- and post-game mean diabetes knowledge scores, increasing from 79.6\u0026ndash;84.4%, t(39) = \u0026minus;\u0026thinsp;2.37, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was recorded. However, for MCW students where delayed post-game knowledge was assessed, no significant differences were observed between the pre-game and delayed post-game mean scores, t(39)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.23, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.23, or between the post-game and delayed post-game mean scores, t(42)\u0026thinsp;=\u0026thinsp;0.93, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.36. In Norville et al.\u0026rsquo;s study [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] where the students were presented with two cancer clinic simulations, a notable improvement was recorded in quiz scores in both simulations; the quiz scores significantly improved in the first clinic from 61.4\u0026ndash;81.7% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with the second clinic mirroring this trend, moving from 52.6\u0026ndash;81.8% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Perceived Value of the Escape Room Activity\u003c/h2\u003e \u003cp\u003eFive studies measured pharmacy students\u0026rsquo; perception and satisfaction levels regarding the escape room experience. Escape room activity was well perceived by the students in all the five studies with pharmacy students showing high satisfaction levels. Overall, students\u0026rsquo; mean perception value was significantly higher than the mean value (neutral point) of the evaluation scale (3.00 on a five-point Likert scale) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In all the five studies, pharmacy students stated that they would recommend the activity to other students [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The escape room activity was an effective way to learn new information related to the disease as agreed by majority of the students in four studies [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Beyond the positive effects on cognitive skills, escape room participation also helped improve the students\u0026rsquo; non-technical skills such as critical thinking [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and problem-solving [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Escape room participation also helped the students to learn from their peers [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The escape room activity helped the students to collaborate and practice the components of the Pharmacists\u0026rsquo; Patient Care Process (PPCP) \u0026ndash; Collect, Assess, Plan, Implement, Monitor/Follow-up [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Students\u0026rsquo; positive perceptions and high satisfaction towards escape room participation did not alter over time [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Also, a correlation analysis between sociodemographic characteristics and satisfaction levels showed that students with lower GPA scores expressed higher levels of satisfaction toward the escape room activity (r = -0.20, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.4.3 Feasibility of a Disease-themed Escape Room\u003c/h2\u003e \u003cp\u003eOnly one study evaluated the feasibility of a disease-themed escape room. Majority of the groups (20 out of 26), representing 77%, successfully escaped the room. The average escape time was 22 minutes with a fastest escape time of 12 minutes 9 seconds [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The results of the SWOT analysis highlighted student engagement, collaboration, enjoyment, learning outcome mapping among others as the strengths of a disease-themed escape room; limited depth to content, time required for resetting the room, student preparedness as the weaknesses; collaboration competency development, potential for interprofessional learning activities among others as the opportunities; and staff contact time, space, potential for contamination between group (for physical escape room), assessment of learning activities among others as threats against the adoption of disease-themed escape room [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4.0 Discussion","content":"\u003cp\u003eEscape rooms have become increasingly popular in healthcare education, as demonstrated by the significant number of studies emerging since 2020 (n\u0026thinsp;=\u0026thinsp;3). Escape rooms represent an engaging and enjoyable method for delivering educational content and are now a commonly used tool in medical [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and pharmacy training [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. They have become a popular and interactive teaching approach aimed at enhancing student learning and engagement in higher education [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEscape room activity is designed to help students simulate real-life professional scenarios, enabling them to put theoretical knowledge into practical use. Escape rooms were typically delivered physically as shown in the majority of the studies in this review. However, the growing use of virtual technology during the COVID-19 pandemic has contributed to a shift from face-to-face to virtual escape rooms, leading to their expanded use in healthcare education, particularly in pharmacy education.\u003c/p\u003e \u003cp\u003eFollowing the COVID-19 pandemic, in-person escape rooms were transitioned to virtual formats, demonstrating the adaptability of digital escape rooms in delivering effective learning experiences online. This shift was facilitated by accessible digital tools like video conferencing platforms and Google Forms, which enabled online collaboration and team-based gamified activities. Several digital tools, such as Google Forms, Google Hangouts, Email, and other learning management systems, were commonly adopted in some of the reviewed studies to supplement the physical escape rooms. Particularly, incorporating digital tools into in-person escape rooms has been shown to support instructors by organizing activities more efficiently. In the reviewed studies, these digital tools were used as either part of the game challenge or as a communication or interaction medium. In this era of artificial intelligence, developing more hybrid escape rooms that incorporate virtual and augmented reality technologies could offer a more immersive educational experience [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary learning goals of escape rooms in healthcare education often center on deepening knowledge of pharmacist-led patient care, followed by the development of procedural competencies. This focus may be attributed to the puzzle-based nature of escape rooms, which typically demand the application of theoretical understanding as seen in the majority of the reviewed studies. Evidence from five studies showed significant knowledge improvement on disease topics, highlighting the effectiveness of escape rooms in pharmacy training. Furthermore, disease-themed escape rooms have shown potential for broad applicability, as evidenced by statistically significant knowledge gains regardless of student group, curriculum structure, or instructional content [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The demonstrated effectiveness of disease-themed escape rooms\u0026mdash;evident in significant knowledge gains across diverse student groups and educational settings\u0026mdash;supports their adoption in various instructional formats. These escape rooms can be implemented as co-curricular activities, integrated into pharmacotherapy courses, used as capstone projects in chronic disease management, or designed to include students from multiple health professions to foster interprofessional collaboration and learning. While a recent review of escape rooms emphasized the enhancement of non-technical skills like teamwork and communication [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], these skills were not the primary focus in most of the studies examined in this review. Because escape rooms are team-based and centered on problem-solving, they naturally encourage discussion and reflection on teamwork and leadership [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The collaborative effort required to achieve shared goals can help learners build non-technical skills such as communication and teamwork [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Team-based activities in escape rooms can highlight and leverage individual strengths within a group, and students have expressed appreciation for seeing these diverse abilities applied through practical, hands-on learning [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The development of these non-technical skills, such as critical thinking and problem-solving skills, is considered crucial across all healthcare fields and is vital for maintaining patient safety. As such, further research is needed to assess how effectively escape rooms support the development of these skills, especially in interprofessional education settings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis review highlighted key design elements in the use of disease-themed escape rooms within pharmacy education. Most studies featured teams of 3 to 8 participants, a size that typically encourages active involvement from all members [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Additionally, the most frequently used time limits for completing the escape rooms were 30 and 60 minutes. While specific reasons for these time constraints were not always provided, completing tasks within a set timeframe is considered important to help learners meet objectives without becoming discouraged or disengaged [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Implementing disease-themed escape rooms can present logistical difficulties, particularly related to physical space and group size. Since standard escape rooms usually hold only 8 to 12 participants, they can be challenging to use with larger classes unless the activity is repeated multiple times [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Research by Eukel et al. and Adams in the health professions has demonstrated that serious games like these can be effectively implemented in educational settings with small groups of fewer than 20 participants [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. To address the logistical challenges posed by large class sizes, particularly in terms of space and resources, escape rooms can adopt a hybrid format, which combines traditional in-person elements with online components, as shown in one of the studies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Also, evaluating how long it takes to complete the learning activities is essential for establishing a suitable time limit for the escape room, as identified in one study [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe studies reviewed emphasized the important roles facilitators play during gameplay, including providing hints, acting as physicians in simulations, and monitoring group interactions. Common challenges with escape rooms, such as students' negative feedback about the lack of guidance and lack of meaningful hints, emphasize the vital roles of facilitators [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, it is recommended that facilitators intervene only when essential, to encourage greater learner independence. Considering the crucial role facilitators play in the gameplay, future research could focus on exploring their viewpoints and finding strategies to optimize their involvement in order to improve student learning outcomes.\u003c/p\u003e \u003cp\u003eMajority of the reviewed studies aimed to assess learners' responses to disease-state-themed escape rooms, with most reporting positive perceptions, including a sense of enjoyment derived from the gaming experience. One study conducted a longitudinal evaluation of student satisfaction and found no statistically significant difference between immediate feedback and responses collected four weeks later, reinforcing the sustained positive perceptions students had toward the escape room activity [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Particularly, students agreed that they will recommend the activity to other students and also identified the escape room activity as an effective way to learn new information related to the disease [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Nevertheless, earlier research has highlighted the negative impact of student stress experienced during traditional simulations or objective structured clinical examination (OSCE) assessments [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEscape room activity does pose some challenges such as staff contact time, space, potential for contamination between group (for physical escape room), and assessment of learning activities as identified in one of the studies [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Regardless, the strengths and opportunities identified in the study supports the adoption of disease-themed escape room in pharmacy education.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Limitations\u003c/h2\u003e \u003cp\u003eThis review has several limitations. With only six studies analyzed, it is difficult to draw firm conclusions about the effectiveness of disease-themed escape rooms in undergraduate pharmacy education. The limited number of studies also restricts the generalizability of the findings, particularly regarding broader implementation. Nonetheless, the review offers promising insights for targeted applications in specific chronic disease management contexts. Secondly, all the included studies were conducted in the USA, Malaysia, and New Zealand, which limits the geographical diversity of the findings and may affect their applicability to other educational systems or cultural contexts. However, there is evidence of transferability of disease-themed escape room to other educational settings. Additionally, this review included only articles published in English, which may have led to the unintentional exclusion of relevant studies available in other languages, potentially limiting the comprehensiveness of the findings. Finally, an important limitation was the absence of a control group, which made it difficult to compare student performance in achieving the learning objectives.\u003c/p\u003e \u003c/div\u003e"},{"header":"5.0 Conclusion","content":"\u003cp\u003eDisease-state-themed escape rooms show promising effectiveness in learning disease topics among pharmacy undergraduates. The significant improvement in knowledge, students\u0026rsquo; satisfaction levels, and critical thinking skills among students who undertook the escape room activity supports their adoption in other disease states across different regions. However, the limited number of studies included in this review restricts its generalizability and calls for further research, particularly randomized controlled trials, to establish a comparison between the disease-state-themed escape room arm and control arm.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Not applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analysed during the current study\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding: No funding was received for this study\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003eCode availability: Not Applicable\u003c/p\u003e\n\u003cp\u003eAuthors' contributions\u003cstrong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eCEA conceptualized the study; All authors were involved in the literature review; CEA \u0026amp; OAN extracted the data from the reviewed studies; CEA prepared Figure 1. OAN prepared Tables 1 \u0026amp; 2; OA prepared Table 3. All authors (CEA, OAN, IJO, UEC, CKN, OA, CSA, VOA, KEN, CSN) wrote the final and first drafts. \u0026nbsp;All authors (CEA, OAN, IJO, UEC, CKN, OA, CSA, VOA, KEN, CSN) read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgments: None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHelena Manojlovic. Escape room as a teaching method. OpEE [Internet]. 2022 [cited 2025 May 10];9. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.bme.hu/oee/article/view/39279\u003c/span\u003e\u003cspan address=\"https://journals.bme.hu/oee/article/view/39279\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHintze TD, Samuel N, Braaten B. A Systematic Review of Escape Room Gaming in Pharmacy Education. Am J Pharm Educ. 2023;87:100048.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanchez E, Plumettaz-Sieber M. Teaching and Learning with Escape Games from Debriefing to Institutionalization of Knowledge. In: Gentile M, Allegra M, S\u0026ouml;bke H, editors. Games and Learning Alliance [Internet]. Cham: Springer International Publishing; 2019 [cited 2025 May 10]. pp. 242\u0026ndash;53. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://link.springer.com/\u003c/span\u003e\u003cspan address=\"http://link.springer.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-3-030-11548-7_23\u003c/span\u003e\u003cspan address=\"10.1007/978-3-030-11548-7_23\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeldkamp A, Van De Grint L, Knippels M-CPJ, Van Joolingen WR. Escape education: A systematic review on escape rooms in education. Educational Res Rev. 2020;31:100364.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManzano-Le\u0026oacute;n A, Rodr\u0026iacute;guez-Ferrer JM, Aguilar-Parra JM, Mart\u0026iacute;nez Mart\u0026iacute;nez AM, Luque, De La Rosa A, Salguero Garc\u0026iacute;a D et al. Escape Rooms as a Learning Strategy for Special Education Master\u0026rsquo;s Degree Students. IJERPH. 2021;18:7304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacKenzie I, Parsons K, Lee YP. Escape rooms in pharmacy education: More than just a game. Currents Pharm Teach Learn. 2024;16:102201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNicholson S. Creating Engaging Escape Rooms for the Classroom. Child Educ. 2018;94:44\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGordillo A, L\u0026oacute;pez-Fern\u0026aacute;ndez D. Are Educational Escape Rooms More Effective Than Traditional Lectures for Teaching Software Engineering? A Randomized Controlled Trial. IEEE Trans Educ. 2024;67:660\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrepperud P. Educational escape games in primary and secondary education: a framework synthesis review. Educ Inq. 2025;1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRathbone AP, Richardson CL, Mundell A, Lau WM, Nazar H. Exploring the role of pharmacy students using entrustable professional activities to complete medication histories and deliver patient counselling services in secondary care. Exploratory Res Clin Social Pharm. 2021;4:100079.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlenezi S, Alanazi M, Aljazaeri R, Almuzaini M, Alrasheidi S, Shamlan WB, et al. Community Pharmacies in the Asian Countries of Developing Health System: Formation, Regulation, and Implication. Pharmacy. 2023;11:127.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChukwu OA. Beyond medicines provision: community pharmacists roles in meeting patient needs through value-added pharmacy services. J Pharm Health Serv Res. 2020;11:299\u0026ndash;301.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerthod F, Bouchoud L, Grossrieder F, Falaschi L, Senhaji S, Bonnabry P. Learning good manufacturing practices in an escape room: Validation of a new pedagogical tool. J Oncol Pharm Pract. 2020;26:853\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNybo SE, Klepser SA, Klepser M. Design of a disaster preparedness escape room for first and second-year pharmacy students. Currents Pharm Teach Learn. 2020;12:716\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEric Nybo S, Sahr M, Young M, Axford K, Sohn M, Lyons M, et al. Design of a large-scale escape room for first-year pharmacy student orientation. Currents Pharm Teach Learn. 2020;12:1340\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEukel HN, Frenzel JE, Cernusca D. Educational Gaming for Pharmacy Students \u0026ndash; Design and Evaluation of a Diabetes-themed Escape Room. Am J Pharm Educ. 2017;81:6265.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKavanaugh R, George S, Lamberton N, Frenzel JE, Cernusca D, Eukel HN. Transferability of a diabetes escape room into an accelerated pharmacy program. Currents Pharm Teach Learn. 2020;12:709\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlakogiannis R, Stefanidis A, Hernandez N, Nogid A. A heart failure themed escape room approach to enhance pharmacy student learning. Currents Pharm Teach Learn. 2020;12:940\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe Y, Chen X, Ma H, Zhao R, Zhou H, Yang Y. Effectiveness of Escape Room in Medical Education: A Systematic Review and Meta-Analysis. Games Health J. 2024;13:419\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuek LH, Tan AJQ, Sim MJJ, Ignacio J, Harder N, Lamb A, et al. Educational escape rooms for healthcare students: A systematic review. Nurse Educ Today. 2024;132:106004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReed DA, Cook DA, Beckman TJ, Levine RB, Kern DE, Wright SM. Association Between Funding and Quality of Published Medical Education Research. JAMA. 2007;298:1002.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor M, Hoch J, Porter K. Educational interventions to improve emotional intelligence in nursing and medical students: A systematic review. JNEP. 2022;13:19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReed DA, Beckman TJ, Wright SM, Levine RB, Kern DE, Cook DA. Predictive Validity Evidence for Medical Education Research Study Quality Instrument Scores: Quality of Submissions to JGIM\u0026rsquo;s Medical Education Special Issue. J GEN INTERN MED. 2008;23:903\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilby KJ, Kremer LJ. Development of a cancer-themed escape room learning activity for undergraduate pharmacy students. Int J Pharm Pract. 2020;28:541\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorville K, Philip A, Halford Z. The design, implementation and evaluation of hybrid cancer clinic simulations: Escaping the norm. J Oncol Pharm Pract. 2023;29:162\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrishnan S, Blebil AQ, Dujaili JA, Chuang S, Lim A. Implementation of a hepatitis-themed virtual escape room in pharmacy education: A pilot study. Educ Inf Technol. 2023;28:14347\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBackhouse A, Malik M. Escape into patient safety: bringing human factors to life for medical students. BMJ Open Qual. 2019;8:e000548.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuckian J, Eveson L, May H. The great escape? The rise of the escape room in medical education. Future Healthc J. 2020;7:112\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBadr AF. The Geriatric Virtual Escape Room in Pharmacy Education: Female Students Escape Significantly Faster than Male Students. Pharmacy. 2022;10:36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCain J. Exploratory implementation of a blended format escape room in a large enrollment pharmacy management class. Currents Pharm Teach Learn. 2019;11:44\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakri A, Vlachopoulos D, Martina RA. Digital Escape Rooms as Innovative Pedagogical Tools in Education: A Systematic Literature Review. Sustainability. 2021;13:4587.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLathwesen C, Belova N. Escape Rooms in STEM Teaching and Learning\u0026mdash;Prospective Field or Declining Trend? A Literature Review. Educ Sci. 2021;11:308.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaker CM, Crabtree G, Anderson K. Student pharmacist perceptions of learning after strengths-based leadership skills lab and escape room in pharmacy practice skills laboratory. Currents Pharm Teach Learn. 2020;12:724\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHermanns M, Deal B, Campbell AM, Hillhouse S, Opella JB, Faigle C, et al. Using an Escape Room toolbox approach to enhance pharmacology education. JNEP. 2017;8:89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams V, Burger S, Crawford K, Setter R. Can You Escape? Creating an Escape Room to Facilitate Active Learning. J Nurses Prof Dev. 2018;34:E1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIgnacio J, Dolmans D, Scherpbier A, Rethans J-J, Chan S, Liaw SY. Stress and anxiety management strategies in health professions\u0026rsquo; simulation training: a review of the literature. BMJ STEL. 2016;2:42\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Escape Room, Gamified learning, Disease States, Pharmacy Students, Pharmacy Education","lastPublishedDoi":"10.21203/rs.3.rs-6636552/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6636552/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTraditional lecture-based approaches are usually inadequate in enhancing applicability, clinical skills, and engaging students. Escape rooms have been increasingly studied due to their ability to facilitate critical thinking, collaborative learning, and immersive learning. Since pharmacists are an integral part of healthcare, their extensive clinical knowledge of communicable and non-communicable disease states is crucial to adequate patient care. Therefore, we systematically evaluated the effectiveness of disease-state-themed escape rooms among pharmacy students, who are future pharmacists.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eWe carried out an extensive search across PubMed, Google Scholar, and Cochrane using appropriate keywords and Boolean operators. We screened articles for eligibility, ensuring that only escape room studies themed on disease states among pharmacy undergraduates were included. Quality assessment was done using the MERSQI tool.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 1,146 studies screened, 6 studies published between 2017 to 2023 met the eligibility criteria. The study participants ranged from 36 to 418. The escape rooms assessed disease states such as diabetes, heart failure, cancer, and hepatitis. There was a significant improvement in the knowledge assessment score on the disease topics across most studies after participating in the disease-state-themed escape room activity. The studies also showed a positive students\u0026rsquo; perception and satisfaction levels about the escape room activity, with the majority of the students expressing willingness to recommend the activity to other students. Additionally, improvements in critical thinking and collaborative learning were reported among the students.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDisease-state-themed escape rooms show promising effectiveness in learning disease topics among pharmacy undergraduates. However, the limited number of studies included in this review restricts its generalizability and calls for further research, particularly randomized controlled trials, to establish a comparison and determine their true impact on learning outcomes and long-term knowledge retention.\u003c/p\u003e","manuscriptTitle":"Disease-state-themed Escape Room Simulations in Undergraduate Pharmacy Education: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-07 09:43:22","doi":"10.21203/rs.3.rs-6636552/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c53caa7-c308-4faf-91dc-f5df90ff8a64","owner":[],"postedDate":"July 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-18T08:53:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-07 09:43:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6636552","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6636552","identity":"rs-6636552","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}