Abstract
Objective. To describe the development and assessment of an integrated virtual escape room in a cardiology course.
Methods. A virtual escape room was developed to reinforce therapeutics, pharmacology, pharmacokinetics, medicinal chemistry, pharmacogenomics, and calculations related to cardiology in an integrated pharmacy course and was completed by two student cohorts. Groups of four to five students had 40 minutes to complete virtual escape room puzzles, and each puzzle had to be solved correctly prior to advancing. After completion of the activity, learners met with facilitators to debrief. Students completed pre- and postsurveys to assess knowledge changes and their perceptions of the experience.
Results. One hundred twenty-six second-year Doctor of Pharmacy (PharmD) students completed the escape room, and 79% (n=55) and 93% (n=52) of students completed pre- and postsurveys for the 2020 and 2021 cohorts, respectively. Results showed a significant improvement in student knowledge on pre- to postsurvey knowledge questions (2020 presurvey mean [SD]=43.1 [22.6], postsurvey mean [SD]=74.1 [19.6]; 2021 presurvey mean [SD]=52.0 [15.8], postsurvey mean [SD]=67.1 [19.2]). Most students in both cohorts (88%) agreed that logistics of the escape rooms were amenable to learning and applying information, and 86% enjoyed working through puzzles.
Conclusion. The virtual escape room was well received by students and served as an effective tool for reinforcing and integrating cardiology concepts. The virtual nature of the activity makes it practical and easily replicable to implement at other institutions, which can benefit from using the format, logistics, and materials described in this study to decrease faculty workload and costs associated with implementing this educational technique.
INTRODUCTION
Pharmacy curricula has shifted toward the implementation of more active experiences to engage students. Gamification, including escape rooms, is an active learning strategy that has been implemented in pharmacy education.1-6 An escape room can be defined as a “live-action team-based game where players discover clues, solve puzzles, and accomplish tasks in one or more rooms to accomplish a specific goal in a limited amount of time.”7 Literature has suggested that educational escape rooms can increase knowledge, improve clinical skills, promote critical thinking, allow for the application of concepts and encourage teamwork.7-10 Benefits of virtual escape rooms include lower costs and minimal preparation for coordinators after initial development, with the ability to use the activities for multiple years.9
The curricular meshing of pharmaceutical sciences and clinical practice is an important strategy in health care education.11,12 Thus, the objective of this study was to describe the development and assessment of a virtual escape room to reinforce cardiology concepts. The activity was designed to reinforce therapeutics, pharmacology, pharmacokinetics, medicinal chemistry, pharmacogenomics, and calculations, and to encourage students to apply knowledge of foundational sciences to clinical scenarios.
METHODS
This activity was developed for second–professional year students in a concentrated systems-based therapy cardiology course, which meets five days per week for nine weeks at the end of the fall semester. The integrated course is taught in a team-based learning format. Students completed the activity in a practicum during the last week of the course in fall 2020 and 2021. To develop the virtual escape room, faculty from foundational and clinical sciences identified key concepts to be reinforced while also considering course learning objectives, challenging topics, and reflecting on student performance in previous years. The virtual escape room applied concepts related to pharmacology, therapeutics, guideline-directed medication therapy, medicinal chemistry, pharmacokinetics, pharmacogenomics, and patient education. These concepts were used to develop puzzles, which were uploaded into Google Forms (Google LLC), with settings that required students to correctly answer each puzzle prior to advancing. Puzzles included pictograph equations, diagrams, word scrambles, chemical structures, treatment algorithms, and a game board, and each puzzle required students to apply content from foundational and clinical sciences. Figure 1 shows example puzzles. Additional information regarding puzzles are summarized in Appendix 1.
Example Puzzles from Cardiology Virtual Escape Room.
Three facilitators assisted in the escape room activity, with three to five learner groups each. Each group consisted of four to six students, depending on class size. To ensure that all facilitators were providing consistent learner instructions, a facilitator’s guide was developed. Learners were permitted to select their own groups, and groups were then posted, with facilitator and Zoom (Zoom Video Communications Inc) information. Learners were not provided with any information related to the content of puzzles prior to the activity.
To initiate the activity, students were provided with instructions from the facilitator’s guide, including how to advance through the game and how to request a clue. Learners were informed that they could use resources during the activity, but communication between teams was not permitted. Prior to starting the escape room, students were given a link to the presurvey, which included knowledge-based multiple-choice questions corresponding to a concept addressed in each puzzle (eight in 2020 and 11 in 2021). Learners were then sent to Zoom breakout rooms and provided with a link to the puzzles. Teams were permitted to request two clues with the “Ask for Help” button. While learners were completing the puzzles, facilitators navigated through the breakout rooms to ensure that everyone was engaged in the activity and to address questions. Learners were given 40 minutes to complete the activity. Facilitators documented start and finish times for each team to identify the “winners.”
Immediately following the escape room, facilitators led student groups through a 10-15 minute debrief, where they answered questions about the puzzles, clarified concepts, and discussed learner accomplishments as a result of the activity. Presurvey knowledge multiple-choice questions were not discussed in the debrief. At the end of the debrief, learners were asked to complete a postsurvey with the same multiple-choice questions to assess knowledge changes, as well as perception questions using five-point Likert items.
This was a required pass-fail activity, with all participants receiving a passing grade. The course grade was not impacted by student performance. In order to motivate students to perform well, the first three groups to “escape” were given preferential scheduling for a later program assessment.
The development of the escape room activity required approximately 12 faculty hours during the first implementation; facilitators met to discuss concepts and logistics (approximately one hour), brainstormed ideas and developed puzzles (approximately seven hours), and one coordinator used Google Forms to create the form with the puzzles (approximately one hour). Creation of the facilitator’s guide took approximately one hour. Development of knowledge questions for the surveys on the institution’s online learning management system took approximately two hours. Faculty time was drastically decreased for the second implementation of the escape room in 2021, with approximately 30 minutes spent updating groups and the facilitator’s guide and approximately three hours developing three additional puzzles.
For statistical analysis, data were summarized as means, standard deviations (SD), and proportions. Individual knowledge-based multiple-choice question results were analyzed with the McNemar test, with statistical significance defined as p<.05, as each student response was paired from the pre- and postsurveys with an anonymous code. Students that did not complete both surveys were excluded from the analysis. Total pre-post survey scores were compared with a paired t test (Prism 7, GraphPad Software LLC). Data were analyzed using Microsoft Excel and Prism. The study was deemed exempt by the institutional review board.
RESULTS
One hundred twenty-six second-year Doctor of Pharmacy (PharmD) students participated in the escape room (70 in 2020 and 56 in 2021), and 79% (n=55) and 93% (n=52) of students completed the pre- and postsurveys for the 2020 and 2021 cohorts, respectively. Seventeen of 24 student groups successfully completed all puzzles in the allocated time.
Analysis of knowledge-based multiple-choice questions revealed statistically significant improvements in knowledge of certain topics in both cohorts, including pharmacology and potency of statins (p<.001, p<.01 for 2020 and 2021, respectively), and medication identification and dosing for warfarin (p<.001). Other multiple-choice questions showed significant improvements in one of the two cohorts. Additional information related to knowledge changes is shown in Table 1.
Assessment of Knowledge Gains in Virtual Cardiology Escape Rooms
The average scores for knowledge multiple-choice questions improved in both cohorts. Mean (SD) pre- and postsurvey scores for 2020 were 43.1 (22.6) and 74.1 (19.6), respectively, (p<.001). For 2021, mean (SD) pre- and postsurvey scores were 52.0 (15.8) and 67.1 (19.2), respectively, (p<.001).
While 4% of students in 2020 and none in 2021 answered all questions correctly on the presurvey, 17% and 12% of students successfully answered all questions correctly on the postsurvey in 2020 and 2021, respectively. All students who achieved a perfect score on the presurvey also achieved a perfect score on the postsurvey. A majority of students improved scores from the pre- to postsurvey (76% and 79% for 2020 and 2021, respectively).
Student feedback is summarized in Tables 2 and 3. The majority of students (88%) felt the logistics of the virtual escape room were amenable to learning and applying information. Themes from student comments about the activity included the low stress and fun environment, the ability to recognize areas of weakness, the ability to apply concepts learned in class, and promoting students to think outside the box.
Student Self-Perceived Abilities on the Virtual Cardiology Escape Room
Student Perceptions of the Virtual Cardiology Escape Room
Description of Puzzles and Concepts in the Virtual Cardiology Escape Room
DISCUSSION
Educational games have been shown to be a motivating, interactive technique that allow students to apply knowledge, receive immediate feedback, and improve confidence.13,14 Many content areas in pharmacy curricula are suitable for educational games.15 This study examined the use of a virtual escape room in two student cohorts to reinforce important cardiology concepts. The virtual escape room was the first activity of its kind for these students and was well received, with many students supporting the use of additional escape rooms throughout the curriculum.
One of the main disadvantages of physical escape rooms in health professions curricula is the cost and faculty time associated with development and implementation.16 The implementation of virtual escape rooms simplifies logistics and eliminates many costs associated with in-person educational gaming activities. As with a physical escape room, a significant time commitment is required for the development of puzzles, but time commitment for facilitators for virtual escape rooms is minimal, as the significant setup required for physical escape room props is not necessary. The required time commitment is also less significant after the first year of implementation, as groups, puzzles, and facilitator guides can be edited rather than needing to be created. Aside from faculty workload, the cost of implementing the virtual escape room was free, as the platforms that were used were either free of charge or already being used at the institution. Virtual escape rooms can also be more easily implemented with remote teaching and/or on satellite campuses.
Students’ performance and the formative debrief that followed each activity provided instructors with insights on content areas that were more challenging for students, allowing instructors to design educational interventions in subsequent courses to address these issues. For example, when instructors discovered students’ suboptimal knowledge retention of drug-drug interaction concepts following this activity, they were able to plan additional emphasis on these concepts in future iterations of the course.
Overall, students performed better on knowledge questions following the escape room. While there were consistencies with knowledge changes on some questions in both cohorts, other questions were significantly improved in only one student cohort, possibly indicating that students may benefit from certain puzzles based on their preferred learning style. The pre- and postsurvey data show that while the escape room was beneficial at improving knowledge, the number of students who achieved a perfect score on the postsurvey was still suboptimal, indicating that the escape room activity may be used to supplement reinforcement but should not be a standalone tool to prepare students for examinations.
Students in pharmacy programs often learn in disciplinary silos and struggle to connect information from foundational science or see the relevance of content that is not directly clinical.17 Activities incorporating foundational and clinical concepts may lead to improved retention of knowledge.18 However, combining concepts can be challenging, as this can take a considerable amount of time, and care must be taken to avoid repetitive information and to appropriately balance different concepts in the activity.18,19 This study describes how a virtual escape room can be used to integrate cardiology concepts and help students understand the importance of using foundational knowledge to make clinical decisions. Activities that include integrated concepts may allow students to have expanded appreciations of both foundational and clinical sciences.18 Additionally, although not quantifiable, the development of the escape room fostered interdisciplinary collaboration among faculty developers.
This study has multiple strengths, including the inclusion of two student cohorts, inclusion of foundational and clinical concepts, and reproducibility of positive outcomes. Additional studies are needed to determine whether educational games are more effective at reinforcing specific types of knowledge over other types of educational activities.
Limitations of this study include its implementation at a single institution and the lack of a control group. Another limitation was that activity coordinators were not able to identify whether the students that did not finish the escape room puzzles were the same students that obtained lower scores on the postsurvey, since surveys were anonymous. The authors anticipate that the debrief may have contributed to knowledge gains, since all students completed the debrief with their facilitator after the escape room activity and prior to the postsurvey, regardless of whether they completed all puzzles. An additional limitation is that facilitators could not ensure that all students actively participated in the activity. Peer evaluations could be used in the future to help ensure active participation from all students. Future studies could also examine changes in long-term knowledge retention as a result of escape room activities.
CONCLUSION
Virtual escape rooms can be used in pharmacy curricula to reinforce knowledge and integrate concepts. Most of the resources necessary to develop and implement virtual escape rooms are likely already being used by educational institutions, making these activities practical and replicable. Institutions can benefit from using the format, logistics, and materials described in this study to decrease faculty workload and costs associated with this educational technique.
- Received September 27, 2021.
- Accepted June 7, 2022.
- © 2023 American Association of Colleges of Pharmacy
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