Escape Room, Psychological Safety, Simulation Orientation, Simulation Prebriefing



  1. Robertiello, Gina
  2. Genee, Jordan
  3. Marrera, Amnerys


Abstract: Orientation to the environment and equipment promotes psychological safety in simulation. Providing orientation activities also increases learner perceptions of simulation effectiveness, confidence, and learning overall. Escape rooms, used by educators from primary levels through graduate programs, promote skills in teamwork, creative problem-solving, and critical thinking ability. Creating an escape room-themed simulation experience with the objective of orienting learners to the simulation environment and equipment is an interactive way to prepare learners for simulation, while encouraging teamwork and group dynamics.


Article Content

Effective prebriefing strategies affect satisfaction, participation, and overall effectiveness of a simulation experience (Chamberlain, 2017). Prebriefing is an essential part of the International Nursing Association for Clinical Simulation and Learning (INACSL) standards for best practice for both simulation design and facilitation (INACSL, 2016). Orientation to the space, equipment, and simulator should occur as part of the prebriefing to promote a psychologically safe learning environment (Turner & Harder, 2018). A simulation experience with an escape room theme can help accomplish these objectives while encouraging teamwork and group dynamics.



Research exploring prebriefing in nursing simulation education is limited. A study conducted by Chamberlain (2017) in two Midwest baccalaureate colleges of nursing measured student perceptions of overall simulation effectiveness, learning, and self-confidence when provided no prebriefing, prebriefing learner engagement and orientation activities, prebriefing orientation activities alone, or prebriefing learner engagement alone. Results showed student perceptions of overall simulation effectiveness, learning, and confidence were significantly higher with the use of prebriefing activities compared to no prebriefing. In addition, the group without prebriefing noted limited dialogue between learners during the simulation, whereas those who were prebriefed felt comfortable discussing and agreeing on a plan for the patient. Therefore, best practice emphasizes providing learners with a thorough prebriefing that reflects the concepts of situated learning theory, focusing on learning engagement and orientation activities before beginning a simulation scenario.


Students' psychological safety is an essential component of simulation learning. Ensuring psychological safety decreases anxiety in stressful situations and optimizes learning in the simulation environment. In a literature review conducted by Turner and Harder (2018), orientation to the simulation environment, including seeing and touching the manikin and supplies, is considered a foundational activity to high-fidelity patient simulation that decreases learner apprehension and promotes a psychologically safe learning environment.


An escape room is a timed immersive experience that uses puzzles, riddles, and clues to direct participants to complete objectives and, most often, escape a locked room. Escape room experiences often conclude with a group debriefing in which participants can work through the intended outcome and what they found challenging. Escape rooms have been used by educators from primary levels through graduate programs as they promote skills in teamwork, creative problem-solving, and critical thinking (Wiemker, Elumir, & Clare, 2015). They have also been instrumental in health professions education. Wu, Wagenschutz, and Hein (2018) implemented an escape room for medical students of varying levels of training to practice leadership competencies and team management.


Adams, Burger, Crawford, and Setter (2018) ambitiously incorporated 10 educational objectives from nurse residency seminars into an escape room. Most of the objectives applied hospital policies and procedures, such as fall prevention, patient identification, and preventing common health care-associated infections. Participants were 167 nurse residents with less than 18 months of clinical experience, partnered with 46 experienced nurses. Lastly, Connelly, Burbach, Kennedy, and Walters (2018) utilized a simulation room to create an escape room to recruit high school and community college students interested in pursuing nursing as a profession. There is no current literature exploring the use of escape rooms with the objective of orienting learners to the simulation environment.



Feedback from quality improvement surveys indicated undergraduate baccalaureate nursing students at our university did not feel adequately prepared to function in the simulation environment. Comments addressed confusion as to where to find supplies, how to operate equipment, and the functionality of the manikin. Our team in the simulation center, where students perform almost half of their clinical rotation hours, worked together to brainstorm an active learning experience to orient nursing students to the simulation environment and supplies while creating a psychologically safe space for learning.


Drawing from Kolb's experiential learning theory, an escape room was created and implemented during the spring 2018 semester. Experiential learning theory finds active involvement by learners with problem-solving and decision-making enhances the learning experience (Ulrich & Mancini, 2014). The objectives of this experience include student orientation to the simulation room, manikin, supply closet, and medication cart; the practice of dosage calculation problems; review and practice of skills required in the experience (such as patient assessment and SBAR report); and the encouragement of teamwork in an emergency situation.


The scenario was created utilizing INACSL standards of best practice (INACSL, 2016) for implementation at the beginning of the second semester of nursing curriculum classes. Clinical groups of 6 to 10 students are allotted 15 minutes to complete the experience. The clinical instructor, acting as moderator, reads the following script aloud before beginning: "Your patient is in distress! Use the clues and solve the riddles to find what you need to intervene. You will have 15 minutes. There are no clues in or around the sharps container. To begin, look for your first clue. Hint: The clues are on purple index cards."


Once the timer begins, the moderator goes to a separate control room not visible to participants. The control room contains a flowsheet indicating where clues are located and where they will lead participants, answers to problems, and appropriate responses and hints. The patient, played by a high-fidelity manikin, is experiencing an anaphylactic reaction. The manikin wears an allergy band that says "peanuts" and holds a delivery menu with a peanut-containing entree circled. Clues first lead the students to assess their patient. They will note stridor on auscultation of lung fields and interact with the bedside monitor to discover the patient is tachypneic and hypoxic. Students are prompted for supplies to intervene (oxygen) and to prepare to give SBAR report to the physician. After answering dosage calculation problems and deciphering the physician's telephone number (number to control room), the moderator will receive the SBAR report and order a stat dose of intramuscular epinephrine. To unlock the medication cart, students will need to follow hieroglyphic-like clues to find supplies labeled with the numbers to open the cart and find the medication (see supplemental digital content, available at, for Figure). The students locate the correct needle/syringe to administer the epinephrine before the scenario concludes.


The clues in the scenario appeal to various learning styles and afford students an active learning opportunity to practice using the touch screen vital sign monitor, manikin, and medication cart and locate supplies (Tutticci, Coyer, Lewis, & Ryan, 2016). The activity naturally fosters communication skills and teamwork as students work together, an important skill with application to the clinical practice setting. Upon completion of the activity, the moderator leads debriefing, and any unclear details of the simulation or equipment are discussed. Consistent with experiential learning theory, reflection plays an integral part in the learning process (Ulrich & Mancini, 2014).



Feedback from simulation faculty acting as moderators has been positive, with praise for the active learning experience as a means to orient learners to the environment. Responses to quality improvement surveys distributed to all 264 participating students indicate that the escape-the-simulation encounter has been beneficial, meeting preset learning objectives. Based on feedback, an introduction video has been created for use before students begin the simulation. Directions, suggestions, and objectives are outlined in the video to ensure clarity. Further research is recommended to evaluate student perceptions of psychological safety in simulation after participating in the escape room. Orienting learners to their environment is an essential part of simulation to ensure success. Creating an escape room experience is an innovative way to give students hands-on exposure to the supplies and equipment while building group dynamics.




Adams V., Burger S., Crawford K., Setter R. (2018). Can you escape? Creating an escape room to facilitate active learning. Journal for Nurses in Professional Development, 34(2), E1-E5. [Context Link]


Chamberlain J. (2017). The impact of simulation prebriefing on perceptions of overall effectiveness, learning, and self-confidence in nursing students. Nursing Education Perspectives, 38(3), 119-125. [Context Link]


Connelly L., Burbach B., Kennedy C., Walters L. (2018). Escape room recruitment: Description and lessons learned. Journal of Nursing Education, 57(3), 184-187. [Context Link]


International Nursing Association for Clinical Simulation and Learning (2016). Standards of best practice: Simulation. Clinical Simulation in Nursing, 12(S), S1-S20. [Context Link]


Turner S., Harder N. (2018). Psychological safe environment: A concept analysis. Clinical Simulation in Nursing, 18, 47-55. [Context Link]


Tutticci N., Coyer F., Lewis P. A., Ryan M. (2016). High-fidelity simulation: Descriptive analysis of student learning styles. Clinical Simulation in Nursing, 12(11), 511-521. [Context Link]


Ulrich B., Mancini B. (2014). Mastering simulation: A handbook for success. Indianapolis, IN: Sigma Theta Tau International. [Context Link]


Wiemker M., Elumir E., Clare A. (2015, November). Escape room games: Can you transform an unpleasant situation into a pleasant one? Retrieved from[Context Link]


Wu C., Wagenschutz H., Hein J. (2018). Promoting leadership and teamwork development through escape Rooms. Medical Education, 52, 550-573. [Context Link]