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Trapped as a Group, Escape as a Team:
Applying Gamification to Incorporate
Team-building Skills Through an ‘Escape
Room’ Experience
Xiao Chi Zhang , Hyunjoo Lee , Carlos Rodriguez , Joshua Rudner , Teresa M. Chan ,
Dimitrios Papanagnou
1. Emergency Department, Thomas Jefferson University Hospitals 2. Department of Emergency Medicine,
Thomas Jefferson University 3. Faculty of Health Sciences, Department of Medicine, Division of
Emergency Medicine, McMaster University
Corresponding author: Xiao Chi Zhang, xzhang09@gmail.com
Disclosures can be found in Additional Information at the end of the article
Abstract
Teamwork, a skill critical for quality patient care, is recognized as a core competency by the
Accreditation Council for Graduate Medical Education (ACGME). To date, there is no consensus
on how to effectively teach these skills in a forum that engages learners, immerses members in
life-like activities, and builds both trust and rapport. Recreational ‘Escape Rooms’ have gained
popularity in creating a life-like environment that rewards players for working together, solving
puzzles, and completing successions of mind-bending tasks in order to effectively ‘escape the
room’ in the time allotted. In this regard, escape rooms share many parallels with the
multitasking and teamwork that is essential for a successful emergency department (ED) shift.
A pilot group of nine emergency medicine (EM) residents and one senior EM faculty member
underwent a commercial escape room as part of a team-building exercise in January 2018. The
escape room required participants to practice teamwork, communication, task delegation, and
critical thinking to tackle waves of increasingly complex puzzles, ranging from hidden objects,
physical object assembly (i.e., jigsaw puzzles), and symbol matching. Activities required
members to recognize and utilize the collective experiences, skills, knowledge base, and
physical abilities of the group. After the game, players underwent a structured ‘game-master’
debriefing facilitated by an employee of the commercial escape room; this was followed by a
post-event survey facilitated by a faculty member, which focused on participants’ feelings,
experiences, and problem-solving techniques.
Escape rooms afford learners the opportunity to engage in an activity that rewards teamwork
and effective leadership through experiences that directly link to specific ACGME milestones
and educational learning theories. EM participants were engaged in the activity and felt that
the escape room reproduced an environment analogous to the ED. The debriefing that followed
the activity provided a satisfactory conclusion to the experience; but learners preferred a more
organized debriefing format that provided them with constructive and specific feedback on
their performance.
Categories: Emergency Medicine, Medical Education, Medical Simulation
Keywords: medical education, teamwork, communication, escape room, graduate medical education,
faculty development, simulation
1 2 2 2 3
2
Open Access Technical
Report DOI: 10.7759/cureus.2256
How to cite this article
Zhang X, Lee H, Rodriguez C, et al. (March 02, 2018) Trapped as a Group, Escape as a Team: Applying
Gamification to Incorporate Team-building Skills Through an ‘Escape Room’ Experience. Cureus 10(3):
e2256. DOI 10.7759/cureus.2256
Introduction
Teamwork is arguably one of the most difficult skills to teach learners in the health professions,
especially in chaotic and unpredictable environments, such as the emergency department (ED).
Team members must overcome varied levels of training and expertise, conflicting personalities,
and diverse skill sets to effectively function as a unit. Studies continue to demonstrate that
effective teamwork and collaboration, particularly in high-stakes, high-acuity environments,
have the ability to decrease mortality and cost [1, 2]. Trust has also been cited as a critical
teamwork element in the military literature, in which a team with an established level of trust
can effectively communicate and function with surgical precision [3].
Training opportunities in teamwork must be safe, low-stakes, high-impact, and dynamically-
engaging if they are to nurture the development of collaborative behaviors. Although teamwork
remains a core competency by the Accreditation Council for Graduate Medical Education
(ACGME), there is no consensus as to how to effectively teach this skill. Effective team training
demands receptive and engaged learners, immersive learning activities and experiences, and
participant trust and rapport.
Committed to creating a fun and interactive team training activity, the investigators turned to
the growingly popular ‘Escape Room’ as a medium to immerse learners in an environment
similar to the ED. Escape Rooms are live-action, team-based games where players must work
together, solve clues, and complete a series of mind-bending, fitness-challenging tasks in order
to ‘escape the room’ in under 60 minutes [Nicholson S. (2015). Peeking behind the locked door:
a survey of escape room facilities. White paper available at
http://scottnicholson.com/pubs/erfacwhite.pdf]. Players (or learners) must learn how to quickly
acclimate themselves in a foreign environment with other players (possibly strangers) of
various skill sets, establish trust, and communicate specific goals and tasks in order to assess
the environment, analyze clues, solve complicated problems, reassess the environment, and
set-up additional goals and dispositions. To a certain extent, this experience is analogous to
caring for real patients in an ED setting. While several effective team-building exercises are
described in the healthcare literature [4-7], there is currently no mention of the use of
commercial escape rooms as opportunities for team training for ED providers.
In this technical report, the investigators describe the use of an escape room as a pilot team-
building exercise for providers working in the ED of Thomas Jefferson University Hospital in
Philadelphia, Pennsylvania. The investigators contracted with a local escape room agency to
allow 10 participants from the ED to participate in a one-hour escape room session, followed by
a post-event debriefing.
Technical Report
Study settings
The commercial escape room agency was selected based on convenience of location, given its
proximity to the hospital (less than 1 mile). The average rate of successful ‘escapes’ at this
location is measured by the agency to be 20%. Four unique escape room formats are available at
this particular location, each with a unique theme and unique set of puzzles and challenges.
Each escape room also contains multiple sub-rooms to sequentially escape from as the activity
unfolds.
At the end of the game, players underwent a structured, escape-room debriefing, in which the
escape room ‘game-master’ described the puzzles and respective solutions; this allowed players
to recount their experiences and problem-solving techniques. The observer (XCZ) did not
provide any post-game feedback, nor did he participate in the debriefing.
2018 Zhang et al. Cureus 10(3): e2256. DOI 10.7759/cureus.2256 2 of 9
Study participant selection
Participants were selected on a first-come, first-serve basis, after a flyer that advertised the
activity was electronically mailed to ED residents and faculty. The activity was advertised three
weeks in advance. The investigation was reviewed and approved by the Institutional Review
Board of Thomas Jefferson University.
Materials required
Participants were not required to bring any additional tools or materials to the escape room.
Group structure
Ten participants were assigned to a single group without any predetermined roles or task
designations. Their only assigned group goal was to effectively escape the room within 60
minutes. One of the study investigators (XCZ) also entered the escape room to observe team
behaviors and record team interactions; he did not participate in the activity, and participants
were asked to ignore his presence.
Detailed activity description
To escape the room, participants must practice teamwork, communication, task-delegation,
critical thinking, and divergent thinking to tackle a series of increasingly complex puzzles,
ranging from hidden objects, physical object assembly (i.e., jigsaw puzzles), counting, and/or
symbol matching. Throughout the activity, the game master watches the participants’ progress
through several cameras that are physically mounted throughout the room. Players may receive
sporadic visual hints, displayed on a television monitor in the room, which are provided by the
game master if participants either fail to progress in solving clues or if participants wish to
directly receive a clue.
Specific puzzle information and details surrounding the escape room were unknown to the
authors and the participants prior to reserving the escape room, as this information is
considered proprietary knowledge to the escape room agency.
Activity evaluation
The investigators used a validated, post-study survey evaluation adapted from a post-focus
group interview guide in order to obtain written feedback about the escape room activity [8].
The referenced survey was developed and successfully used at McMaster University for
postgraduate EM resident physicians to assess a modular assessment program. The escape room
questionnaire consists of 18 questions, which are included in Appendix A. Responses from the
questionnaire were evaluated via an open-axial qualitative assessment by XCZ, HL, and CR.
Results
Ten total participants (eight second-year EM residents, one third-year EM resident, and one EM
faculty member) participated in this activity. There were approximately 10 to 12 unique puzzles
with topics ranging from, but not limited to, recognizing hidden objects, symbol substitutions,
mathematical challenges, searching for objects in images, rearranging objects based on visual
aids, light manipulation, assembly of a physical object, riddles, and pattern identification. The
team received only three hints throughout the activity (average per agency, 10-15) and escaped
the room in 46 minutes (average success rate per agency, 20%).
A post-activity survey analysis (n=10) revealed that eight out of 10 participants had previously
participated in escape room activities. Everyone, however, had previously participated in a
2018 Zhang et al. Cureus 10(3): e2256. DOI 10.7759/cureus.2256 3 of 9
team-building activity, with ‘sports’ being the most common activity (nine out of 10
participants). All participants reported similarities between the escape room and the ED, with
common themes focusing on chaos, communication, strategic thinking, differential diagnoses,
teamwork, uncertainty, task delegation, and time constraints. Participants also contrasted the
escape room to the ED, highlighting that the escape room felt more linear, clue-based, and low
stakes (Table 1).
Survey Questions Common Themes
Q4 - Please recall the interaction you had with your colleagues
in the game. Were they similar to tasks you perform in the ED?
Task Switching; Task Delegation; Data
Compilation; Plan Development; Task
Specification; Disposition Planning
Q5 - Please recall the interaction you had with your colleagues
in the game. Were they similar to the interactions you have
had with your applications in the ED?
Polite; Taking Turns; Independent Data Collection;
Collective Brainstorming and Data Sharing
Q6 - Please recall the debriefing conducted by the game
master at the conclusion of the game. Was this similar to the
debriefing at the end of your shift?
Different than Healthcare Debriefing; Inadequate
Debriefing; Different Debriefing Style
Q10 - What are some immediate lessons you learned by
working with your peers in the Escape Room?
Contribution of Unique Skills; Appreciation of
Skill Development Outside the Workplace; Organic
Practice of Leadership Skills
Q17 - If you were to redesign this team-building activity, what
would you want to include to make it a more effective activity
that focuses on team work and communication?
Fewer Sequential Puzzles; More Concurrent
Puzzles; Diversifying Participants; More
Comprehensive Debriefing with Constructive
Feedback
TABLE 1: Selected Participant Survey Responses Following the Escape Room
ED = Emergency Department
Nine out of 10 participants endorsed similarities in the social and interpersonal interactions
that take place in both the game and the ED; these include co-managing stressful situations,
settling differences in opinion, and providing periodic status updates. While all of the
participants appreciated the post-escape room debriefing, half of the participants would have
preferred a more structured debriefing, similar to a debriefing following a simulation, which
typically includes formative feedback based on observed behaviors. Nine participants reported
that the escape room experience motivated them to learn more about teamwork, specifically
how to overcome barriers to teamwork, how to manage conflicting personalities (i.e. introverts
vs. extroverts), how to multitask, and how to resolve personal differences. All participants rated
the escape room as an effective, fun, teambuilding activity, and even recommended including
additional puzzles and additional personnel of varied professions (i.e., nurses, technicians) and
varied levels of training for heightened realism.
Discussion
The authors propose that commercial escape rooms can be utilized as effective team building
activities by immersing participants in interactive, unpredictable, and chaotic environments
2018 Zhang et al. Cureus 10(3): e2256. DOI 10.7759/cureus.2256 4 of 9
that can encourage team members to exercise their unique skill sets to seek out and solve
different challenges. Escape rooms share several similarities to the clinical environment, which
make them successful learning adjuncts for members of clinical teams.
Open-axial qualitative assessment of the survey responses revealed common themes in clinical
(i.e., ED) and escape-room interactions, such as task switching, role delegation, and working
together towards a common goal. Additional common themes included a preference for fewer
sequential puzzles (versus simultaneous challenges that occur in parallel) to more closely align
with the multiple demands that are expected when working in an ED. Participants would have
also preferred a more organized and constructive debriefing.
The educational philosophy of this activity is rooted in behaviorism, social learning, and
cognitivist and constructivist learning theories. In behaviorism, ‘positive’ behavior is
reinforced by providing progression through the escape room process, whereas ‘negative’
behavior either does not help the players (i.e. learners) escape the room or even negatively
impacts their ability to escape (Table 2). There is a large aspect of social learning in this
activity, as learners imitate or perpetuate behaviors of successful puzzle solving. Learners can
also assimilate their previous knowledge and skills (i.e. pattern recognition, mathematical
fluency, trivia knowledge) to help them process environmental clues. The latter is akin to the
cognitivist approach to learning.
Aspects of constructivism are also embedded in this activity: learners construct their own
knowledge based on real-time experiences of advancing through several challenges in the
escape room. In accordance with the ACGME EM Milestones, escape rooms also afford the
learners the opportunity to practice several milestones: Patient Care (PC8 – Task Switching)
and Interpersonal Communication Skills (ICS1 – Interpersonal and Communication Skills and
ICS2 – Leading Patient-Centered Care Teams) (Table 2). In order to escape the room, each
player must demonstrate the ability to switch tasks between assimilating clues, solving puzzles,
and reassessing the environment under high-stress situations using flexible communication
strategies. Participants must coordinate their efforts to solve complicated puzzles and
recommend changes in their team to establish optimal efficiency (i.e. redistributing the team
members from focusing on one puzzle to searching for additional clues). These challenges
could not be more similar to a busy Monday shift in the ED.
2018 Zhang et al. Cureus 10(3): e2256. DOI 10.7759/cureus.2256 5 of 9
ACGME
Milestone Escape Room Activity Relevant Educational Learning
Theories
PC8: Task
Switching
Level 1: Solves a single puzzle amidst a chaotic
environment; Level 2: Pays attention to discovered clues while
completing a task; Level 3: Actively communicates with team
members to share new hints or solutions; Level 4: Actively
reassesses environment to assign new tasks after a stage is
completed
Constructivist: Players use
previous puzzle-solving
knowledge to help process
clues. Cognitivist: Players
acquire new knowledge based
on real-time puzzle solving
ICS1:
Interpersonal
and
Communication
Skills
Level 1: Establishes rapport with fellow players; Level 2:
Negotiates and manages simple conflicts during the game;
Level 3: Effectively communicates with struggling players to
minimize stress when engaged in a complex puzzle; Level 4:
Uses flexible communication strategies to assign appropriate
tasks to assist with puzzle-solving
Social Learning: Players
imitate puzzle-solving
behaviors with
success. Behaviorism: Positive
behavior is reinforced by
progression in the escape
room
ICS2: Leading
Patient-
Centered Care
Teams
Level 1: Participate as an individual player; Level 2:
Communicates pertinent clues and/or solutions to the team
leader; Level 3: Demonstrates clear communication with team
members; Level 4: Recommends changes in team behaviors to
solve complicated puzzles (i.e. assigns a new player to a
problem or considers an alternate approach)
Social Learning: Players
imitate puzzle-solving
behaviors with
success. Behaviorism: Positive
behavior is reinforced by
progression in the escape
room
TABLE 2: Accreditation Council for Graduate Medical Education (ACGME) Milestones
Specific to Emergency Medicine (EM) with Corresponding Learning Theories Found
in an Escape Room Activity
ACGME = Accreditation Council for Graduate Medical Education
PC = Patient Care
ICS = Interpersonal and Communication Skills
Source: https://www.acgme.org/Portals/0/PDFs/Milestones/EmergencyMedicineMilestones.pdf [9]
There are several limitations worth noting. While this activity was originally designed to be an
inclusive team-building event that was open to all eligible ED staff, the study investigators were
unable to accrue a diverse group of participants within the enrollment period due to scheduling
conflicts. Furthermore, commercial escape rooms can be expensive, making it costly to conduct
this activity with a large group of students, residents, and/or faculty. It is possible, however, to
divide larger groups into more manageable sizes of six to 10 learners. The presence of an
observer in the escape room may have led to a Hawthorne effect, which can be addressed in
future iterations using the surveillance recorders available in the escape room. Finally, the
debriefing was limited to the post-activity discussion facilitated by the agency's game master;
future team-building exercises may benefit from a standard debriefing, focusing on observed
behaviors and results to provide learners with constructive feedback. An economical alternative
2018 Zhang et al. Cureus 10(3): e2256. DOI 10.7759/cureus.2256 6 of 9
to commercial escape room is to construct an emergency department-themed escape room with
EM-specific puzzles and challenges set in a private residence with each room representing
different locations in the ED. This allows the creators and participants to become more engaged
in puzzle solving and enables more constructive feedback.
Conclusions
The escape room team-building activity was well received by our EM residents and faculty. It
allowed learners to immerse themselves in an engaging, fun, non-threatening, non-clinical,
low-stakes activity that rewarded teamwork and effective leadership. Next steps will include
expanding interprofessional inclusion (i.e., nurses and technicians), as well as designing escape
rooms with more complex puzzles that require parallel processing to closely approximate the
chaotic nature of the ED. The authors found that while the game debriefing provided insight
into actions taken during the game, participants would have preferred a more constructive
feedback session to help them analyze aspects of communication and problem-solving that can
be applied in subsequent scenarios, including the clinical environment.
Appendices
Appendix A – Post escape room survey questionnaire
1. Have you ever used an escape room?
1a. If yes to question #1
1b. What were your initial reactions to it?
1c. I’d like you to compare your expectations to when you were first introduced to it and now,
after having had some time working with the system. Was it any different from what you
expected?
2. Have you ever participated in team-building activities (i.e. team steps, sports activities)?
2a. If yes, what were the activities?
3. I invite you to think about your clinical settings, how do those environments compare to the
escape room?
3a. Can you identify any differences or similarities?
4. Please recall the tasks you performed in the escape room, were these similar to the tasks you
perform in the emergency department (ED)?
5. Please recall the interaction you had with your colleagues in the game, were they similar to
the interactions you have with your applications in the ED?
6. Please recall the debriefing conducted by the game master at the conclusion of the game,
were they similar to the debriefing at the end of your shift?
6a. Why or why not?
7. How do you prepare for your clinical shifts?
2018 Zhang et al. Cureus 10(3): e2256. DOI 10.7759/cureus.2256 7 of 9
8. How do you prepare for the clinical team interactions you have on shifts?
9. How do you prepare for the debriefing that takes place at the end of the shift?
10. What are some immediate lessons you learned by working with your peers in the escape
room?
10a. Do you find this experience useful? Why or why not?
11. Thinking back, which experience from the escape room will motivate you to learn more
about working in a team?
12. Thinking back, which experience from the escape room will dissuade you from working in a
team?
13. What is your perception of teamwork and communication in emergency medicine?
14. How do you determine the value of effective teamwork and communication?
15. How do you determine the value of debriefing at the end of a clinical shift?
16. Was the escape room activity an effective team building activity?
16a. What made it effective?
16b. How will you use this information?
17. If you were to redesign this team building activity, what do you want to include to make it a
more effective activity that focuses on team work and communication?
17a. Prompt: What will you want to take out or change?
17b. Prompt: Why would you implement that change?
18. Do you have any questions for me? Are there topics that we’ve yet to cover? Is there
anything you want to discuss?
Additional Information
Disclosures
Human subjects: Consent was obtained by all participants in this study. Sidney Kimmel
Medical College at Thomas Jefferson University issued approval #18E.055. The Institutional
Review Board (IRB) has evaluated the involvement of human subjects in the proposed research
study entitled: Applying Gamification to Incorporate Team-Building Skills via an Escape-the-
Room Experience" (Departmental) 45 CFR 46.101 (2-anonymous survey) Control #18E.055. In
accordance with Federal-Wide Assurance #00002109 to the U.S. Department of Health and
Human Services, the study was determined to be EXEMPT from IRB review on 02/01/2018
pursuant to Title 45 Code of Federal Regulations Part 46.101(b) governing exempted protocol
declarations. Board #152 was notified of this exemption status at its 02/01/2018 meeting.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or
tissue. Conf licts of interest: In compliance with the ICMJE uniform disclosure form, all
2018 Zhang et al. Cureus 10(3): e2256. DOI 10.7759/cureus.2256 8 of 9
authors declare the following: Payment/services info: All authors have declared that no
financial support was received from any organization for the submitted work. Financial
relationships: All authors have declared that they have no financial relationships at present or
within the previous three years with any organizations that might have an interest in the
submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
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