Due to the COVID-19 pandemic, we were forced to transition an in-person, hands-on nutrition “escape room” to a fully online experience. There is little literature related to the use of escape rooms in nutrition and dietetics, however, they have been used in other disciplines such as nursing and pharmacy. Educational escape rooms have been shown to improve student perceptions and knowledge development and enhance soft skills such as teamwork and communication.
The course, Nutrition Assessment and Communication Laboratory (HUN4025L) is a required course for senior nutrition and dietetics students. This is a newly developed two hour and forty-five-minute face-to-face course that meets once weekly. The primary objective of this course is to reinforce the skills necessary to provide accurate and effective nutrition intervention and communication strategies in various practice settings. This course relies heavily on simulation-based activities including nutrition focused physical exams (NFPE) and practicing effective communication skills. The course enrollment was 53 and was offered for the first time in the spring of 2020.
The nutrition escape room experience was originally developed as an in-person experience as the culminating final project for HUN4025L. It was scheduled to take place in one of the nursing simulation labs with the use of mannequins and medical equipment (beds, medical devices, etc.) to mimic an actual hospital setting. This assignment required students to use knowledge and clues to move through each step of the Nutrition Care Process (NCP), a systematic approach to providing high-quality nutrition care that emphasizes critical thinking, problem-solving, and decision-making. The original plan was that students would enter the simulation lab in small groups and begin in the dietitian’s office where they would look through the inbox at patient charts to determine priority for assessing patients. They would then move through each step of the NCP with their group.
Due to the abrupt transition of all university courses to online delivery (because of COVID-19), we were faced with the challenge of adjusting the escape room assignment from an in-person experience to fully online. The online escape room was organized into nine modules within Canvas. We provided detailed instructions for the assignment in the first module and students proceeded through and completed the escape room individually. After entering, each module contained pertinent information for each step (videos, documents, photos, etc.) and students were required to score 100% on a quiz in order to unlock the next step. Students had unlimited and untimed attempts for each quiz. Although the quizzes were multiple-choice, a majority of the questions were at the ‘analysis’ and ‘evaluation’ levels of the cognitive domain.
The following are examples of steps that were included in the online escape room. In step 2, students were provided with multiple nutrition screening forms of recently admitted patients. They had to review those forms and then prioritize the patient who needed a complete nutritional assessment in order for the student to advance to the next step. Another example includes step 7 which included a video of a swallow study being performed. Students had to view this video in order for them to identify the appropriate intervention based on the patient’s progress. For all of the steps of the escape room if a student chose the wrong intervention, diagnosis, etc. cues/feedback was provided to assist with self-correction.
Debriefing in groups of 8-9 students took place immediately after the students completed the assignment. This debriefing was originally scheduled to take place in a conference room near the nursing simulation lab. However, since the assignment was changed to online, the debriefing took place via Zoom. The questions asked in the debriefing were aimed at not only assessing the overall process of the escape room but also to help students reflect critically on how this assignment can be applied to future practice. Table 1 outlines the questions asked in each debriefing session.
|Table 1: Debriefing Questions|
|Question 1: What were your first impressions of the scenario/idea of the escape room?|
|Question 2: Did you have the knowledge and skills to meet the objectives?|
|Question 3: In what ways was the scenario challenging?|
|Question 4: What three factors were significant enough for you to apply to practice?|
|Question 5: In real life, what might you do differently?|
|Question 6: What went well?|
|Question 7: What could have been changed?|
All students reported a positive first impression of the assignment, and they reported that they had the required knowledge and skills needed to complete it. Some noted that they were initially a bit nervous and unsure of what to expect, but once they entered the assignment, they were pleasantly surprised at how effective it was. Students felt the experienced flowed well; for example, one student noted, “I think the flow of the assignment was really good. I liked that we worked chronologically through the NCP, like we would in an actual clinical setting.” Students particularly appreciated the videos, which helped the process feel “more immersive.” One student said that it was “cool seeing the video of the RD introducing the patients, felt like I was in an escape room; watching swallow study was emotional, seeing the person and seeing what they’ve been through and puts it into perspective.” Students also appreciated the sense of real-life exposure to medical records. One student said it was valuable “being able to analyze the medical records, seeing the intervention and monitoring by looking at the chart.”
While a majority of the feedback was positive, there were a few challenges. A few students mentioned technology challenges such as the needing to download documents and having several browser tabs open at one time. However, most of the challenges reported were related to clinical content such as calculating tube feeding needs and choosing the correct formula. Overall, students felt the escape room helped them learn how to prioritize their caseload, apply the steps of the nutrition care process, and practice and build confidence in their clinical judgment. For example, one student remarked that they “didn’t realize how well I was able to apply it, made me feel better going into the internship; being able to apply it helped confidence/self-efficacy.” Surprisingly, several students notes that they would have enjoyed doing this type of assignment more frequently throughout the semester.
In addition to the debriefing, we also examined the analytics for the quizzes, to gauge student progress through the assignment. These analytics were produced automatically by Canvas. The analytics for the quizzes revealed that students progressed rather quickly through the online escape room. In step 2, prioritizing care, the average time for students to answer the question was 54 seconds with 67% of students answering correctly on the first attempt and most of the other quizzes were similar in terms of time to answer and the percentage of students answering correctly. However, the final question (to “escape”) was an exception , where the average time was only 15 seconds with 86% of students answering correctly on the first attempt. This speedy progress through the escape room assessments suggest to us that that future deployments of this assignment should include more layered criteria and varied assessments to challenge the students more.
Considerations for the Future
We plan on improving this virtual assignment by creating and adding more videos from the simulation lab, challenging clues, and layered criteria to advance through each step. Creating videos using the on-campus simulation lab will really help to enhance student engagement. Also adding interactive quizzes such as matching using images rather than text, sorting/classification, and games or trivia will enhance the student experience. To reestablish the collaborative nature of the escape room, we will also explore completing this assignment in groups, perhaps using Zoom or a similar technology. assignment in groups. Lastly, the addition of smaller-stakes similar assignments throughout the semester would be helpful.