The use of escape room to estimate staffing numbers of nursing professionals: report on the postgraduate teaching experience

ABSTRACT

Covid-19 was characterized by the largest interruption in the teaching-learning process in history. To minimize this event, emergency remote teaching became a strategy to seamless resuming classes. In this context, Information and Communication Technologies (ICT), combined with active learning methodologies, have gained prominence for remote activities. The aim of this study was to report on the experience of applying an escape room to estimate nursing professionals numbers in the context of postgraduate training. It is an active and participatory teaching-learning methodology, developed using the Google Forms tool, in escape room format, with sub-themes on the dimensioning of nursing staff. The reported strategy proved to be viable for application in different settings of nursing training, pre-graduate, post-graduate, as well as in the labor context of continuing education.

Keywords
Education, nursing; Nursing staff, hospital; Covid-19; Education, distance; Gamification

A pandemia da Covid-19 caracterizou-se pela maior interrupção do processo de ensino-aprendizagem da história e, para minimizar esse evento, o ensino remoto emergencial tornou-se estratégia para retomada e continuidade das aulas. Nesse contexto, as Tecnologias da Informação e Comunicação (TICs) associadas às metodologias de aprendizagem ativa ganharam maior protagonismo para execução de atividades remotas. Este estudo objetivou relatar a experiência da aplicação de um escape room sobre o dimensionamento do quadro de profissionais de enfermagem no ensino de Pós-Graduação. Trata-se de uma metodologia de ensino-aprendizagem ativa e participativa, elaborada por meio da ferramenta Google Forms, em formato de escape room, com subtemas acerca do Dimensionamento de Pessoal de Enfermagem. A estratégia construída e relatada demonstrou ser viável para aplicação em diversos cenários de formação da enfermagem, Graduação, Pós-Graduação, bem como no contexto do trabalho, como educação continuada.

Palavras-chave
Educação em enfermagem; Recursos humanos de enfermagem hospitalar; Covid-19; Educação a distância; Gamificação

La pandemia de Covid-19 se caracterizó por la mayor interrupción del proceso de enseñanza-aprendizaje de la historia y, para minimizar ese evento, la enseñanza remota de emergencia pasó a ser la estrategia para la reanudación y continuidad de las clases. En este contexto, las Tecnologías de la Información y Comunicación (TICs) asociadas a las metodologías de aprendizaje activo obtuvieron mayor protagonismo para la realización de actividades remotas. El objetivo de este estudio fue relatar la experiencia de la aplicación de un escape room sobre el dimensionamiento del cuadro de profesionales de enfermería en la enseñanza de postgrado. Se trata de una metodología de enseñanza-aprendizaje activo y participativo, elaborado por medio de la Google Forms, em formato de escape room, con subtemas sobre el Dimensionamiento de Personal de Enfermería. La estrategia construida y relatada demostró ser viable para aplicación en diversos escenarios de formación de enfermería, graduación, postgrado, así como en el contexto del trabajo como educación continuada.

Palabras clave
Educación en Enfermería; Recursos Humanos de Enfermería Hospitalaria; Covid-19; Educación a Distancia; Ludificación

Introduction

The Severe Acute Respiratory Syndrome caused by Coronavirus-2 (SARS-CoV-2), the causative agent of Corona Virus Disease 2019 (Covid-19), reached pandemic level on March 11, 2020. Owing to its highly inter-human transmission, it has prompted changes across all sectors, directly affecting countries’ economies, generating an unprecedented global crisis, especially in the health sector, with overcrowding of services on a global scale^1,2.

In the higher education environment, the Covid-19 pandemic has been characterized by the largest interruption of the teaching-learning process in history, bringing to a standstill the education system worldwide, at least momentarily³. In order to minimize its effects, emergency remote teaching took center stage to resume and continue classes, with an emphasis on the use of Information and Communication Technologies (ICTs)⁴. In the Brazilian context, it is noteworthy that the Ministry of Education, through Ordinance No. 544 of June 2020, authorized, on an exceptional basis, the replacement of face-to-face with digital activities⁵.

ICTs can be defined as devices developed for the purpose of obtaining, storing and processing information that favors and facilitates communication and sharing between people. They have the potential to support a collaborative, critical and reflective teaching-learning process, enabling in this way the education of networked generations⁶.

ICTs are instruments to facilitate the learning process, but as they are a means of supporting the teacher, the educator’s ability to use them is the key factor that will determine the success of the training activity. When associated with active learning methodologies, they reflect the educator’s commitment to mediating learning, moving away from traditional education. It is worth pointing out that the adoption of active learning methodologies is not a passing, unreasonable pedagogical fad, since it has become consolidated as a horizon to be achieved, been even recognized in the National Curriculum Guidelines (DCN)^7,8.

Among numerous active and participatory learning methodologies, the learning trail stands out, defined as a systematic and multimodal set of learning units, with different navigation modes, which can range from linear, prescriptive models to more hierarchical models, with the possibility of reaching a network model, with free and personalized navigation for each student. These personalized navigation schemes, to the extent that variables such as learning objectives, student profile and learning characteristics are recognized, can help to develop competences^9,10. They allow to insert various learning activities and, when associated with digital media, present training itineraries that are closer to the student’s preferences and digital literacy¹¹.

Learning paths can be structured in the format of an “escape room”, a gamification strategy that can be used in teaching. Structured like a game, it is organized in such a way that the participating teams have the challenge of “escaping” the rooms by solving puzzles and challenges presented within a given time. In a fun and competitive way, the team uses clues, puzzles, riddles, crossword puzzles, among other challenges, to solve the proposed stages until they reach the final result, escaping from the room¹².

The escape room, popular among young people, allows students to learn through games in which there is competition (team versus team), but also collaboration (intra-team). In other words, when they are presented with a problem and work as a group to answer it, they need to establish consensus and make decisions collectively. Among many advantages, the escape room provides greater student satisfaction with the learning experience, exposing them to a certain degree of stress in a safe and controlled environment, developing skills and attitudes, encouraging teamwork, communication, creativity, active learning, as well as being valid for the acquisition of professional skills¹³.

A descriptive study in the nursing area showed that escape rooms stimulate learning in a fun way, as well as increasing student motivation, participation and engagement¹⁴. Another study showed that escape rooms enable students to gain more knowledge¹⁵.

In this report, the theme of the escape room was estimating the size of the nursing staff, a management tool included in the knowledge structure of nursing administration¹⁶. Its calculations allowed to estimate the number of professionals needed to carry out nursing activities in different categories. It should be noted that among five nursing work processes, the administration work process requires knowledge and tools to organize the work environment, and identifying the number of staff needed to provide care is of fundamental importance, being a subject of undergraduate nursing education^17,18.

Faced with the challenge of adopting active and participatory teaching-learning methodologies in the context of remote teaching during the Covid-19 pandemic, the question was asked: how can a learning trail in escape room format be used in the teaching-learning process? To answer this question, the study aimed to report the experience of applying an escape room as an active and participatory teaching-learning methodology on the subject of nursing administration.

Method

This is a study that reports on the experience of developing and applying an escape room in the area of teaching the administration of nursing services, focused on the estimations of nursing staffing numbers during the 2021 academic year. An experience report is a qualitative study that aims to describe an experience, phenomenon or process in detail¹⁸.

The proposal was conceived by two students linked to a postgraduate nursing program at a federal university, one for a master’s degree and the other for a doctorate, under the supervision of teachers from the Teaching Strategies in Nursing Administration subject, taught to postgraduate students.

Sequentially, the students, under the supervision of these teachers, went through the following construction process, shown in Figure 1 and described in detail below:

Figure 1
sequence of the construction of the proposal reported in this experience.

At the beginning of the subject “Teaching Strategies in Nursing Administration”, the postgraduates were asked, in pairs, to choose a topic belonging to the Knowledge Structure on Nursing Services Administration¹⁶ and an active and participatory teaching methodology to develop and apply in class to the other students enrolled in this subject. It was up to the postgraduate students to draw up a lesson plan and deliver it in up to 50 minutes, an activity proposed as part of the teaching development of postgraduate students.

The students, under the guidance of the lecturers, decided to work on the subject of “Estimating nursing staff numbers”, an essential management tool for health and nursing services, the purpose of which is to forecast the number and training of workers to directly or indirectly meet the nursing care needs according to the profile of the patients cared for in that service. The importance of this topic is justified by the understanding that proper calculation results in a reduction in mortality and adverse events and, consequently, has an impact on the quality and safety of care^18,19.

The choice of strategy associated with the topic was a consensus; in meetings for discussion and reflection, it was decided to use the escape room, in the form of a learning trail, which was considered suitable for encouraging student participation in the learning process. The escape room is a tool that encourages students to learn and follow the development of their own knowledge. In this strategy, students are kept inside a “room”, which can be physical or virtual, in which the aim is to escape; to do so, it is necessary to solve proposed puzzles, which, when solved, allow them to leave the room successfully and win²⁰.

One of the reasons for choosing the topic and methodology was precisely because it is a complex issue, but one that directly affects the daily life of health services, whether from the perspective of patients, the quality and safety of care or the health of workers. During the Covid-19 pandemic, this issue could be analyzed in the new context, through discussions about the ideal composition of nursing teams, in order to maintain the quality and safety of the care provided, both for patients and nursing professionals, which demonstrates that it is not an innocuous tool, but one that significantly interferes with the quality of care¹⁹. Furthermore, because it involves calculation processes, it is considered a complex subject by students.

The escape room, in the form of a learning trail on nursing staff sizing, seemed appropriate, given that it is an important and complex subject. It was justified by the stimulus for participation that the methodology allows, by stimulating learning in a fun and engaging way. However, the potential for replicating the methodology for other themes in the management work process was pointed out at every opportunity.

To develop the strategy, online meetings were held between the student proponents and the teachers via the Google Meet platform. The students searched for scientific articles and resolutions on which to base the escape room. They followed the Resolution of the Federal Nursing Council COFEN 543/2017²¹, which establishes the minimum parameters for sizing the number of professionals in the different nursing categories. The lesson plan was shared on Google Drive for joint preparation, as well as the construction of the escape room. The general objective of the lesson was to understand and be able to carry out the stages of calculating the size of the nursing staff in hospitalization units. The specific objectives were: to know and understand the Nursing Council resolution on nursing staffing size and to carry out the six steps for estimating the nursing staffing numbers.

The escape room was designed using the Google Forms tool, in the form of a learning trail, with stations divided into sections, called Rooms, as the aim was to escape from these rooms and progress towards solving the riddles. Thus, the escape room was structured into six themed rooms and 21 sections, with each room containing a sub-theme of the nursing staff sizing process: Room 1 (one) - Patient Classification System (SCP in the Portuguese acronym); Room 2 (two) - Average Daily Number of Patients (NMDP in the Portuguese acronym); Room 3 (three) - Total Nursing Hours (THE in the Portuguese acronym); Room 4 (four) - Marinho Constant (KM); Room 5 (five) - Total staff numbers and by category. Room 6 (six): escape room. The flow of the escape room can be seen in Figure 2 below:

Figure 2
Escape room - Estimating nursing staff numbers.

An objective question was prepared with four alternatives for each room, but only one of them was correct. In addition to the four statements, there was an option called “hint”, which students could use before selecting the alternative. Thus, if they chose the correct alternative, students would be directed to the next room and, if they chose the incorrect alternative, they would be directed to the Reinforcement Room, structured with content for revision. After browsing the content, the student could return to the escape room to continue.

The original proposal was for the escape room to be completed in up to 30 minutes, given that the target audience was undergraduate nursing students. Each question had a score of two points and could total 12 points at the end. If the group got the question wrong and went to the reinforcement room, 0.30 points would be deducted; in the event of an infraction, 0.30 points would also be deducted. Thus, with two scoring criteria, the winning team would be the one that “escaped” the room first (time) and also achieved the highest score (correct answers).

Once the escape room had been structured, it was evaluated by two judges with doctoral degrees who work in undergraduate nursing teaching in the area of administration and who use active learning methodologies. The evaluation by the judges consisted of going through the escape room as a student would and, at the end, answering a questionnaire that evaluated the chosen theme, the active learning methodology used, the content and the relevance of the activity, with space for suggestions and comments.

After the feedback, corrections were made by the proponents and, finally, the escape room was applied and tested in the classroom, in remote format, for postgraduate students, as an assessment product for the subject.

Results of the experience

The active and participatory methodology used for estimating the nursing workforce numbers proposed by postgraduate students was implemented in November 2021. At the time of implementation, 21 postgraduate students and four teachers participated. The student proponents presented the lesson plan, sent to the students in advance, along with supporting material for study, which included two scientific articles and the legislation on nursing staff sizing. Prior contact with the material covered in the synchronous moment, considering the flipped classroom, was not initially the focus of the approach, but was required so that the student had access to the content before the class, with individual instruction on prior reading²². Failure to study the topic beforehand would have had a negative impact on the implementation of the strategy and on student participation.

At the beginning of the lesson, a warm-up session was held, with questions about the steps involved in dimensioning using the “Mentimeter” tool. The aim of this dynamic was for the participants to remember the content and organize the steps of the sizing calculation in order to start the escape room.

At the end of this first approach, the rules and guidelines for participating in the escape room were read out and could be consulted at the start of the activity (Section 1). Once all doubts had been cleared up, the link to access the escape room was sent via the Google Meet chat platform and the class was randomly divided into four groups called: Florence Nightingale, Anna Nery, Dorothea Orem and Wanda Horta, nurses who have marked the history of the profession. Each group was accompanied by one of the teachers, who acted as a judge to observe and intervene whenever necessary, guiding the group so that they were able to take part in the activity.

Once the rules of the game had been presented, the participants were given access to Section 2, in which, in order to enter the themed rooms themselves, they had to decipher an access puzzle, structured in the form of a word search and related to the concepts and terms of nursing dimensioning. The correct answer was the intersection of the letters in the word search, which, once solved, directed participants to the next section, theme room 1.

The aim of Thematic Room 1, entitled “Patient Classification System (SCP)”, was for the participants to be able to apply one of the patient classification instruments in the literature for identifying workload (Section 3), that of Fugulin et al.²³. In the first thematic room, two of the four groups went straight to the Reinforcement Room (Section 4) because they had got the first answer wrong, and one of the groups asked for the “Hint” option. Both the Reinforcement Room and the Hint (Section 5) will decelerate progress in the escape room and therefore reduce the possibility of escaping in the first place. In addition to time, 0.3 points were deducted each time the group accessed one of these two options. In the Reinforcement Room of Thematic Room 1, the SCP²³ instrument was available with the respective degrees of nursing dependency, and in the Hint option of the same room, there was an explanation of how the calculation should be carried out.

Thematic Room 2, entitled “Average daily number of patients (NMDP) by degree of dependence”, derives from the compilation of data from the SCP applied, a number obtained by adding up the total score of patients of the different degrees of dependence, divided by the total number of days in the data collection period. The aim was for the participants to calculate this value (Section 6). At this stage, two groups asked for the Hint, thus reducing the possibility of escaping first. Section 7, “Reinforcement of Thematic Room 2”, presented the conceptualization of NMDP, and Section 8, “Hint”, described the calculation to be used.

In Thematic Room 3, entitled “Total Nursing Hours (THE)”, the aim was for participants to calculate THE considering the results of Thematic Rooms 1 and 2 (Section 9). At this stage, two groups requested the Hint. The Reinforcement of Thematic Room 3 (Section 10) presented the minimum reference for the nursing staff, according to COFEN Resolution 543/2017²¹, and the nursing hours per patient in the 24 hours of care. Section 11, “Hint”, described the calculation to be made.

In Thematic Room 4, entitled “Calculating the Marinho Constant (Km)”, the aim was for participants to calculate the Km, considering the proposed weekly working hours of nursing workers (Section 12). At this stage, two groups requested the Hint. Section 13, “Reinforcement of Thematic Room 4”, presented the concept of Km, and Section 14, “Hint”, described the calculation and the information needed to carry it out.

Finally, in Thematic Room 5, entitled “Number of nurses and high school professionals” (Section 15), the aim was to calculate the quantity of professionals (QP) for the hospitalization unit presented in the proposed case, the total number, without specifying by category. At this stage, one of the groups got the answer wrong and went to the Reinforcement Room; after returning to the room, they asked for the Hint. Another group initially asked for the Hint to answer, so one group lost 0.6 points and the other lost 0.3. Section 16, “Reinforcement of Thematic Room 5”, provided information on the importance of calculating the QP, and Section 17, “Hint”, described the calculation to be used.

Also in the same Thematic Room, Section 18 specifically presented the number of nurses and nursing technicians, together with the Reinforcement for the question (Section 19), which included the percentage distribution of professionals according to complexity of care. The Hint (Section 20) contained the definition of the composition of the nursing team for each type of care. The last Section (21) informed the participants that they had escaped from the room and reached the end of the activity, with an invitation for them to evaluate the proposed activity.

All the groups managed to start the escape room and decipher the initial riddle without difficulty. Thirty minutes after the start of the escape room, the four groups informed us that they had not yet finished the activity, so 15 minutes were added to their time. This was due to the fact that all the groups made use of the Hint and Reinforcement Room resources at some point during the activity, either because they had doubts or because they had chosen the wrong alternative.

Of the four groups, two managed to escape, successfully completing the trail; the other two were unable to finish, even with the extra time, and returned to the main Google Meet room. At the end, there was a time for discussion among the postgraduate students about the proposed activity, from a pedagogical point of view, achieving the objectives, participation and engagement.

As a final action, the graduate students proposing the escape room asked the participants to rate the activity on a scale between: Bad (1), Fair (2), Good (3) and Great (4). Considering the feedback obtained, the escape room proposal was considered successful and rated as excellent.

Discussion

Active and participatory methodologies are increasingly gaining traction in nursing education, as they are based on the premise that students play a central role in their education and that their participation, involvement and motivation are crucial for autonomous, critical and reflective learning. Having this in mind, the aim of this experiment was to present the power of a teaching strategy to be used in undergraduate nursing courses, built by postgraduate students under teacher supervision, illuminating possibilities for linking teaching training to undergraduate nursing courses, in addition to research development.

In this experience, the escape room was used as an active and participatory teaching-learning methodology, a proposal that is anchored in the recommendation of the National Health Council (CNS)²⁴ through Resolution 569 of December 2017, which approved Technical Opinion No. 300/2017. This document presents the general principles to be incorporated into the National Curricular Guidelines of health courses: “the use of diversified methodologies for the teaching-learning process, which favor student participation and autonomy” and also “integration between curricular contents, in order to enable collaborative and meaningful learning processes, based on action-reflection-action, based on technical, behavioral, ethical and political competencies”. In this sense, the proposal allowed students to be active participants in the construction of knowledge and teachers to adopt the role of facilitators of this process.

Active methodologies present different strategies for developing content, with the intention that it should be a more meaningful process for the student, encouraging them to take a leading role in the construction of knowledge in a critical-reflective way, while the teacher plays the role of teaching-learning facilitator²⁵. In these methodologies, formative assessment is indicated, which allows students’ difficulties to be addressed, and it is up to the teacher to identify alternatives to continuously improve their development²⁶.

It should be noted the implementation within the context of the Covid-19 pandemic and, therefore, the proposal’s suitability for remote teaching, considering the possibilities and limitations inherent in the very distancing of nursing training. One study found that, after some time in remote activities during the pandemic, students showed a lack of interest and motivation to get involved in teaching strategies²⁷. The escape room could be a strategy to reverse this lack of interest and improve engagement.

It is noteworthy that the topic “Estimating nursing staff numbers” was structured with questions that reflected real problems and situations. However, in addition to the calculation, the questions were designed to stimulate debate on the implications for the quality and safety of patient care, as well as for workers, with regard to the number of professionals appropriate to the workload. In short, the subject of sizing is very powerful for discussing other perspectives of the nurse’s work process: managing.

In the proposed escape room, the teacher took on the role of mediator and supporting actor. Although the teacher was present throughout the activity, the centrality of the action was in the process to be followed by the group of students.

The same strategy, but called escape zoom in another study, was analyzed in a study with nursing students, and a high level of agreement was identified regarding the fact that the strategy favors active and collaborative learning, promoting a different form of learning and teamwork. The students recommended expanding it to other subjects²⁸.

Among the numerous teaching-learning strategies using active and participatory methodologies, studies show that the main ones used in Brazil in the online teaching modality are: Problem-Based Learning (PBL), flipped classroom, peer instruction, gamification, case study, simulation, seminar, virtual learning object (VLO) and problematization with the Maguerez Arc⁸.

It should be noted that the escape room also fits the definition of a VLO, i.e. it is a digital resource that meets a set of characteristics, standards and forms, built in stages, with the primacy of thinking about the learning objectives considering the virtual space. It is recommended that, based on well-established objectives, virtual learning objects enable students to exercise, analyze and interpret concepts and content in an interactive and collaborative way. There are countless ways in which they can be applied in the teaching environment, such as using videos, figures, graphics, cartoons, among others⁹.

It should also be noted that the limitation of the experiment was the inadequate time frame. It was planned that the students would take 30 minutes to complete the activity; however, it was necessary to readjust it at the time of implementation. In the end, even with the extended time, only two of the four participating groups managed to finish and send in their answers, escaping from the room. Another limitation was that, for the initial orientation and presentation of the game rules and scores, all the students had to be present. Delays or late entries at the beginning of the lesson compromised the progress of the activity.

Conclusion

The escape room proposal, as built and implemented by postgraduate students under the format of a learning trail, proved to be a relevant teaching-learning strategy to be used in the context of the Covid-19 pandemic, in remote teaching, with possibilities for application in undergraduate nursing, postgraduate nursing, as well as in the continuing education of nurses. The proposal offers an active and interactive experience, especially with regard to the knowledge structure of nursing administration, which has promoted student engagement by putting them at the heart of the process and requiring them to solve the challenges presented in order to “escape” the room.

The escape room is considered to have triggered engagement and approached the topic in a relaxed way, and was evaluated positively by the participants. In addition, the success of the proposal was linked to previous contact with the subject, either through the inverted classroom or through warm-up exercises, although other forms could be adopted, such as a dialogical presentation.

As a teaching-learning strategy, it is suggested that the escape room be evaluated for its effectiveness in future research and in other scenarios, in order to contribute to the understanding of its applicability in the teaching and learning process.

ACKNOWLEDGMENTS

To the students and teachers of the postgraduate course involved in this report and to the teachers who acted as judges.

• Lima TAB, Volpati NV, Gonçalves GCS, Draganov PB. The use of escape room to estimate staffing numbers of nursing professionals: report on the postgraduate teaching experience. Interface (Botucatu). 2025; 29: e240571 https://doi.org/10.1590/interface.240571

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Edited by

• Editor
  Tiago Rocha Pinto

• Associated Editor
  Marta Quintanilha Gomes

Publication Dates

• Publication in this collection
  24 Mar 2025
• Date of issue
  2025

History

• Received
  28 Aug 2023
• Accepted
  15 Oct 2024