Escape rooms in Medical Education: Deductive Analysis of Designs, Applications and Implementations

Abstract Background: Serious games are conceptualized as a broad topic and overlap segments of more modern forms of education: e-learning, edutainment, game-based learning, and digital game-based learning. Serious Games aligns with digitalization and the modern era and creates novel opportunities for learning and assessment in medical education. Escape rooms, a type of serious games, merge mental and physical aspects to reinforce critical skills useful in daily life. It challenges logic and reasoning and demands careful analysis of situations to correlate and solve different stages of the escape room under pressurized, timed conditions. Furthermore, it serves as an adequate environment to build problem-solving skills, communication skills, and leadership skills through the collaboration of people to achieve a common goal. The aim of this study was to investigate the applications of escape rooms in Medical Education.


Introduction
As of today, serious games have become very popular and combine entertainment with cognition. It is an exceptional concept that may be found slightly challenging to grasp. By isolating the two terms, "game" and "serious", we are provided with a greater insight into this topic.
Referring to the Oxford Learner's Dictionaries [1], the term "game" [2] is defined as "an activity that you do to have fun, often one that has rules and that you can win or lose". This signifies that games encompass a physical activity with an entertaining mental activity. However, an alternative definition states that games are "a sport with rules in which people or teams compete against each other", which may be misleading within this context as the gamification of learning requires effective collaboration, instead of opposition, to achieve a collective goal. "Serious" [3], similar to "game", has multiple definitions, and the correct interpretations should be identified for deeper understanding. An example of an inaccurate interpretation is "bad or dangerous", and although there may be some limitations to serious games, it is generally accepted as a successful learning method. Given the context, it may be explained that "serious" means "needing to be thought about carefully; not only for pleasure" and "that must be treated as important". [4] Hence, serious games are games used for purposes other than entertainment, to allow for experiences that are difficult to create in the real world due to "safety, costs, time, etc." [5], that "may be significant without being solemn, interesting without being hilarious, earnest and purposeful without being humorless and difficult without being frustrating" [4], and this peculiar oxymoron encapsulates the modernization of education.
Serious games are conceptualized as a broad topic and overlap segments of more modern forms of education: e-learning, edutainment, game-based learning (GBL), and digital game-based learning (DGBL) [5] According to Allison Rossett, "the concept of e-learning has been described as a revolution, providing new approaches to learning and performance improvement" [6]. However, today, this concept is familiar due to the impact of covid-19 and uses interactive technology to continue education in unfavorable circumstances.
Edutainment is regarded as an ancient form of education, and it aimed to exhibit education through entertainment. Vastly popular in the 1990s, Zühal Okan explains that "in the rush to adopt this new seemingly harmless technological fad, both educators and parents overlooked its long-term harmful effects." [7] This has caused it to lose its purpose and become obsolete. Examples of these are TV shows with entertaining characters that teach viewers ('Barnie', 'Dora the explorer', etc.), certain board games ('scrabble', 'sudoku', 'monopoly', etc.), and many other forms. Annie Pho and Amanda Dinscore proposed that "Game-based learning refers to the borrowing of certain gaming principles and applying them to real-life settings to engage users" [8] This is a section of serious games that adopts gaming models to fulfill key learning outcomes through "engagement, motivation, role-playing, and repeatability" [5] Types of GBL activities may include escape rooms and role-play scenarios.
Digital game-based learning extends further from GBL and is a method that "incorporates educational content or learning principles into video games to engage learners", Heather Coffey narrated. [9] DGBL also incorporates aspects of immersive learning to create a virtual learning environment. Some examples could be video games like 'the sims', virtual escape rooms, and extended reality, consisting of virtual, augmented, and mixed reality.
With the rapid rate of digitalization of technology and the more recent introduction of gamification, serious games have been proven to be a successful form of learning. Referring to Linda Stege, Giel van Lankveld, and Pieter Spronck's investigation on whether serious games support learning processes, they tested two groups of individuals who received information via text against serious games. They concluded that "serious games can be more effective in learning processes than written texts, but that they do not necessarily motivate students better than a textbook." [10] Overall, serious games are viewed as prosperous through their captivating, cognitive, alluring fashion, instant interaction with the players, and their capability to compose intricate schemes. [11] This review focuses on escape rooms as a type of serious game with the implication of GBL and DGBL.
Over the last decade, escape rooms have flourished in popularity among society, and it serves as a recreational activity for leisure. It, more recently, is being used for teaching and training in educational purposes as a form of GBL and DGBL. It's a collaborative effort in which a group of people is faced with a challenge to overcome, a hidden solution needed to be found, and a reward for overcoming the challenge. [12] Escape rooms display an array of puzzles and can be set up in three ways: linear path, open path, and multilinear path. [12] • The linear path proposes that tasks should be completed in a particular order as a supervised training method and is the simplest form of an escape room. • The open path design introduces a series of puzzles that can be completed in any arrangement and is seen as more complex than the linear path as there is no direct indication of where to start and multiple pathways can be generated for one solution, and they are connected via a metapuzzle (a puzzle that has many puzzles leading into it) • The multilinear path design is the most comprehensive yet challenging type of escape room and incorporates aspects of both the linear and open path designs; it presents puzzles that can be executed parallel to one another and delivers multiple starting and finishing points in the game based on player decisions.
In addition, escape rooms merge mental and physical aspects to reinforce critical skills useful in daily life. It challenges logic and reasoning and demands careful analysis of situations to correlate and solve different stages of the escape room under pressurized, timed conditions. Furthermore, it serves as a adequate environment to build problem-solving skills, communication skills, and leadership skills through the collaboration of people to achieve a common goal.
The simulation of an escape room in education helps to solidify previously attained knowledge through the applications to virtually real-life scenarios. The gamification concept of learning aids the ability of students to engage in practical tasks and thus aids in achieving and implanting necessary learning objectives. [13]- [15] The objective of this research is to address: • What medical fields use escape rooms in education?
• How were the participants structured?
• What type of simulation experience was used?
• How were the escape rooms designed?

Method
Based on previously acknowledged keywords: serious game, escape room, linear path, open path, multilinear path; we searched google scholar identifying the applications of escape rooms in medical education and categorized them accordingly. As described in a similar study reviewing the use of escape rooms in education, "some authors use the term "breakout room" as a synonym for an escape room and narrower terms such as "escape game," "serious escape room," and "breakout box."" [16].
In this research, we reviewed the first 100 hits in Google Scholar with the keywords; ["escape room" AND "medical education"] and synthesized the data. After removing duplicate articles and all immaterial content that doesn't comprise medical applications, a combined 72 articles were analyzed: two from 2017, nine from 2018, twenty from 2019, nineteen from 2020 and twenty-one from 2021. [16] Results Through our analysis, we have decided to categorize the information into the year in which the article was published, the specialty in the medical field, the participant structure, grouped or individual, the experience design; real, hybrid, or digital, and the modality of the delivery. The table below provides an extensive report using the before mentioned categories.

72
Development of an innovative educational escape game to promote teamwork in dentistry [81] Medical fields where escape rooms are used for education Based on the 72 articles, we categorized the escape rooms by the field it was created for. We found out that most of the escape rooms were concerned with nursing education (Number: 18; Percentage:25.0%) and emergency medicine (Number: 16; Percentage:22.2%) and followed by pharmacy (Number: 9; Percentage:12.5%), and interprofessional healthcare education (Number: 9; Percentage:12.5%), totaling 72.2% of the fields examined. Table 2 and Figure 1 depict this information further.   Group vs. Individual based escape rooms Upon synthesizing, we recognized keywords to determine whether the escape room was done as a group or as individuals to create Table 3 and Figure 2. For grouped escape rooms it was generally specified, however occasionally, we had to confirm this by studying the articles' results and thesis for the skills attained by participants; if team building and collaboration skills were received by the participants, they were also selected as grouped escape rooms. 100% of the 66 identified escape rooms were grouped (91.7%) while 6 rooms; 8.3% could not be verified due to the lack of data.   , and a possible reason will be acknowledged in the discussion. As well, in total, 42 or 58.3% of the escape rooms were real, 17 or 23.6% unidentified, 11 or 15.2% digital and 2 or 2.8% mixed, however, more digital escape rooms were identified in 2021, and this will be discussed later. The following table and figure depict this information.

Discussion
Escape rooms are a newer concept and have started being integrated into aspects of medical education. Table 2 and Figure 1 illustrate the fields of medicine that our selected 72 articles contained. The lower percentiles consist of the areas: radiology, dermatology, surgery, core medical training, non-technical, genetic analysis, obstetrics, internal medicine, mental healthcare, patient safety, gastroenterology, infection prevention, dentistry, chemotherapy, and nutrition education, and this may indicate the recent divergence of escape rooms. However, based on our assessment, escape rooms are more commonly used for nursing education, emergency medicine, pharmacy, and interprofessional healthcare. This may be because these fields required essential skills such as "communication", "team-building", "multi-tasking", "critical thinking" and "rapid recall of extensive medical knowledge" [28], [32], [44], [45] and that escape rooms are an engaging method that provides a safe, simulated environment to build and enhance these skills.
Furthermore, Table 3 and Figure 2 signifies not only the importance of teamwork and collaboration skills in the four medical categories in the previous paragraph, but for all other categories too (as all identified escape rooms were grouped based), and it establishes the magnitude of teamwork in medicine and the necessity of implementing it into medical education.
From Table 4 and Figure 5, we are provided with trends linking the type of escape room design with the year. From the total (row), we understand that for all identified designs, there was an equal number of linear and open escape rooms but fewer multilinear rooms. This may be due to the different objectives of the escape rooms. According to Anson Dinh's escape room, their objective was "to improve the clinical knowledge and teamwork skills of medical students" [37], and therefore it didn't require a multitude of parallel puzzles, as they intended to strengthen the core knowledge. Similarly, another linear escape room stated that they intended "to reinforce EM knowledge and professional skills in a fun, team-based, "escape room" style game." [46] Contrastingly, in an exemplary multilinear escape room, their "team-based simulation of an escape room successfully reinforced (their) hospital's patient safety priorities", alluding to their objective being to simulate real circumstances through a "complex active learning session". [27] Additionally, to elaborate on the distributions of escape rooms by year, the total (column) signifies a general increase in the articles published about escape rooms from 2017 to 2021. This may represent the accumulating interest in serious games and escape rooms for medical education. It demonstrates vast success in the modern era and serves as a new and innovative way to support learning.
Moreover, the further categorization, including the simulation experience, further denotes significance. Best illustrated by figure 4, there are trends concerning whether the escape room is digital or real. Up until 2021, there was a standard increase in the number of real escape rooms and no increase in the number of digital escape rooms. However, in 2021, the number of real escape rooms has not yet peaked as time remains for more projections, while the number of digital escape rooms is greater than the other years. Thus, it may be interpreted that the influence of the unfortunate calamity of covid-19 has encouraged the digitalization of escape room games to promote the vital medical objectives in an alternative environment. To verify this, more research should be conducted on whether covid-19 is the main contributing factor to the digitalization of escape rooms for education and how this technique compares in efficacy to real, physical escape rooms.

Conclusion
Therefore, gamification is a concept that aligns with digitalization and the modern era and creates a suitable and enjoyable method of education. The field of serious games has been integrated into learning strategies, and one approach is the usage of escape rooms. We researched and categorized the first 100 hits, in google scholar, of escape rooms used for medical education and analyzed this data. To consolidate the usage of escape rooms in medical education, their general purpose has been to progress interpersonal skills: leadership, teamwork, etc. that are crucial in medical circumstances, to enhance critical thinking and the capability of working under pressure, to solidify key knowledge to support rapid recollection of medical information and applications, and to manage stress to increase confidence and motivation for the student's future careers. From our results, escape rooms have the potential to expand in medical and all education and are promising alongside the progression of technology in the future.