Digital Escape Room Game for Hypovolemic Shock Management: A Mixed-Methods Study in Nursing Education
Phase: NA
Conditions: Nursing Education, Hypovolemic Shock
Sponsor: Baskent University

Title: Digital Escape Room Game for Hypovolemic Shock Management: A Mixed-
Methods Study in Nursing Education 
NCT number: NCT07204899 
Date of the document (reviewed by a human subjects protection review board): 6.05.2025 
 
Study Protocol: 
Methods 
Study design 
This study employed an explanatory sequential mixed-methods design. A randomized 
controlled trial design was used in the quantitative phase. The experimental group participated 
in an online escape room intervention, while the control group received traditional lecture-based 
instruction. Quantitative data were collected to evaluate the effect of the intervention on 
students’ knowlegde level and satisfaction. 
Following the quantitative phase, a purposive sample of students from the experimental 
group was invited to participate in focus group interviews. The qualitative phase was conducted 
to explore students’ perceptions and experiences in greater depth, providing contextual insights 
into the mechanisms underlying the quantitative results. Integrating the two phases allowed for 
a more comprehensive understanding of the educational impact of the online escape room 
intervention, combining measurable outcomes with rich narrative accounts. 
Setting and participants 
The study was conducted between June and July 2025 with third-year nursing students 
enrolled at a foundation university in Ankara, Türkiye. Students were invited to participate 
through an in-class announcement, and the inclusion criterion was being a third-year nursing 
student who provided informed consent.  
Power analysis was performed using G*Power 3.1 (F tests, repeated measures 
ANOVA—between-group effect). Based on two groups and three measurement points, a 

repeated measures correlation of 0.50, an effect size of f=0.35, a two-way 𝛼=0.05, and a power 
of 1−𝛽=0.80, the required total sample size was calculated as 𝑁=46 (23 participants in each 
group). Considering possible attrition, a total sample size of 30 participants was planned for 
each group. Accordingly, 58 volunteer students were recruited for the quantitative phase and 
randomly assigned to either the intervention or control groups. For the qualitative phase, 12 
students were purposively selected from among those who had participated in the quantitative 
phase. In addition, nurse educators with at least five years of experience in teaching and 
mentoring students were included as participants. Data collection for the qualitative phase was 
carried out through focus group interviews and continued until no new themes emerged, 
indicating thematic saturation. 
Randomisation and Blinding 
Eligible participants were randomly assigned to either the experimental group, which 
received the digital escape room game intervention, or the control group, which received 
traditional classroom-based education, in a 1:1 allocation ratio. Randomisation was performed 
using 
an 
online 
random 
sequence 
generator 
(Research 
Randomizer, 
https://www.randomizer.org/) by an independent statistician who was not involved in 
participant recruitment, intervention delivery, or outcome assessment.  
Given the nature of the interventions, blinding of participants and facilitators was not 
feasible. However, to minimise performance and detection bias, outcome assessors and data 
analysts remained blinded to group allocation throughout the study. All data were coded 
anonymously, and statistical analyses were conducted using coded identifiers (Group A/Group 
B) until the final interpretation phase. 
Pre-application of the study  
A preliminary application was undertaken to assess the clarity, feasibility, and 
functionality of both the data collection instruments and the digital escape room game. This 

stage was conducted with 10 fourth-year nursing students enrolled in the 2024–2025 academic 
year. Participants were asked to complete the data collection forms, engage with the escape 
room game, and provide structured feedback regarding the comprehensibility of the forms, the 
usability of the game design, and the alignment of tasks with the intended learning outcomes. 
Based on the feedback obtained, minor revisions were made to enhance the precision of 
the data collection tools and to optimize the flow and instructional components of the game. 
Following these adjustments, both the instruments and the game were finalized for the main 
study. To maintain methodological rigor and avoid potential bias, students who participated in 
the pre-application were excluded from the final sample. 
Implementation phase of the study 
All students who agreed to participate first completed the Sociodemographic 
Information Form, followed by the Hypovolemic Shock Information Form as a pretest. After 
the pretest, all participants received a two-hour traditional lecture on hypovolemic shock and 
nursing management. The lecture covered the following topics: definition, etiology and risk 
factors, pathophysiology, clinical findings and diagnosis, medical treatment approaches, 
nursing care and processes, nursing diagnoses and interventions, patient education, and 
psychosocial support. Students were then randomly assigned to either the intervention or 
control group, ensuring comparable mean pretest knowledge scores. 
Control Group (n = 28): In addition to the two-hour theoretical training, no further 
intervention was provided. Immediately after the lecture and again one month later, students 
completed the Hypovolemic Shock Information Form as a posttest. After completion of the 
study, control group participants were also given the opportunity to experience the digital 
escape room game. 
Intervention Group (n = 27): Following the pretest and theoretical training, students 
played a digital escape room game on hypovolemic shock and nursing management developed 

by the researchers using the Genially platform. The design and procedures of the game are 
detailed in the “Experimental procedure” section. Immediately after the intervention and again 
one month later, students completed the Hypovolemic Shock Information Form as a posttest. 
In addition, the GAMEX (Game Experience) Scale was administered, and a subset of students 
participated in a focus group interview. 
Experimental procedure 
This study was conducted with third-year undergraduate nursing students to evaluate 
knowledge and management of hypovolemic shock. It comprised two stages: (1) development 
and implementation of the HYPSEM ERG, and (2) testing the game and assessing outcomes. 
Stage 1: The HYPSEM (HYPovolemic Shock EMergencies) ERG was developed, introduced 
to students, and made available for one week. 
Stage 2: Upon completion, students’ knowledge and satisfaction were evaluated. 
HYPSEM game procedure 
HYPSEM is a web-based digital escape room addressing hypovolemic shock (HVS). It 
was designed to examine whether escape rooms enhance motivation to learn about HVS. 
Development on the Genially platform enabled the creation of interactive click-and-point 
rooms, fostering engagement. Hosting the game online ensured universal access without spatial 
or temporal constraints. 
Implementation proceeded as follows: 
● Students first received a face-to-face briefing in which the designer introduced escape 
rooms, explained the Genially platform, and outlined the collaborative structure of the 
game. 
● They were then given one week to play individually at their convenience. 

● The designer shared contact information to provide technical support. Students could 
request unlimited hints and were reassured that feedback would be available even 
without prior experience. 
● After successfully completing the final test and exiting the escape room, students filled 
out a post-test questionnaire. 
Escape room design 
HYPSEM simulates a hospital room scenario involving a patient with hypovolemic 
shock, requiring students to access essential information from the patient’s file to prevent 
adverse 
outcomes. 
The 
game 
can 
be 
accessed 
via 
Genially 
( 
https://view.genially.com/685bc3f26dbc4e0ec352beb0/interactive-content-hastaneden-kacis-
oyunu). 
Students had 15-20 minutes to solve six puzzles. Content aligned with prior lectures, 
practice sessions, and case studies; no new information was introduced during gameplay to 
facilitate smooth progression. Access was provided via QR code. The game opened with a 
clinical narrative, followed by rules, instructions, and symbol explanations. 
The puzzles included multiple-choice, true/false, sequencing, and clinical reasoning 
tasks related to shock type, stage, management, and nursing interventions. Clues were drawn 
from patient files, physical examination findings, laboratory results, and vital signs. Incorrect 
responses triggered warning signals as feedback. A countdown timer imposed time constraints, 
and hints were embedded in items such as the patient file, behind a door, an electrocardiograph, 
a medication bag, and above a cupboard. Successful management of the patient and hospital 
exit designated students as “heroes.” Students could replay the game without restriction during 
the one-week study period. 
Data collection 

Data were collected face-to-face and via Google Forms between June 2 and July 20, 
2025. In this study, multiple instruments were employed to assess students’ knowledge of shock 
management, their satisfaction with the game, and their perceptions of the digital escape room. 
Quantitative data  
Sociodemographic Information Form 
Sociodemographic data, including participants’ age, gender, and prior experiences, were 
collected using a form developed by the researchers based on the literature (Bonaduce, 2024; 
Şat et al., 2025). 
Hypovolemic Shock Information Form 
A 20-item true-false test was administered to measure students’ theoretical knowledge 
of hypovolemic shock. The form was reviewed by seven field experts to establish content 
validity and was administered both as a pretest and a posttest. 
GAMEX (Game Experience) Scale 
Students’ experiences with the digital escape room were evaluated using the 27-item, 5-
point Likert-type GAMEX scale (Eppman et al., 2018). The instrument comprises six subscales: 
enjoyment, absorption, creative thinking, involvement, absence of negative effects, and 
dominance. The Turkish adaptation was validated and found reliable by Arıkan Dönmez et al. 
(2024). Scale scores range from 27 to 135, with higher scores indicating a more positive gaming 
experience. Cronbach’s alpha was 0.93 for the total scale, and subscale alphas ranged from 0.67 
to 0.929. 
Qualitative data 
Focus group discussions with students and facilitators were organized within one week 
after the completion of the HYPSEM game. The sessions were held via the Zoom video 
conferencing platform and followed a semi-structured interview form. Three female researchers 
with expertise in qualitative research served as moderators to ensure both consistency and depth 

of the discussions. The interview form consisted of four open-ended questions addressing 
participants’ expectations prior to the game and whether these were fulfilled, the emotions they 
experienced during the activity, the game’s contribution to their learning (e.g., knowledge, 
practical skills, decision-making), and their opinions on the broader use of digital escape room 
games in nursing education. The discussions explored not only students’ experiences and 
perceptions of the usefulness of the HYPSEM game, but also their suggestions for areas of 
improvement. Each focus group included three to five participants and lasted between 45 and 
80 minutes. All sessions were audio-recorded and subsequently transcribed verbatim. 
 
Statistical Analysis Plan (SAP): 
Quantitative data analyses were conducted using IBM SPSS Statistics version 25. 
Descriptive statistics (mean, standard deviation, minimum, and maximum) were calculated for 
all study variables. The internal consistency of the GAMEX scale and its subdimensions was 
assessed using Cronbach’s α coefficients. 
To evaluate baseline equivalence between groups, independent samples t-tests were 
performed. The effectiveness of the intervention over time was examined using a repeated-
measures analysis of variance (ANOVA) with one within-subjects factor (time: pre-test, post-
test 1, post-test 2) and one between-subjects factor (group: GAMEX vs. control). Mauchly’s 
test of sphericity was applied to verify the assumption of sphericity, and where violations 
occurred, the Greenhouse–Geisser correction was used. Effect sizes for ANOVA results were 
reported as partial η². 
In addition, Bonferroni-adjusted pairwise comparisons were conducted to explore 
differences across the three time points within each group. Independent samples t-tests were 
also carried out at each measurement point to assess between-group differences. For these 
comparisons, Cohen’s d values were calculated to estimate the magnitude of differences (0.2 = 
small, 0.5 = medium, 0.8 = large). Statistical significance was set at p < .05 for all analyses. 

Qualitative data were derived from audio-recorded focus group discussions, which were 
transcribed verbatim and analyzed thematically following Braun and Clarke’s (2006) six-phase 
framework: (1) familiarization with the data, (2) generating initial codes, (3) searching for 
themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. 
Coding was independently conducted by two researchers using MAXQDA Analytics Pro 2022 
software. Codes were then grouped into subthemes based on similarities, and consensus was 
reached through regular discussions and deliberations. A third researcher verified themes, and 
the entire research team engaged in reflective discussions to enhance interpretive rigor. To 
ensure trustworthiness, Lincoln and Guba’s (1985) criteria were applied: credibility through 
peer debriefing and researcher triangulation; dependability through independent coding; 
confirmability via detailed documentation and audit trails; and transferability through thick 
description of the study context and the inclusion of direct participant quotations. Data 
collection and analysis were concluded once thematic saturation was reached. 
Mixed methods analysis/Data triangulation /Data integration 
After separately analyzing quantitative and qualitative data, integration was carried out 
to achieve a comprehensive understanding of the research problem. Mixed methods integration 
enables the examination of convergence and complementarity between different forms of 
evidence, thereby increasing the validity and robustness of the study (Creswell & Plano Clark, 
2018; Fetters et al., 2013). Data triangulation was employed to mitigate the limitations of 
relying solely on a single method and to ensure that both measurable outcomes and contextual 
insights were considered in addressing the research objectives. In this study, integration was 
pursued not to duplicate findings but to provide methodological rigor, support the credibility of 
interpretations, and generate a more holistic view of the educational impact of the digital escape 
room intervention (Guetterman et al., 2015; McCrudden et al., 2021).