Effects of a web-based serious game on postpartum hemorrhage management knowledge, self-efficacy, and self-regulated learning: a randomized controlled trial among nursing students in western Türkiye

Evidence on web-based serious games for low-frequency obstetric emergencies remains limited. This study evaluated a serious game for postpartum hemorrhage (PPH) management and explored indirect associations through self-efficacy and self-regulated learning. This two-arm randomized controlled trial was conducted from October 2025 to January 2026 in the nursing department of a public university in western Türkiye. Using census recruitment, all 159 eligible third-year nursing students were invited; 120 consented and were randomized 1:1. Both groups received three 40-minute theoretical sessions. The intervention group additionally completed an individual, self-paced, 30–50-minute browser-based serious game featuring a single branching PPH scenario, clinical decision-making, and immediate physiological feedback. Data were collected using a descriptive information form, the Postpartum Hemorrhage Management Knowledge Assessment Form, the Postpartum Hemorrhage Management Self-Efficacy Assessment Form, and the Self-Regulated Learning Scale for Clinical Nursing Practice. Knowledge was treated as the primary outcome, whereas self-efficacy and self-regulated learning were treated as secondary outcomes. A blinded analyst performed baseline-adjusted ANCOVA and exploratory indirect-effect analysis using IBM SPSS Statistics version 27.0 and PROCESS macro version 5.0 (Model 4; 5,000 bootstrap samples). For the primary outcome, the intervention group had significantly higher adjusted posttest knowledge scores than the control group (adjusted means: 13.27 vs. 11.78; adjusted mean difference = 1.49, 95% CI [0.77, 2.21], p < .001). Supportive secondary analyses also indicated higher self-efficacy (39.46 vs. 37.29; adjusted mean difference = 2.17, 95% CI [0.63, 3.71], p = .006), and self-regulated learning (66.23 vs. 62.70; adjusted mean difference = 3.53, 95% CI [0.63, 6.43], p = .017). The exploratory indirect-effect analysis identified a statistically significant indirect association through self-efficacy between group allocation and post-intervention knowledge (indirect effect = 0.27, 95% bootstrap CI [0.03, 0.68]), whereas the indirect association through self-regulated learning was not statistically significant (indirect effect = -0.03, 95% bootstrap CI [-0.24, 0.19]). Adding the serious game to theoretical instruction was associated with higher immediate posttest knowledge, task-specific self-efficacy, and self-regulated learning scores. Because the control condition was not time- and attention-matched, the findings do not isolate game-specific effects or establish retention, transfer to clinical performance, or causal mediation. ClinicalTrials.gov, NCT07229573 retrospectively registered on 13 November 2025.