Improving Knowledge and Confidence in DKA Care: Escape Room Simulation for New Grad Nurses

Abstract

PURPOSE: New graduate nurses entering the emergency department (ED) at a Level 1 trauma center often report limited confidence in managing diabetic ketoacidosis (DKA) after orientation. Current orientation relies on handouts and case studies; however, educators observe ongoing difficulty in independently managing DKA patients. Evidence supports simulation-based education as a strategy to improve clinical judgment, competence, and self-efficacy. This project aimed to improve new graduate nurses’ knowledge and confidence in DKA management by incorporating an escape room simulation during orientation. Outcomes were evaluated using pre- and post-test comparisons. METHODS: This quality improvement integrated an escape room simulation during new graduate orientation. Participants completed a pretest, DKA education and a guided case study. At the end of orientation, new grad nurses participated in a timed, scenario-based escape room requiring identification of abnormal laboratory values, initiation of appropriate interventions, and application of the DKA flowsheet. Pre- and post-tests were administered, and performance metrics such as completion time were collected. Descriptive statistics were used to compare pre- and post-intervention outcomes. RESULTS: Implementation of a simulation-based DKA escape room was associated with improvements in knowledge and confidence among new graduate ED nurses. Baseline findings demonstrated limited prior exposure to DKA, indicating a knowledge gap in management. Nine matched participants demonstrated improvement across nearly all assessment items, with mean knowledge scores increasing from 5.44 to 8 out of 11. Confidence ratings improved across all domains, including DKA management, insulin initiation, and use of the standardized DKA flowsheet. One knowledge item declined slightly post-intervention, possibly reflecting ambiguity or cognitive overload during the 30–45-minute simulation. These findings align with evidence supporting simulation-based education. IMPLICATIONS FOR PRACTICE: A simulation-based escape room offers a scalable, low-cost strategy to enhance knowledge and confidence among new graduate nurses. This approach supports transition to independent practice, promotes patient safety, and is adaptable to other high acuity clinical pathways while supporting sustainable integration of evidence-based education into orientation programs.