Adaptive Gamification in Obstetric Nursing

The main outcome variable will be academic performance, LG, understood to reflect new knowledge acquired on the subject under study. The degree of assimilation of the theoretical and practical concepts of pregnancy and childbirth in each of the four clinical cases will be evaluated. To this aim, an "ad hoc" questionnaire comprising 40 multi-ple-choice questions was designed by the PI, who is a certified Nurse Specialist in Obstetrics and Gynecology (Midwife) and the lecturer in charge of the class. The items were constructed to strictly align with the specific curricular contents and learning ob-jectives of the 'Reproductive Health' syllabus. To ensure external content validity prior to administration, this initial draft will be reviewed by an external panel of five experts (three academic midwives and two obstetricians). Regarding reliability, since this is a pilot study, internal consistency and item analysis will be calculated post hoc to validate the instrument for future trials.

The students' subjective perception of the usefulness, fun, and moti-vation generated by the activity will be evaluated using the Gameful Experience Scale (GAMEX). This validated 27-item instrument in Spanish is suitable for measuring game experience in nursing students' training. It uses Likert-type re-sponses to measure the multidimensional nature of the gamified experience in the educational context. The six dimensions include enjoyment, abstraction, creative thinking, activation, absence of negative effects, and mastery. This model demonstrated high overall reliability, with a Cronbach's alpha of 0.85. The scoring format uses a five-point Likert scale. In the proposed study, measurement will be con-ducted exclusively at the end of the intervention (Session 4) to capture the students' overall perception of the program. Prior to analysis, items with negative wording (reverse punctuation) will be recoded so that higher scores consistently reflect a more positive.

Age is understood as the time that a person has lived, counting from birth to the time of the survey, measured in whole years; sex is understood as a variable that refers to the social and cultural construction that defines the roles, behaviors, activities, and attributes that a society considers appropriate, with the answer options male, female, and non-binary; and the average grade considered to mean the average grade achieved in the first year of the nursing program to monitor the differences between the groups.

The students' psychological and behavioral predisposition to game dynamics and narratives will be assessed using the PPDS in its validated Spanish version. The PPDS is a psychometrically validated instrument composed of 21 items rated on a six-point Likert scale specifically designed to identify player pro-files in the context of educational gamification based on narratives to measure the frequency of certain behaviors, where 1 means "Never" and 6 means "Always". After a student completes the questionnaire, the system does place them in a single cat-egory but generates five independent scores, one for each profile, showing which of the following profiles they align with the most: Tryhard (achievement- and com-petency-oriented); Coacher (oriented toward leadership and help); Esthetic (narra-tive and visual beauty-oriented); Joker (oriented to humor and surprise); or Toxic (a technical gamification term referring to players oriented toward testing system limits, seeking loopholes).