Effectiveness of Gamification with a Narrative Adapted to the Player’s Profile in Obstetric Nursing Competencies: A Cluster Randomized Controlled Pilot Trial Protocol

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The concept of this manuscript is highly innovative and timely. Some suggestions for revisions are presented below, which may be of reference value for the author. If the author can make further improvements, the rigor of this manuscript will be enhanced:
1. We have noticed that the sample size (n=38) in the manuscript is very small for detecting significant differences between the two groups. The author is requested to consider whether it can support the hypothesis of the entire manuscript.
2. Please provide more authoritative references for "Precision Education", so as to prove the academic nature of the relevant theory and also enhance the scientific nature of the manuscript.
3. Please further clarify the role of AI in the experiment, especially in the "2. Materials and Methods" section. Appropriate descriptions of the role of AI in it can be added.
4. Please further describe the "Invariant" of "Clinical Difficulty" in table 1.
5. Please determine whether the "Novelty Effect" described in the "4. Discussion" section is valid and whether it is consistent with the description of the literature in "1. Introduction"? It is stated in "1. Introduction" that it is "the first few weeks", why can it be determined as "four sessions" in the following text?
6. The analysis of PPDS only stays at the descriptive level, and the key variables have not been elaborated in detail.

Author Response

We sincerely thank the reviewer for their positive appraisal of our manuscript as "highly innovative and timely", and for their constructive feedback. We have carefully addressed each of the points raised, which have undoubtedly enhanced the scientific rigor and clarity of our protocol

1. 
   We have noticed that the sample size (n=38) in the manuscript is very small for detecting significant differences between the two groups. The author is requested to consider whether it can support the hypothesis of the entire manuscript.

RESPONSE

We appreciate this critical observation. We agree that a sample size of 38 participants is insufficient for a confirmatory efficacy trial. However, as explicitly stated in our design, this is a pilot feasibility study. The primary goal of our hypothesis testing at this stage is not to provide definitive evidence of superiority, but rather to calculate the preliminary effect size and inform the power calculation for future multicenter trials. We have clarified this limitation and the scope of our hypothesis in the "Sample Size" section to prevent any misinterpretation.

2. 
   Please provide more authoritative references for "Precision Education", so as to prove the academic nature of the relevant theory and also enhance the scientific nature of the manuscript.

RESPONSE

We completely agree with this suggestion. We have enriched the Introduction and Discussion sections by adding authoritative references that ground the concept of "Precision Education" within the framework of health professions education, thereby strengthening the theoretical foundation of our protocol

3. 
   Please further clarify the role of AI in the experiment, especially in the "2. Materials and Methods" section. Appropriate descriptions of the role of AI in it can be added.

RESPONSE

Thank you for this valuable suggestion. We have expanded the "Interventions" section to clarify the specific role of Artificial Intelligence. Generative AI is used exclusively offline during the preparation phase to assist in drafting the narrative scripts adapted to the different PPDS profiles. It does not interact with students in real-time. Furthermore, all AI-generated content is strictly reviewed, curated, and validated by the Principal Investigator before being implemented on the Wix platform to ensure clinical accuracy and ethical safety.

4. 
   Please further describe the "Invariant" of "Clinical Difficulty" in table 1.

RESPONSE

We have updated Table 1 and the surrounding text to explicitly define the term "Invariant". We have clarified that the physiological parameters of the simulated patients, the clinical complexity, and the multiple-choice knowledge questions are mathematically and clinically identical for both the control and xxperimental groups. The adaptation focuses exclusively on the narrative "wrapper" (tone, visual aesthetics, and side missions).

5. 
   Please determine whether the "Novelty Effect" described in the "4. Discussion" section is valid and whether it is consistent with the description of the literature in "1. Introduction"? It is stated in "1. Introduction" that it is "the first few weeks", why can it be determined as "four sessions" in the following text?

RESPONSE

We appreciate the reviewer pointing out this terminology discrepancy. We have clarified in the text that the study timeline spans four consecutive weeks, with one session scheduled per week. Therefore, the "four sessions" correspond directly to the "first four weeks" mentioned in the literature regarding the decline of the novelty effect. Tracking the students longitudinally over this one-month period allows us to monitor if engagement is genuinely maintained by the adaptive design once the initial technological novelty wears off.

6. 
   The analysis of PPDS only stays at the descriptive level, and the key variables have not been elaborated in detail.

RESPONSE

We understand the reviewer's desire for a more robust inferential analysis of the PPDS variables. However, given our pilot sample size (n=38) , dividing the experimental group (n=20) among the five possible PPDS profiles results in exceptionally small sub-group cell sizes. Conducting inferential statistics on these micro-groups would violate basic statistical assumptions and introduce a severe risk of type II errors. Consequently, to maintain statistical rigor, we have explicitly stated that the analysis of the five PPDS profiles must remain strictly descriptive and exploratory at this pilot stage. We have added a brief justification in the data analysis section to clarify this methodological decision.

Reviewer 2 Report

Comments and Suggestions for Authors

General Comments

I would like to thank the Authors and the Editors for the opportunity to review this protocol. The manuscript addresses a contemporary and relevant topic in nursing education, namely the potential contribution of adaptive gamification to the development of obstetric competencies among nursing students. The idea of tailoring gamified educational experiences according to player profiles is original and potentially valuable, and the protocol reflects a genuine effort to innovate in simulation-based learning. I also appreciated the Authors’ intention to ground the intervention in a structured pedagogical framework and to explore a promising area that may deserve further development in future studies..

At the same time, I believe that the manuscript would benefit from substantial revision in order to strengthen its methodological clarity, internal coherence, and overall scientific robustness. My comments are offered in a constructive spirit and with the hope that they may help the Authors further improve what could become an interesting and useful contribution.

 

Specific Comments

Major Comments

 

INTRODUCTION

1. The Introduction is generally well structured and addresses a relevant educational issue. However, I would kindly suggest that, in the definition of gamification, the Authors also cite one of the original and most widely recognized definitions proposed by Deterding et al. (2011).

 

Deterding, S., Dixon, D., Khaled, R., & Nacke, L. (2011). From game design elements to gamefulness: Defining ‘gamification’. Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments, 9–15. https://doi.org/10.1145/2181037.2181040

 

2. Several of the studies cited in the Introduction are written in Spanish. While these are certainly valuable contributions, I would encourage the Authors to consider balancing them with a greater number of English-language references, when possible, in order to facilitate accessibility for an international readership and allow readers to engage more easily with the cited literature.

 

METHODS

1. The protocol states that this is a “cluster-randomized” pilot trial with one cluster per arm, corresponding to two natural practice shifts only. This is a major design limitation because with only one cluster in each arm, the intervention effect is completely confounded with cluster-level differences. In practice, this means that any observed difference may be due to the shift itself rather than the intervention. The manuscript acknowledges clustering and proposes calculating ICC and design effect, but these measures are not meaningfully estimable in a reliable way with only two clusters. Likewise, participant-level Mann–Whitney testing does not solve the lack of independence problem.

I would kindly suggest that the Authors reconsider the study design if only two natural groups are available. In this case, it may be more appropriate to describe the study as a quasi-experimental pilot or a non-randomized feasibility study. If possible, the Authors could also consider an individual randomized design, if the risk of contamination can be adequately controlled. If the Authors decide to maintain the current cluster design, I would recommend clearly acknowledging this limitation and stating that, with only one cluster per arm, the comparisons between groups should be interpreted with caution and considered exploratory only.

2. The proposed use of Mann–Whitney U tests for global Learning Gain and satisfaction ignores the dependence introduced by clustering and repeated measures. Averaging the four session scores into a single global LG may simplify the dataset, but it does not resolve the core issue that participants are nested within only two clusters. Moreover, the protocol mentions repeated measures but does not explain how baseline differences in prior achievement, prior gamification exposure, or PPDS profiles will be handled analytically.

If the Authors decide to keep the current design, I would suggest explaining more clearly that the efficacy analyses should be considered descriptive and exploratory. In this context, it may be more appropriate to give greater attention to feasibility outcomes, effect sizes interpreted with caution, and descriptive summaries of the two groups, while relying less strongly on p-values and giving more importance to confidence intervals. It would also be helpful to clarify exactly how the “global Learning Gain” was calculated, for example whether it represents the mean of the gains observed in each session or another type of summary measure, and why this choice is educationally meaningful. In addition, the manuscript would benefit from a brief explanation of how missing data from one or more sessions might influence the global score.

3. The protocol states that participants are blinded to allocation and study hypothesis. In practice, it seems unlikely that students receiving profile-adapted narratives, differentiated codes, tailored feedback, and side missions will remain unaware that their experience differs from the standard version. Also, because the intervention is delivered in separate shifts, students may discuss their experiences outside class. I would suggest using a more precise description than “single blinding.” It may be clearer to explain that participants were not informed of the comparative hypothesis, that outcome scoring was objective, and that part of the statistical analysis was masked. It would also be helpful to distinguish more clearly between blinding to the study hypothesis, blinding to group allocation, and masking of the data analysts. In addition, I would recommend acknowledging that, given the nature of the intervention, participant blinding to differences between the two study conditions was likely only partial.
4. The authors recognize contamination and describe group separation and changing passwords, but because the participants are classmates from the same program, contamination through informal communication remains a major risk. This is especially important because the intervention is highly experiential and salient. I would suggest giving greater importance to contamination as a key feasibility aspect of the study and explaining clearly how it will be measured. It would be helpful for the Authors to specify what they would consider as evidence of cross-contamination and how this would be recorded during the study. In addition, the manuscript could clarify whether participants will be asked at the end of each session if they discussed the platform or the activities with students in the other group. Finally, I believe it would be useful to explain how any contamination, if detected, will be taken into account in the analysis and interpretation of the findings.

 

5. The PI is both lecturer and intervention facilitator, and recruitment occurs during the first class session of a mandatory curricular activity. Although the manuscript states that all students participate educationally while only consenting students contribute data, the risk of perceived coercion remains significant. The mention that the intervention is designed to improve preparation for the final exam may also reinforce undue influence. I would suggest providing more detail on the consent procedure and the safeguards used to protect voluntary participation. In particular, it would be helpful to clarify whether consent is obtained by someone independent from the lecturer, and whether students are able to refuse participation without the lecturer knowing who declined until grading has been completed. The manuscript would also benefit from a clearer explanation of how the confidentiality of consent status is preserved. In addition, the Authors may wish to reconsider or soften any wording that could be perceived as an academic inducement. Finally, it would be useful to specify whether students who do not participate in the research still complete the same educational activities under the same classroom conditions.

 

Minor Comments

1. The Abstract would benefit from some additional editorial refinement. I would kindly suggest carefully checking the punctuation throughout (row 18). It may also be preferable not to repeat the total number of participants in parentheses if this information has already been clearly stated in the sentence.
2. The title is interesting and reflects the focus of the study well; however, it appears somewhat long and could perhaps be revised slightly to improve clarity and readability. Along the same lines, it may be helpful to standardize the term “player’s profile” throughout the manuscript in order to ensure stylistic consistency.
3. More generally, I believe the Abstract would benefit from some language polishing. At present, a few expressions seem slightly too strong for a pilot protocol. For example, the phrase “enhances academic performance” sounds rather conclusive, whereas the purpose of the present study seems to be more appropriately related to feasibility assessment and the estimation of preliminary effects. In the same section, the sentence ending with “enhances academic performance in obstetrics This study aims…” appears to require clearer punctuation or separation in order to improve the flow of the text.
4. I would also suggest revisiting the definition of “sex,” as the current wording appears to refer more closely to gender as a social and cultural construct. A conceptual clarification here would strengthen the precision of the manuscript.
5. Finally, the statement that “AI has been used to generate the narrative and aspect characteristics of adapted gamification” feels somewhat broad and could be described in greater detail. It may be useful for the Authors to specify more clearly the scope of AI use and to confirm that all generated outputs were reviewed by the research team from both a clinical and educational perspective.

Author Response

We are deeply grateful to the reviewer for their meticulous and constructive evaluation of our protocol. The methodological and ethical insights provided, particularly regarding the study design limitations and the risk of coercion, have been immensely helpful. We have substantially revised the manuscript following your guidance to ensure methodological clarity and scientific robustness. Please find our point-by-point responses below. 

INTRODUCTION

1. The Introduction is generally well structured and addresses a relevant educational issue. However, I would kindly suggest that, in the definition of gamification, the Authors also cite one of the original and most widely recognized definitions proposed by Deterding et al. (2011).

 

1. Several of the studies cited in the Introduction are written in Spanish. While these are certainly valuable contributions, I would encourage the Authors to consider balancing them with a greater number of English-language references, when possible, in order to facilitate accessibility for an international readership and allow readers to engage more easily with the cited literature.

RESPONSE

We completely agree. We have incorporated the seminal definition of gamification by Deterding et al. (2011) into the Introduction. Furthermore, we have reviewed our bibliography and replaced several localized Spanish references with high-impact English-language literature to better serve an international readership. 

METHODS

1. The protocol states that this is a “cluster-randomized” pilot trial with one cluster per arm, corresponding to two natural practice shifts only. This is a major design limitation because with only one cluster in each arm, the intervention effect is completely confounded with cluster-level differences. In practice, this means that any observed difference may be due to the shift itself rather than the intervention. The manuscript acknowledges clustering and proposes calculating ICC and design effect, but these measures are not meaningfully estimable in a reliable way with only two clusters. Likewise, participant-level Mann–Whitney testing does not solve the lack of independence problem.

I would kindly suggest that the Authors reconsider the study design if only two natural groups are available. In this case, it may be more appropriate to describe the study as a quasi-experimental pilot or a non-randomized feasibility study. If possible, the Authors could also consider an individual randomized design, if the risk of contamination can be adequately controlled. If the Authors decide to maintain the current cluster design, I would recommend clearly acknowledging this limitation and stating that, with only one cluster per arm, the comparisons between groups should be interpreted with caution and considered exploratory only.

RESPONSE

We sincerely appreciate the reviewer’s rigorous statistical evaluation. We completely agree that having only one cluster per arm (two natural practice shifts) constitutes a major design limitation, as the intervention effect is inherently confounded with cluster-level differences.

Given the ecological constraints of our academic setting, an individual randomized design avoiding contamination within the same classroom shift is logistically unfeasible. Therefore, as kindly suggested by the reviewer as an alternative, we have decided to maintain the "cluster-randomized" terminology—which accurately reflects the random allocation of the two available shifts—while explicitly acknowledging the limitations of this approach.

We have revised the "Data Analysis" and "Limitations" sections to state clearly that with only one cluster per arm, comparisons between groups must be interpreted with caution and are strictly exploratory. Furthermore, we agree that calculating the Intraclass Correlation Coefficient (ICC) and design effect is not statistically reliable with only two clusters. Consequently, we have removed this specific proposal from the Data Analysis section of the protocol.

1. The proposed use of Mann–Whitney U tests for global Learning Gain and satisfaction ignores the dependence introduced by clustering and repeated measures. Averaging the four session scores into a single global LG may simplify the dataset, but it does not resolve the core issue that participants are nested within only two clusters. Moreover, the protocol mentions repeated measures but does not explain how baseline differences in prior achievement, prior gamification exposure, or PPDS profiles will be handled analytically.

If the Authors decide to keep the current design, I would suggest explaining more clearly that the efficacy analyses should be considered descriptive and exploratory. In this context, it may be more appropriate to give greater attention to feasibility outcomes, effect sizes interpreted with caution, and descriptive summaries of the two groups, while relying less strongly on p-values and giving more importance to confidence intervals. It would also be helpful to clarify exactly how the “global Learning Gain” was calculated, for example whether it represents the mean of the gains observed in each session or another type of summary measure, and why this choice is educationally meaningful. In addition, the manuscript would benefit from a brief explanation of how missing data from one or more sessions might influence the global score.

RESPONSE

We thank the reviewer for these highly constructive methodological recommendations. As agreed in the previous point, we have explicitly stated that inferential efficacy analyses will be treated as strictly descriptive and exploratory. Following your advice, we have updated the "Data Analysis" section to emphasize that we will rely less strongly on p-values and give greater importance to effect sizes and confidence intervals.

Regarding baseline differences, the original manuscript detailed that prior achievement (Pre-test Form 0 and academic records) would be checked for homogeneity. We have now expanded this to state that prior gamification exposure and PPDS profiles will also be descriptively compared at baseline to identify any major imbalances.

Regarding the "global Learning Gain" (LG), the manuscript previously stated that it is calculated by averaging the LG scores from the four individual sessions. We have added a brief sentence clarifying its educational meaningfulness: it reflects the student's overall assimilation of the obstetric module, which mitigates the impact of single-session performance fluctuations.

Finally, regarding missing data, the manuscript noted that a complete-case analysis approach is utilized per session. We have added a brief clarification stating that if a student misses a session, their global LG score will be calculated as the mean of their completed sessions only

1. The protocol states that participants are blinded to allocation and study hypothesis. In practice, it seems unlikely that students receiving profile-adapted narratives, differentiated codes, tailored feedback, and side missions will remain unaware that their experience differs from the standard version. Also, because the intervention is delivered in separate shifts, students may discuss their experiences outside class. I would suggest using a more precise description than “single blinding.” It may be clearer to explain that participants were not informed of the comparative hypothesis, that outcome scoring was objective, and that part of the statistical analysis was masked. It would also be helpful to distinguish more clearly between blinding to the study hypothesis, blinding to group allocation, and masking of the data analysts. In addition, I would recommend acknowledging that, given the nature of the intervention, participant blinding to differences between the two study conditions was likely only partial.

RESPONSE

The reviewer makes a highly pertinent point regarding the terminology of blinding in experiential educational interventions. We completely agree that "single blinding" overstates the condition, as students will inevitably realize they are participating in a novel digital experience.

Following your precise recommendations, we have removed the term "single blinding" from the manuscript. We have revised the "Randomization and masking" section to clearly distinguish between the different levels of masking. We explicitly acknowledge that participant blinding to the educational differences is likely only partial. However, we clarify that participants remain naïve to the comparative study hypothesis. Furthermore, we emphasize that outcome scoring relies on objective multiple-choice questions and that the data analyst (co-author) is strictly masked to group allocation.

1. The authors recognize contamination and describe group separation and changing passwords, but because the participants are classmates from the same program, contamination through informal communication remains a major risk. This is especially important because the intervention is highly experiential and salient. I would suggest giving greater importance to contamination as a key feasibility aspect of the study and explaining clearly how it will be measured. It would be helpful for the Authors to specify what they would consider as evidence of cross-contamination and how this would be recorded during the study. In addition, the manuscript could clarify whether participants will be asked at the end of each session if they discussed the platform or the activities with students in the other group. Finally, I believe it would be useful to explain how any contamination, if detected, will be taken into account in the analysis and interpretation of the findings.

 RESPONSE

We deeply appreciate the reviewer highlighting this practical reality of educational research. We completely agree that informal communication among classmates is a major risk to internal validity .

Following your valuable feedback, we have elevated cross-contamination to a key feasibility outcome . Regarding how it will be measured, we carefully considered adding a formal self-report question at the end of each session. However, to minimize survey fatigue—given that students are already completing the PPDS, four pre/post-tests, and the GAMEX scale within tight 120-minute sessions —we opted for an active observational approach. As detailed in the revised "Limitations" section, the Principal Investigator will use the pre-established "Field Diary" to actively monitor and record any spontaneous student disclosures, observable breaches of the "game contract," or evidence of cross-contamination between the shifts.

We have also clarified that any qualitative evidence of contamination gathered in the Field Diary will be explicitly reported and factored into the interpretation of the exploratory efficacy results, as it could dilute the observed effect sizes. We agree with the reviewer that future, fully-powered trials should incorporate a formal self-report contamination item.

1. The PI is both lecturer and intervention facilitator, and recruitment occurs during the first class session of a mandatory curricular activity. Although the manuscript states that all students participate educationally while only consenting students contribute data, the risk of perceived coercion remains significant. The mention that the intervention is designed to improve preparation for the final exam may also reinforce undue influence. I would suggest providing more detail on the consent procedure and the safeguards used to protect voluntary participation. In particular, it would be helpful to clarify whether consent is obtained by someone independent from the lecturer, and whether students are able to refuse participation without the lecturer knowing who declined until grading has been completed. The manuscript would also benefit from a clearer explanation of how the confidentiality of consent status is preserved. In addition, the Authors may wish to reconsider or soften any wording that could be perceived as an academic inducement. Finally, it would be useful to specify whether students who do not participate in the research still complete the same educational activities under the same classroom conditions.

 RESPONSE

We deeply appreciate the reviewer raising these critical ethical concerns. We completely agree that the dual teacher-researcher role presents inherent risks.

To be fully transparent regarding the logistical constraints of this single-center pilot, it is not possible to use an independent researcher to obtain consent. Because the PI must manage the master database linking participant codes to Wix access identities, the PI cannot be realistically blinded to the students' consent status.

To rigorously mitigate the risk of coercion within these practical constraints, we have reinforced the following safeguards:

• We have entirely removed the sentence stating that the activity reinforces "preparation for the final exam" to eliminate any perceived academic inducement.
• We have clarified that all students complete the exact same gamified activities as part of their standard curriculum, ensuring equitable learning regardless of research participation.
• As pre-specified in the protocol, we rely on a strict temporal firewall: the research data analysis is conducted strictly after the official academic transcripts have been finalized and locked. This guarantees that a student's decision to participate (or their game performance) cannot bias their official course grade.

 

Minor Comments

1. The Abstract would benefit from some additional editorial refinement. I would kindly suggest carefully checking the punctuation throughout (row 18). It may also be preferable not to repeat the total number of participants in parentheses if this information has already been clearly stated in the sentence.
2. The title is interesting and reflects the focus of the study well; however, it appears somewhat long and could perhaps be revised slightly to improve clarity and readability. Along the same lines, it may be helpful to standardize the term “player’s profile” throughout the manuscript in order to ensure stylistic consistency.
3. More generally, I believe the Abstract would benefit from some language polishing. At present, a few expressions seem slightly too strong for a pilot protocol. For example, the phrase “enhances academic performance” sounds rather conclusive, whereas the purpose of the present study seems to be more appropriately related to feasibility assessment and the estimation of preliminary effects. In the same section, the sentence ending with “enhances academic performance in obstetrics This study aims…” appears to require clearer punctuation or separation in order to improve the flow of the text.
4. I would also suggest revisiting the definition of “sex,” as the current wording appears to refer more closely to gender as a social and cultural construct. A conceptual clarification here would strengthen the precision of the manuscript.
5. Finally, the statement that “AI has been used to generate the narrative and aspect characteristics of adapted gamification” feels somewhat broad and could be described in greater detail. It may be useful for the Authors to specify more clearly the scope of AI use and to confirm that all generated outputs were reviewed by the research team from both a clinical and educational perspective.

 

RESPONSE

We are very grateful for these meticulous editorial observations, which have significantly improved the readability and precision of our manuscript. We have implemented the suggested minor revisions as follows:

• Abstract refinement: ee corrected the missing punctuation before "This study aims..." and removed the redundant "(n=38)". We also softened the language to reflect the pilot nature of the study, changing "enhances academic performance" to "evaluates the potential to support academic performance".
• Title: we appreciate the reviewer's suggestion to shorten the title for readability. However, as this is a protocol, we respectfully prefer to maintain the current title because it explicitly details the population, the intervention, and the study design, which aligns with standard methodological reporting guidelines.
• Stylistic consistency: we have reviewed the entire manuscript to ensure the term "player's profile" is used uniformly throughout.
• Definition of "Sex/Gender": the reviewer is completely correct. Because our definition referred to a "social and cultural construction," we have corrected the variable name from "sex" to "gender" to ensure conceptual precision.
• Use of AI statement: we have expanded the final "Use of Artificial Intelligence" declaration to explicitly confirm that AI was used solely as an offline drafting tool and that all generated narratives were strictly reviewed and validated by the research team for clinical and educational accuracy before implementation

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript is well designed and demonstrates sound scientific rigor throughout. The study is methodologically robust, and the analyses appear to be conducted appropriately and reported with clarity. Moreover, the work addresses a topic of clear relevance and presents an approach that is both interesting and potentially valuable to the scientific community.

The study presents a relatively modest sample size; however, it appears to be sufficient to adequately address the research objectives and to support the analyses conducted. While a larger cohort would undoubtedly enhance the generalizability and statistical power of the findings, the current sample provides an acceptable basis for carrying out this investigation and drawing meaningful conclusions within the stated scope of the study.

Nevertheless, the authors may wish to consider the following recommendations in order to further strengthen the manuscript:

• The authors should consider that multiple classifications of player profiles exist in the literature. It is advisable to clearly justify in the text why they have selected the specific framework or typology adopted in this study (ref. 20). Providing this context will help readers understand the rationale behind the choice, situate the work within the broader field of player profiling, and prevent potential confusion regarding the scope and applicability of the results.
• Given the central role attributed to personality within the proposed framework, it would be advisable to include a dedicated paragraph discussing the influence of player profiles on gamification experiences. Specifically, the manuscript would benefit from briefly addressing how different personality traits or player typologies may shape engagement, motivation, and responsiveness to gamified interventions, thereby providing a more nuanced interpretation of the results.
• Lines 225–239 are clearly written and provide an adequate description of the methodology. However, the inclusion of a schematic diagram or infographic summarizing the methodological process would greatly enhance clarity and accessibility. A visual representation of the study design, procedure, and key variables would facilitate readers’ understanding and allow for a more immediate and intuitive grasp of the overall research framework.
• The authors indicate that sociodemographic data were collected; however, it is not entirely clear why these variables were not further explored at the statistical level. Incorporating additional analyses that examine the potential influence of sociodemographic factors could strengthen the study by providing a more comprehensive understanding of the sample and by identifying possible moderating or confounding effects. Such analyses would likely enhance the robustness and interpretability of the findings. Moreover, incorporating these analyses would create valuable opportunities for comparison with findings reported in previous studies. Examining the role of sociodemographic variables could facilitate a more meaningful discussion of similarities and differences across samples and contexts, thereby situating the results more firmly within the existing literature and enhancing the external validity of the study.
• The Discussion section currently consists of only two paragraphs, followed by an extensive subsection on Limitations and the Dissemination Plan. It is highly recommended to expand the Discussion substantially to bring it to the standard expected for a scientific article. This could include, for example, a more thorough comparison with previous studies that are directly or indirectly related to the topic (e.g., https://doi.org/10.1002/cae.22576), an interpretation of the findings in the broader context of the field, and a discussion of potential theoretical or practical implications. Expanding this section would strengthen the manuscript’s contribution and provide readers with a clearer understanding of its significance.
• The Conclusions section would benefit from being strengthened by explicitly emphasizing the study’s original and meaningful contributions. In its current form, the section does not clearly convey how the research advances knowledge in the field. Highlighting the novel insights, practical implications, or theoretical significance of the findings would make the conclusions more compelling and demonstrate the added value of the study within the broader scientific context.

Author Response

We are deeply grateful for the reviewer’s encouraging assessment of our study as methodologically robust and highly relevant. Your constructive recommendations have been invaluable in refining the theoretical framework and clarifying the methodological contributions of our protocol. Please find our point-by-point responses below

• The authors should consider that multiple classifications of player profiles exist in the literature. It is advisable to clearly justify in the text why they have selected the specific framework or typology adopted in this study (ref. 20). Providing this context will help readers understand the rationale behind the choice, situate the work within the broader field of player profiling, and prevent potential confusion regarding the scope and applicability of the results.

RESPONSE

We thank the reviewer for this excellent observation. We completely agree that situating our choice within the broader field of player profiling is essential.

While various classifications of player profiles exist in the literature, our primary rationale for selecting the PPDS is linguistic and psychometric. The PPDS is specifically adapted and psychometrically validated in Spanish . Applying non-adapted frameworks to a Spanish-speaking student cohort could introduce significant linguistic and cultural biases. Therefore, utilizing a framework already validated in our target population's native language was the most methodologically rigorous choice available. We have added a brief justification to the Introduction to clarify this point

• Given the central role attributed to personality within the proposed framework, it would be advisable to include a dedicated paragraph discussing the influence of player profiles on gamification experiences. Specifically, the manuscript would benefit from briefly addressing how different personality traits or player typologies may shape engagement, motivation, and responsiveness to gamified interventions, thereby providing a more nuanced interpretation of the results.

RESPONSE

We strongly agree with the reviewer that expanding on the theoretical link between player personality and gamification outcomes adds essential depth to our framework. Following this valuable suggestion, we have inserted a brief statement in the Introduction highlighting how different personality traits fundamentally shape student engagement, intrinsic motivation, and overall responsiveness to gamified interventions.

• Lines 225–239 are clearly written and provide an adequate description of the methodology. However, the inclusion of a schematic diagram or infographic summarizing the methodological process would greatly enhance clarity and accessibility. A visual representation of the study design, procedure, and key variables would facilitate readers’ understanding and allow for a more immediate and intuitive grasp of the overall research framework.

RESPONSE

We thank the reviewer for this excellent suggestion. We completely agree that a visual representation greatly enhances the clarity of the procedural framework while avoiding textual redundancy. To achieve this, we have replaced the text-based list of the session timeline with a new, comprehensive schematic diagram (Figure 2) in the "Interventions" section. This infographic visually summarizes the exact 120-minute workflow (Pre-Assessment, Briefing, Gamified Simulation, and Debriefing), providing the immediate and intuitive grasp of the methodology requested by the reviewer.

• The authors indicate that sociodemographic data were collected; however, it is not entirely clear why these variables were not further explored at the statistical level. Incorporating additional analyses that examine the potential influence of sociodemographic factors could strengthen the study by providing a more comprehensive understanding of the sample and by identifying possible moderating or confounding effects. Such analyses would likely enhance the robustness and interpretability of the findings. Moreover, incorporating these analyses would create valuable opportunities for comparison with findings reported in previous studies. Examining the role of sociodemographic variables could facilitate a more meaningful discussion of similarities and differences across samples and contexts, thereby situating the results more firmly within the existing literature and enhancing the external validity of the study.

RESPONSE

We thank the reviewer for pointing out this missed opportunity. Originally, we planned to use the sociodemographic data solely to verify baseline homogeneity between the clusters. However, we completely agree that exploring their potential moderating influence adds significant value to the study and facilitates future cross-contextual comparisons.

We have updated the "Data Analysis" section to include an exploratory objective: we will perform correlation analyses (e.g., Spearman) to assess the relationship between age, prior academic grades, and the global Learning Gain. We will also descriptively explore potential gender differences regarding performance and satisfaction. However, to maintain statistical rigor, we have added a note of caution explicitly stating that, given our pilot sample size ($n=38$), these sociodemographic subgroup analyses will be treated strictly as exploratory and hypothesis-generating to prevent underpowered conclusions.

• The Discussion section currently consists of only two paragraphs, followed by an extensive subsection on Limitations and the Dissemination Plan. It is highly recommended to expand the Discussion substantially to bring it to the standard expected for a scientific article. This could include, for example, a more thorough comparison with previous studies that are directly or indirectly related to the topic (e.g., https://doi.org/10.1002/cae.22576), an interpretation of the findings in the broader context of the field, and a discussion of potential theoretical or practical implications. Expanding this section would strengthen the manuscript’s contribution and provide readers with a clearer understanding of its significance.

RESPONSE

We thank the reviewer for this encouragement to highlight our study's value. We believe our current Conclusions section already outlines the primary theoretical and practical contributions (such as validating a scalable AI workflow and shifting the paradigm towards "Precision Education"). However, to ensure that the study's original contribution to the advancement of knowledge is conveyed even more explicitly as requested, we have added a brief, definitive closing statement to the final paragraph emphasizing its novel impact on nursing curricula

• The Conclusions section would benefit from being strengthened by explicitly emphasizing the study’s original and meaningful contributions. In its current form, the section does not clearly convey how the research advances knowledge in the field. Highlighting the novel insights, practical implications, or theoretical significance of the findings would make the conclusions more compelling and demonstrate the added value of the study within the broader scientific context.

RESPONSE

We thank the reviewer for this constructive recommendation to highlight our study's value. Since this manuscript is a Study Protocol, we cannot yet discuss the significance of empirical findings. However, we completely agree that the anticipated theoretical and practical contributions of our proposed framework should be stated more forcefully. To explicitly convey how this research advances knowledge in the field without adding unnecessary length, we have added a brief, definitive closing statement to the final paragraph. This statement emphasizes that the study provides a novel, cost-effective blueprint to advance Precision Education in nursing.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the careful and thorough revisions you have made in response to the previous round of review. I appreciate the effort invested in improving the manuscript and clarifying the study protocol. The revised version reads clearly and presents a well-structured and methodologically sound research design.

After reviewing the revised manuscript, I do not have further comments or suggestions for revision. I believe the manuscript is ready for the next stage of the editorial process.

Thank you again for your diligent work on this study. I wish you the best with the publication of the paper and with the successful implementation of the project.

Author Response

We sincerely thank the reviewer for these highly encouraging words and for recognizing the effort invested in refining this protocol. Your constructive feedback during the previous round was instrumental in improving the methodological clarity and structural soundness of our research design.

Although no further revisions were requested in this round, we would like to inform the reviewer that we have continued to polish the text to ensure the highest academic standard. The manuscript has been processed through the publisher's official English language editing service (certificate provided to the Editorial Office), and we have proactively implemented additional minor linguistic and grammatical improvements in this final version. We deeply appreciate your invaluable guidance and your well wishes for the implementation of the project.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you to the Authors for their careful and thorough revision of the manuscript. I appreciate the attention given to the comments and suggestions provided during the review process, as well as the substantial efforts made to address the methodological and editorial issues previously raised.

At this stage, I have no further comments to add. I hope that the revisions implemented will contribute positively to the evaluation process and support the successful publication of the manuscript.

Author Response

We deeply appreciate the reviewer’s positive feedback and the time dedicated to evaluating our revised manuscript. The constructive comments and suggestions provided during the previous review round were essential in significantly improving both the methodological structure and the editorial clarity of this protocol.

While no further comments were raised at this stage, we would like to inform the reviewer that we have proactively continued to polish the manuscript to ensure the highest academic quality. Specifically, the text has undergone a final language review through the publisher's official English editing service (certificate provided to the Editorial Office), and we have implemented additional minor linguistic and grammatical improvements in this final version. We sincerely thank you for your invaluable guidance and your well wishes for the successful publication of our work.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you very much for the effort made in carrying out the proposed revisions. The manuscript has improved in many aspects. However, the Discussion section continues to be excessively brief. The Discussion is limited to lines 466–484, meaning it does not even reach 20 lines. In contrast, the subsection on Limitations occupies more than one full page.

A research article should not present only two paragraphs of scientific discussion; therefore, I strongly encourage the authors to improve this section. In my previous review, I already suggested some ideas that could be easily developed and that would help expand the Discussion, particularly by comparing the results with previous studies from other authors. I trust that the authors will make this effort so that the manuscript can be improved and reach the necessary scientific standard to ultimately be considered for publication.

Author Response

We thank the reviewer for recognizing the improvements made and for the continued feedback regarding the Discussion section. As emphasized in our previous response, this manuscript is a Study Protocol. Since the trial has not yet been conducted, it is methodologically impossible for us to compare "results" or empirical findings with previous studies without fabricating data.

However, we fully agree with your core argument that the theoretical discussion of our proposed framework must be more robust. To achieve the scientific standard you rightfully expect, we have expanded the Discussion section by adding a new, comprehensive paragraph. This addition compares our proposed methodology with the challenges highlighted by previous authors in the field, specifically discussing how our PPDS-adapted model aims to overcome the "novelty effect" and the limitations of generic interventions. We trust this expansion provides the theoretical depth requested while strictly adhering to the boundaries of a Study Protocol.