Impact of self-directed learning strategy, an innovative method in nursing undergraduates: A randomized controlled trial

Impact of self-directed learning strategy, an innovative method in nursing undergraduates: A randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of self-directed learning strategy, an innovative method in nursing undergraduates: A randomized controlled trial Sabina Chaudhary, Adarsh Lata Singh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7801690/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Nursing education is adapting to advancing healthcare technologies and changing patient needs. Self-directed learning (SDL) is essential for fostering lifelong learning among nursing students. Game-based learning (GBL) has emerged as a novel approach to improve engagement and SDL skills, yet its effectiveness against traditional methods in nursing undergraduates is still not well studied. Methods This study is a prospective, randomized, controlled trial aimed at evaluating the effectiveness of game-based learning (GBL) as an innovative self-directed learning strategy compared to conventional self-directed learning (SDL) in nursing education. Conducted at Smt. Radhikabai Meghe Memorial College of Nursing in India, it involved 140 nursing undergraduates who were randomly assigned to either an experimental group using an antimicrobial stewardship game or a control group utilizing traditional learning materials. Each participant attended a 90-minute orientation session before beginning a 12-week intervention period. The study focused on measuring SDL abilities through the Self-Directed Learning Instrument (SDLI) and knowledge acquisition with a questionnaire specifically targeting antimicrobial resistance and stewardship. Secondary outcomes included assessments of perceived cognitive, affective, and psychomotor learning via the CAP Perceived learning scale. Statistical analyses employed R software, utilizing nonparametric tests and ANCOVA models to adjust for baseline differences and covariates, with a significance level set at p < 0.05. Results At the 12-week follow-up, the experimental group showed significantly higher median knowledge scores (12.0 vs. 9.0, p < 0.001) and SDLI scores (72.0 vs. 59.0, p < 0.001) compared to the control group. ANCOVA analysis indicated a significant adjusted mean difference for knowledge (-3.1, p < 0.001) and SDLI (-12.3, p < 0.001). All secondary outcomes also demonstrated significant improvements in the experimental group (all p < 0.001), with sensitivity analyses affirming the robustness of these findings across various statistical models. Conclusion Game-based learning significantly improves knowledge acquisition and self-directed learning in undergraduate nursing students over traditional methods, and its incorporation into nursing curricula is advised to develop essential lifelong learning skills for the evolving healthcare sector. Trial registration number: Trial Registered Prospectively at Clinical Trials Registry - India [CTRI/2024/01/061599 (Registered on: 18/01/2024)] ; URL: https://ctri.nic.in/Clinicaltrials/rmaindet.php?trialid=92950&EncHid=87481.96317&modid=1&compid=19 Game-based learning Nursing education Randomized controlled trial Self-directed learning Self-directed learning instrument (SDLI) CONSORT 2025 Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Globally, the nursing profession is undergoing substantial changes due to technological advancements and complex patient care challenges. To adapt, nurses must prioritize continuous knowledge acquisition, with self-directed learning (SDL) as a key component. Relying solely on knowledge from formal education is insufficient; thus, enhancing SDL skills is vital for keeping pace with the expanding nursing knowledge and fostering lifelong learning. SDL empowers students to evaluate their learning needs, set goals, seek resources, and measure progress, thus encouraging critical thinking and professional autonomy. [ 1 – 3 ] The goal is to shift students from being passive learners to becoming active participants in their educational journeys. However, studies indicate that nursing students' competencies in SDL, particularly in specific areas, are still lacking. [ 4 , 5 ] SDL is an educational framework that is grounded in adult learning theories, particularly andragogy, and is gaining traction in nursing education. Knowles (1975) defines SDL as a process in which individuals recognize their learning needs, establish learning objectives, locate pertinent resources, choose and implement appropriate learning strategies, and evaluate their learning outcomes. This method positions the learner at the center of the educational process, highlighting the importance of personal responsibility, autonomy, and active involvement. [ 6 ] As a result, the role of the educator evolves from being a content expert to that of a supportive facilitator. SDL is based on a complex theoretical framework, reflecting John Dewey's educational philosophy that emphasizes personal development through educator facilitation. Zimmerman's self-directed learning model is based on Bandura's social cognitive theory, highlighting the interaction of behavioral, environmental, and personal factors. [ 7 ] Garrison's model further elaborates SDL by focusing on motivation, self-management, and self-monitoring. [ 8 ] The goal of integrating SDL into nursing education is to develop skilled, self-reliant professionals capable of critical thinking and adaptability in patient care. [ 9 – 11 ] In the field of educational innovation, SDL is a foundational competency that underpins numerous learner-centered strategies, particularly in nursing education. SDL is essential for preparing nurses for continuous professional development, enhancing learner autonomy, and boosting self-confidence and practical skills. It promotes critical thinking by involving students in analytical, reflective, and evidence-based practices necessary for complex patient care. Research indicates a strong positive correlation between SDL capabilities and academic performance as well as clinical proficiency. [ 9 , 11 – 14 ] Students skilled in SDL tend to exhibit superior clinical problem-solving and critical thinking skills, resulting in nurses who are adaptable, confident, and efficient in applying their knowledge in varied clinical scenarios. [ 15 , 16 ] Traditional SDL methods may not adequately engage today's digital-native learners or effectively address motivational factors for sustainable SDL. [ 17 ] In nursing education, innovative teaching strategies such as problem-based learning (PBL), simulation-based learning, flipped classrooms, learning contracts, team-based learning, virtual reality, augmented reality, and game-based learning are enhancing self-directed learning by promoting critical thinking, lifelong learning, and professional development. [ 17 , 18 ] Game-based learning (GBL) is an innovative pedagogical approach that incorporates play elements—such as points, leaderboards, and interactive challenges—to create engaging and motivating learning environments. [ 19 ] It enhances self-directed learning by encouraging active participation and improving knowledge retention. Evidence suggests GBL is more effective than traditional teaching, offering benefits like intrinsic motivation, independence, timely feedback, progress tracking, and personalized challenges. [ 20 – 22 ] Despite its potential to improve knowledge retention and engagement in health-professional education, GBL has strategic gaps that must be addressed to effectively support SDL in nursing education. [ 20 , 21 ] Significant research gaps encompass the long-term effects of GBL, its efficacy across diverse student demographics, and its influence on emotional and behavioral learning outcomes. Furthermore, while existing literature emphasizes the general benefits of GBL, it falls short in examining its specific influence on SDL competencies and the development of lifelong professional skills. There is also a notable lack of randomized controlled trials assessing the effects of GBL on SDL competencies among undergraduate nursing students. The study explores the effectiveness of a game-based learning intervention that is aligned with self-directed learning principles, utilizing a randomized controlled trial (RCT) to address existing methodological and population gaps. Its goal is to enhance the relationship between GBL and SDL skills among nursing students, thereby providing a foundation for evidence-based curriculum development and educational policy. The findings could facilitate the creation of customized GBL resources designed to better assist nursing students in navigating specific challenges in their field. The research introduces a framework that integrates self-determination theory (SDT) [ 23 ] with gamification to improve self-directed learning. It asserts that fulfilling psychological needs for autonomy, competence, and relatedness via gaming elements can enhance intrinsic motivation and yield favorable educational results. By employing Lander's theory of gamified learning [ 24 ] in conjunction with Garrison's model of self-directed learning, educators can cultivate stimulating environments that enable learners to assume control of their educational experiences and enhance their self-directed learning competencies. Figure 1 illustrates a framework in which gaming features address the psychological needs identified in Self-Determination Theory (SDT) by promoting learners' autonomy, skill development, and social connections through teamwork and competition. Participation in activities that incorporate gaming elements nurtures feelings of autonomy, competence, and belonging. This, in turn, boosts motivation, leading to increased engagement and persistence in educational tasks, improved problem-solving abilities, and enhanced academic performance. Objective The primary objective was to compare the effect of game-based learning as an innovative self-directed learning strategy with the conventional self-directed learning strategy on knowledge acquisition and self-directed learning abilities in nursing undergraduates through a randomized controlled trial comparing impacts at 12 weeks and determining game-based learning's superiority. Hypothesis: H 1 : The incorporation of game-based learning as an innovative self-directed learning strategy will be superior to the conventional learning method in improving self-directed learning abilities among nursing undergraduates. H 2 : Nursing students in the game-based learning group will have higher knowledge scores than those in the conventional learning group. Methods Trial design This study was designed and reported in accordance with the CONSORT 2025 guidelines for randomized trials. [ 25 ] The study protocol was prospectively registered (CTRI/2024/01/061599) and received approval from the Institutional Ethics Committee of Datta Meghe Institute of Higher Education & Research (DMIHER(DU)/IEC/2023/141C). This research was a prospective, randomized, controlled, data analyst-blinded, single-center superiority trial involving two parallel groups with a 1:1 allocation ratio. The follow-up period lasted 12 weeks, with assessments conducted at four time points: baseline (pre-test), immediate post-intervention, 4 weeks post-intervention, and 12 weeks post-intervention. A flow diagram illustrating the progress through the phases of the randomized trial, including enrollment, intervention allocation, follow-up, and data analysis for the two groups, is presented in Fig. 2 . Setting The study was conducted at Smt. Radhikabai Meghe Memorial College of Nursing (SRMMCON), Wardha, Maharashtra, India, an institution affiliated with Datta Meghe Institute of Higher Education & Research. Participants The accessible population consisted of 200 first- and third-semester B.Sc. Nursing students at SRMMCON. The inclusion criteria included (1) enrollment in the B.Sc. Nursing program, (2) being in the first or third semester of study, (3) agreeing to informed consent, (4) basic proficiency in English, and (5) access to a device with internet connectivity. The exclusion criteria were (1) prior formal training in antimicrobial resistance/stewardship, (2) a record of irregular class attendance, and (3) an expressed desire to withdraw. Intervention and comparator Following a pretest, all participants from both semesters attended a 90-minute structured teaching session that focused on the concept, importance, and process of self-directed learning. This session served as a common co-intervention for both groups and was conducted before the random assignment. Experimental Group (AMS Game) Intervention Components and Materials : The experimental group was exposed to the Antimicrobial Stewardship (AMS) game, an educational tool developed by the Commonwealth Partnerships for Antimicrobial Stewardship Programme (CwPAMS) and Focus Games Ltd. The game is designed to teach the fundamentals of antimicrobial resistance, stewardship, and infection control, encouraging group discussion and behavior change. Administration and Duration : The intervention began with an initial in-person gaming session where participants were organized into small teams. Following this, four subsequent gaming sessions were conducted online, once a week, for four weeks. Participants received unique login credentials to access the online sessions. Control Group (Information Booklet) Comparator Components and Materials : The researcher developed a standardized information booklet for the control group. This booklet addressed the same topics as the game, including antimicrobial resistance, antimicrobial stewardship, and infection control. Administration and Duration : Participants were allotted one hour for an initial self-study session using the booklet. They were then encouraged to pursue further self-learning with the provided material over the next four weeks. Prohibited Co-interventions To avoid confounding factors that could affect the outcomes, neither group received formal lectures or additional instruction on antimicrobial resistance, stewardship, or infection control during the four-week intervention period. Strategies to Improve Adherence and Fidelity Several strategies were implemented to promote adherence to the intervention protocols and maintain the fidelity of the trial's execution. Participant Adherence : Weekly reminders were sent to participants through WhatsApp and email to promote consistent participation. The researcher conducted weekly Zoom meetings to support self-directed learning techniques and to address any questions related to the learning methods. Adherence to the program was assessed using attendance records from the initial session as well as login data from four online gaming sessions. Fidelity and Contamination Prevention : To reduce communication risks and prevent contamination between groups, participants were required to maintain the confidentiality of their assignments. The control group was informed that they would have access to the AMS game after the study, while the experimental group received unique login codes for online sessions, which required webcam usage for identity verification. Outcomes The trial assessed both primary and secondary outcomes at four time points: baseline, immediately after the intervention, 4 weeks post-intervention, and 12 weeks post-intervention, utilizing consistent data collection tools. The primary outcomes included knowledge and the Self-Directed Learning Instrument (SDLI) score, with the goal of determining whether game-based learning is more effective than traditional self-directed learning (SDL) in enhancing nursing undergraduates' knowledge and SDL skills. The secondary outcomes focused on the development of critical process and performance skills, allowing for a thorough evaluation of the learning strategies' impacts across cognitive, affective, and psychomotor domains. Primary Outcomes Knowledge acquisition: Knowledge acquisition was evaluated using a 15-item multiple-choice questionnaire that was developed by researchers (see Supplementary File S1) and validated for its focus on antimicrobial resistance, antimicrobial stewardship, and infection control. Scores on the questionnaire ranged from 0 to 15 and were classified into three categories: inadequate (≤ 50%, score ≤ 7.5), moderately adequate (51–75%, score 7.6–11.25), and adequate (> 75%, score > 11.25). Content validity was established through an expert review, while reliability was confirmed with a Cronbach’s alpha of 0.78 and an intraclass correlation coefficient (ICC) of 0.80 from test–retest evaluations. The English language version of the questionnaire has been uploaded as a supplementary file. To assess knowledge improvement and retention, the differences in pre- and post-intervention scores between groups were analyzed. Self-Directed Learning (SDL) Abilities: Self-Directed Learning (SDL) abilities were evaluated using the Self-Directed Learning Instrument (SDLI) [ 26 ] , which consists of 20 items rated on a five-point Likert scale, covering areas such as learning motivation, planning and implementing, self-monitoring, and interpersonal communication. Total scores range from 20 to 100, with higher scores indicating greater SDL ability. The SDLI exhibits strong reliability (Cronbach’s α = 0.916) and has been validated through Delphi studies. The intervention's effectiveness was assessed by comparing pre- and postintervention SDLI scores between groups. Secondary Outcomes CAP Perceived Learning Competency: This competency was assessed using the Cognitive, Affective, and Psychomotor (CAP) Perceived Learning Scale, which consists of nine items rated on a six-point Likert scale. Developed by Rovai et al. (2009) [ 27 ] , this scale provides sub scores for cognitive, affective, and psychomotor learning, with a maximum possible score of 54. Higher scores reflect a greater perceived level of learning. The scale has demonstrated internal consistency (α = 0.79) and has established concurrent validity. Notable improvements in post-intervention scores in the experimental group compared to the control group underscore the effectiveness of the intervention. Data collectors and outcome assessors were not involved in intervention delivery. The data analyst was blinded to group allocation throughout the analysis phase. Harms During the 12-week trial, we closely monitored and documented any negative effects reported by participants. Both interventions were non-pharmacological: the experimental group engaged in game-based self-directed learning, while the control group utilized conventional learning with printed materials. Therefore, we did not expect or observe any significant adverse events. We prioritized participant safety by encouraging students to share any discomfort during our weekly zoom meetings or through email and WhatsApp. We paid special attention to potential sources of stress, such as technical difficulties, time constraints, or feelings of inadequacy experienced while engaging in self-directed tasks. Sample size The target sample size for the trial was predetermined to ensure adequate statistical power to detect a significant difference between the experimental group utilizing game-based self-directed learning and the control group using conventional methods. This decision was informed by a meta-analysis by Bai et al. (2020) [ 28 ] , which indicated that gamification had a medium effect size (Cohen's d = 0.5) on student learning outcomes. The study sought to determine similar effects on knowledge acquisition and self-directed learning (SDL) ability. Using G*Power version 3.1.9.7, a two-sample comparison of means was performed, establishing a required minimum of 64 participants per group at a two-sided alpha level of 0.05 with 80% power. To account for a potential 10% attrition rate during a 12-week follow-up, the sample size was increased to 70 participants per group, resulting in a total of 140 enrolled students. This calculation was in line with the main analytic plan, which aimed to use ANCOVA to compare adjusted mean differences in knowledge and SDL ability (SDLI) scores at the 12th week while taking into account baseline scores and covariates like age, semester, and previous exposure to game-based learning to avoid confounding variables. All participants were included in an intention-to-treat analysis with no follow-up losses, thereby achieving the desired sample size. The analysis confirmed that the sample was sufficient to detect the hypothesized effects, as evidenced by narrow confidence intervals and high model explanatory power (R² = 0.877 for knowledge and R² = 0.986 for SDLI) in the final ANCOVA models. Randomization and allocation concealment Participants were randomized in a 1:1 ratio into either a game-based self-directed learning (experimental) group or a conventional self-directed learning (control) group to ensure balanced allocation and minimize selection bias. Randomization was stratified by academic semester to address differences in baseline knowledge and self-directed learning (SDL) experience between junior and senior students. An independent researcher generated the allocation sequence using computer-generated random numbers from R software (version 4.4). A permuted block design with varying block sizes (4 and 8) was employed to reduce predictability while maintaining group balance throughout the enrollment process. Upon confirming eligibility and obtaining informed consent, each participant was assigned a unique identification number. Allocation envelopes, which were sequentially numbered, opaque, and sealed, were prepared by the independent researcher and securely stored to remain inaccessible to the study team. These envelopes were opened only after baseline data collection and prior to the intervention. The success of the randomization process was verified by analyzing baseline demographic and outcome variables, which revealed no statistically significant differences between the groups (all p > 0.05), thereby affirming the integrity of the allocation process. Blinding In a study comparing a game-based self-directed learning intervention to conventional self-study, blinding of participants and the researcher was not feasible. Nevertheless, two strategies were employed to ensure objective assessment: outcome measures were collected using self-administered electronic questionnaires, and the data analyst remained blinded throughout the analysis process. Datasets were de-identified and labeled by an independent researcher to prevent bias during statistical modeling and result reporting. Although a formal assessment of blinding success was not conducted, the combination of self-reported outcomes and blinded data analysis mitigated the risk of bias, in line with best practices for non-pharmacological randomized studies. Statistical methods The analysis was conducted using R software (version 4.4) with a significance level of α = 0.05. It began with a verification of data completeness and an assessment of distribution using the Shapiro–Wilk test. The majority of outcomes exhibited deviations from normality, necessitating the utilization of non-parametric methods for data summarization and comparisons. Continuous variables were reported as medians with interquartile ranges, while categorical variables were presented as frequencies and percentages. The Wilcoxon rank-sum test was employed to examine differences between groups for continuous outcomes, and Pearson's chi-square or Fisher's exact test was utilized for categorical variables. For the primary outcomes—knowledge scores and SDLI scores at 12 weeks—ANCOVA models were used to estimate adjusted mean differences, taking into account baseline values and covariates such as age, gender, academic semester, residential status, and prior exposure to game-based learning. Robust standard errors addressed heteroscedasticity, and model adequacy was evaluated through R² values, which were found to be high for both outcomes. Sensitivity analyses confirmed the robustness of the findings across various model specifications. All participants who completed randomization were included in the intention-to-treat analysis, achieving complete follow-up with no exclusions for missing data. All analyses adhered to the original group allocation, and no interim analyses were conducted that could have influenced the trial’s conduct or interpretation. Results Participant Flow The trial, which took place from September to December 2024 at Smt. Radhikabai Meghe Memorial College of Nursing in Wardha, India, included 200 eligible undergraduate nursing students. Out of these, 140 students were randomly selected and assigned in a 1:1 ratio to either a game-based self-directed learning (experimental) group or a conventional self-directed learning (control) group. All participants completed the 12-week study without any dropouts and attended all assessments, which consisted of baseline, immediate post-test, 4-week follow-up, and 12-week follow-up, as detailed in the CONSORT flow diagram. Recruitment The recruitment process for the study occurred from September 10 to September 16, 2024, involving first- and third-semester B.Sc. Nursing students. Eligible participants needed to be enrolled in the nursing program, have basic English skills, possess internet access, and have no prior training in antimicrobial stewardship or infection control. Written informed consent was obtained before participation in the study. A stratified randomization method was employed to ensure balanced representation, selecting 70 students from each semester across the trial groups. Intervention and Comparator Delivery The experimental intervention consisted of a structured self-directed learning (SDL) program that was followed by the Antimicrobial Stewardship (AMS) educational game. This game was developed by the Commonwealth Partnerships for Antimicrobial Stewardship Programme (CwPAMS) in collaboration with Focus Games Ltd. Following a 90-minute orientation session focused on SDL principles, participants in the experimental group engaged in four weekly online sessions, each lasting 60 minutes, where they played the AMS game over a four-week period. These sessions were conducted via Zoom, allowing participants to collaborate in small teams. The researcher acted solely as a facilitator, providing technical support and encouraging peer discussion, without delivering any instructional content. Attendance was monitored through mandatory camera use and session logs. The participants in the control group received the same self-directed learning (SDL) orientation as those in the experimental group. Subsequently, they were given a detailed printed learning booklet that covered topics such as antimicrobial resistance, stewardship, and infection control. They were instructed to engage in self-study for one hour immediately following the orientation and to continue their independent study using the same materials over the next four weeks. Unlike the experimental group, this group did not have access to any interactive or gamified elements. To support the self-directed learning process, both groups were offered weekly Zoom check-ins to address logistical questions. However, it is important to note that these sessions did not include any content instruction to avoid potential contamination of the study. Both groups had a high level of adherence, with all participants attending all scheduled sessions and finishing all assessments. Technical support was provided to five participants in the experimental group who experienced brief connectivity issues during gaming sessions; these issues were resolved promptly without affecting participation or data completeness. There were no changes to the assigned interventions, and no participants switched groups. At the end of the 12-week follow-up, all participants in the control group were granted access to the AMS game as part of the post-trial benefit, in accordance with the study’s ethical commitment to equity. Baseline Data The baseline characteristics are detailed in Table 1 . The two groups exhibited a satisfactory balance concerning key demographic and academic variables. Most participants were female (70.0%) and aged 20 years or younger (85.7%), with equal representation from first- and third-semester cohorts (50% each). Additionally, residential status and prior experience with game-based learning were similarly distributed between the groups. The pre-intervention scores for all primary and secondary outcomes—including knowledge, total and subscale scores from the Self-Directed Learning Instrument (SDLI), as well as perceived CAP learning scores (cognitive, affective, and psychomotor)—revealed no statistically significant differences (all p > 0.05). The median baseline knowledge scores were 7.0 [6.0–9.0] for the experimental group and 7.0 [6.0–8.0] for the control group (p = 0.96), while the median SDLI scores were 55.0 [45.0–66.0] for the experimental group and 55.0 [45.0–64.0] for the control group (p = 0.96). These results confirm successful randomization and establish a comparable foundation for assessing the effects of the intervention. Table 1 Baseline demographic, academic, and outcome characteristics of participants by study group Overall Stratified Characteristic N = 140 1 Experimental Group N = 70 1 Control Group N = 70 1 p-value 2 Age 0.016 0.99 First semester 70 (50.0) 35 (50.0) 35 (50.0) Third semester 70 (50.0) 35 (50.0) 35 (50.0) Residence 0.089 With parents 56 (40.0) 32 (57.1) 24 (42.9) With relatives 9 (6.4) 2 (22.2) 7 (77.8) With friends 9 (6.4) 5 (55.6) 4 (44.4) Alone in rented room 34 (24.3) 12 (35.3) 22 (64.7) In college hostel 32 (22.9) 19 (59.4) 13 (40.6) Prior exposure to GBL 10 (7.1) 5 (50.0) 5 (50.0) > 0.99 Pre-knowledge score 7.0 (6.0, 9.0) 7.0 (6.0, 9.0) 7.0 (6.0, 8.0) 0.96 Pre-Learning motivation 22.0 (19.0, 25.0) 22.0 (19.0, 26.0) 22.0 (19.0, 25.0) 0.92 Pre-Planning & implementing 12.0 (9.5, 14.5) 12.0 (9.0, 15.0) 12.0 (10.0, 14.0) 0.94 Pre-Self-monitoring 10.0 (8.0, 12.0) 10.0 (8.0, 12.0) 10.0 (9.0, 12.0) 0.94 Pre-Interpersonal communication 11.0 (8.0, 13.0) 11.0 (9.0, 13.0) 11.0 (8.0, 14.0) 0.88 Pre-SDLI Score 55.0 (45.0, 65.0) 55.0 (45.0, 66.0) 55.0 (45.0, 64.0) 0.96 Pre-Perceived cognitive learning 9.0 (8.0, 10.0) 9.0 (8.0, 10.0) 9.0 (8.0, 10.0) 0.97 Pre_Perceived affective learning 9.0 (8.0, 10.0) 9.0 (8.0, 11.0) 9.0 (8.0, 10.0) 0.074 Pre_Perceived psychomotor learning 9.0 (8.0, 10.0) 9.0 (8.0, 10.0) 9.0 (8.0, 10.0) 0.74 Pre_CAP Score 27.0 (24.0, 30.5) 27.0 (25.0, 31.0) 27.0 (24.0, 30.0) 0.40 Pretest knowledge level 0.86 Inadequate knowledge 83 (59.3) 42 (50.6) 41 (49.4) Moderately adequate knowledge 57 (40.7) 28 (49.1) 29 (50.9) Pretest SDL level 0.079 Low SDL ability 89 (63.6) 46 (51.7) 43 (48.3) Moderate SDL ability 47 (33.6) 20 (42.6) 27 (57.4) High SDL Level 4 (2.9) 4 (100.0) 0 (0.0) 1 n (%); Median (Q1, Q3) 2 Pearson's Chi-squared test; Fisher's exact test; Wilcoxon rank sum test Numbers Analyzed, Outcomes, and Estimation All 140 randomized participants completed the 12-week follow-up without any attrition or exclusions. The intention-to-treat analysis encompassed the entire cohort, with 70 participants in each group providing complete outcome data at four assessment points. No imputation was necessary, and the analyses preserved the original group allocations. At the 12-week follow-up, the experimental group demonstrated significantly greater improvements across all measured domains. Primary outcomes: Knowledge acquisition At 12 weeks, the experimental group demonstrated significantly higher median knowledge scores [12.0 (11.0–13.0)] compared to the control group [9.0 (7.0–11.0); p < 0.001]. No participants in the experimental group displayed inadequate knowledge, while 27.1% of the control group did. Furthermore, over 60% of the participants in the experimental group achieved adequate knowledge, in contrast to only 14.3% of those in the control group. (Table 2 ). Table 2 Endline knowledge outcomes at 12 weeks by study group Characteristic Overall N = 140 1 "A" Group N = 70 1 "B" Group N = 70 1 p-value 2 12th week Posttest knowledge score 11.0 (9.0,12.0) 12.0 (11.0,13.0) 9.0 (7.0,11.0) < 0.001 12th week posttest level < 0.001 Inadequate knowledge 19 (13.6) 0 (0.0) 19 (27.1) Moderately adequate knowledge 68 (48.6) 27 (38.6) 41 (58.6) Adequate knowledge 53 (37.9) 43 (61.4) 10 (14.3) 1 Median (Q1,Q3); n (%) 2 Wilcoxon rank sum test; Pearson's Chi-squared test The scores in the experimental group increased significantly from the baseline [7.0 (6.0–9.0)] to the 12-week score [12.0 (11.0–13.0)]. In contrast, the control group exhibited only a slight improvement, moving from 7.0 (6.0–8.0) to 9.0 (7.0–11.0). (Fig. 4 ). As presented in Table 3 , after adjusting for baseline knowledge scores using ANCOVA, participants in the experimental group obtained significantly higher knowledge scores than those in the control group (adjusted mean difference − 3.1, 95% CI − 3.4 to − 2.8; p < 0.001), indicating a strong effect of the game-based intervention. Baseline knowledge served as a significant predictor of the 12-week scores (β = 0.92, 95% CI 0.83–1.0; p < 0.001). In contrast, other covariates—such as age, sex, semester, residence, and prior exposure to game-based learning—did not exhibit a significant association with endline knowledge. The model demonstrated a satisfactory fit, with R² = 0.877 and adjusted R² = 0.868, accounting for nearly 88% of the variance in endline knowledge scores. Table 3 ANCOVA results for knowledge outcomes at 12 weeks (robust HC3 estimates) Knowledge (Posttest3) ANCOVA — robust (HC3) Beta 95% CI p-value Group Experimental Group — — Control Group -3.1 -3.4 to -2.8 < 0.001 Pre_Knowledge Score 0.92 0.83 to 1.0 < 0.001 Age <= 20 years — — 21–25 years -0.01 -0.48 to 0.46 0.96 Gender Male — — Female -0.08 -0.44 to 0.28 0.65 Semester First semester — — Third semester -0.16 -0.49 to 0.16 0.32 Residence With parents — — With relatives 0.54 -0.16 to 1.3 0.13 With friends -0.08 -0.77 to 0.60 0.81 Alone in rented room 0.10 -0.32 to 0.53 0.62 In college hostel 0.06 -0.38 to 0.49 0.80 Prior exposure to Game based Learning Yes — — No 0.06 -0.59 to 0.71 0.85 R² 0.877 Adjusted R² 0.868 Sigma 0.945 Statistic 92.2 p-value < 0.001 df 10 Log-likelihood -185 AIC 394 BIC 429 Deviance 115 Residual df 129 No. Obs. 140 Abbreviation: CI = Confidence Interval Self‑Directed Learning Abilities By 12 weeks, participants in the experimental group demonstrated significantly higher Self-Directed Learning Inventory (SDLI) scores [72.0 (64.0–78.0)] compared to the control group [59.0 (49.0–67.0); p < 0.001]. Over 22.9% of the experimental group achieved the highest SDLI level, whereas only 2.9% of the control group did. Additionally, more than half of the control group (55.7%) remained at the lowest level, in contrast to 17.1% in the experimental group (Table 4 ). All process-related outcomes favored the experimental group at 12 weeks. Median scores were significantly higher for learning motivation [28.0 (26.0–30.0) vs 23.0 (20.0–26.0)], planning and implementation [16.0 (13.0–18.0) vs 13.0 (11.0–15.0)], self-monitoring [13.0 (11.0–15.0) vs 11.0 (9.0–13.0)], and interpersonal communication [15.0 (13.0–17.0) vs 12.0 (10.0–14.0)]; all p < 0.001. Table 4 Endline self-directed learning (SDLI) outcomes at 12 weeks by study group Characteristic Overall N = 140 1 Experimental Group N = 70 1 Control Group N = 70 1 p-value 2 12th week posttest SDLI Score 67.0 (57.0,75.0) 72.0 (64.0,78.0) 59.0 (49.0,67.0) < 0.001 12th week posttest SDLI level < 0.001 Low SDL abilities 51 (36.4) 12 (17.1) 39 (55.7) Moderate SDL abilities 71 (50.7) 42 (60.0) 29 (41.4) High SDL abilities 18 (12.9) 16 (22.9) 2 (2.9) 1 Median (Q1,Q3); n (%) 2 Wilcoxon rank sum test; Pearson's Chi-squared test In longitudinal trend, the experimental group showed significant improvements from a baseline score of 55.0 to 72.0 over 12 weeks, while the control group experienced minimal increases, moving from 55.0 to 59.0. (see Fig. 5 ). The ANCOVA results indicated that the experimental group had significantly higher SDLI scores compared to the control group, with an adjusted mean difference of − 12 (95% CI − 13 to − 12; p < 0.001). Baseline SDLI was identified as a strong predictor (β = 0.86, 95% CI 0.84–0.88; p < 0.001). Furthermore, female gender was associated with lower scores (β = − 0.64, 95% CI − 1.2 to − 0.06; p = 0.032), while living with relatives correlated with higher scores (β = 1.3, 95% CI 0.16–2.4; p = 0.025). Other variables, such as age and previous exposure to game-based learning, did not show significant effects. The model fit was excellent (R² = 0.986, adjusted R² = 0.985), accounting for nearly 99% of the variance in SDLI outcomes. (Table 5 ) Table 5 ANCOVA results for self-directed learning (SDLI) outcomes at 12 weeks (robust HC3 estimates) SDLI (Posttest3) ANCOVA — robust (HC3) Beta 95% CI p-value Group Experimental Group — — Control Group -12 -13 to -12 < 0.001 Pre SDLI Score 0.86 0.84 to 0.88 < 0.001 Age <= 20 years — — 21–25 years 0.26 -0.50 to 1.0 0.50 Gender Male — — Female -0.64 -1.2 to -0.06 0.032 Semester First semester — — Third semester -0.24 -0.77 to 0.28 0.37 Residence With parents — — With relatives 1.3 0.16 to 2.4 0.025 With friends 0.04 -1.1 to 1.2 0.95 Alone in rented room 0.41 -0.28 to 1.1 0.24 In college hostel 0.08 -0.62 to 0.78 0.82 Prior exposure to Game based Learning Yes — — No 0.87 -0.19 to 1.9 0.11 R² 0.986 Adjusted R² 0.985 Sigma 1.54 Statistic 940 p-value < 0.001 df 10 Log-likelihood -253 AIC 530 BIC 565 Deviance 304 Residual df 129 No. Obs. 140 Abbreviation: CI = Confidence Interval Secondary outcomes: CAP perceived learning outcome : The CAP perceived learning outcomes revealed significant differences at the 12th-week assessment. The experimental group outperformed the control group in several areas: perceived cognitive learning [12.0 (11.0–13.0) vs 9.0 (8.0–10.0)], perceived affective learning [11.0 (10.0–12.0) vs 9.0 (8.0–10.0)], perceived psychomotor learning [12.0 (11.0–13.0) vs 9.0 (8.0–10.0)], and the overall CAP perceived learning score [35.0 (31.0–39.0) vs 27.0 (23.0–30.0)]. All comparisons showed statistical significance with p < 0.001. Figure 6 illustrates the longitudinal trend of the CAP perceived learning outcomes. Harms Both interventions exhibited a low-risk educational nature, with no serious adverse events reported. Five participants experienced minor technical difficulties, but real-time support promptly resolved these issues. Furthermore, we observed no psychological distress or negative emotional responses, confirming the trial's minimal risk and eliminating the need for formal harm grading. Ancillary Analyses Sensitivity analyses indicated that experimental group participants outperformed the control group at 12 weeks across various statistical models, including ANOVA and ANCOVA, with significant results (all p < 0.001). (Table 6 ) Table 6 Sensitivity analyses of knowledge and SDLI outcomes using alternative model specifications Outcome Model Contrast (Grp) Estimate Std. Error CI Lower CI Upper p-value Knowledge 1) ANOVA (lm) Control Group vs Exp. Group -3.057143 0.3558943 -3.760854 -2.353432 < 0.001 Knowledge 2) ANOVA (lm) — robust SE Control Group vs Exp. Group -3.057143 0.3558943 -3.760854 -2.353432 < 0.001 Knowledge 3) ANCOVA (baseline only) Control Group vs Exp. Group -3.057143 0.1575639 -3.368715 -2.745571 < 0.001 Knowledge 4) ANCOVA (baseline only) — robust SE Control Group vs Exp. Group -3.057143 0.1575639 -3.368715 -2.745571 < 0.001 Knowledge 5) ANCOVA (baseline + covars) Control Group vs Exp. Group -3.103189 0.1681226 -3.435824 -2.770554 < 0.001 Knowledge 6) ANCOVA (baseline + covars) — robust SE Control Group vs Exp. Group -3.103189 0.1681226 -3.435824 -2.770554 < 0.001 SDLI 1) ANOVA (lm) Control Group vs Exp. Group -12.128571 1.8934694 -15.872535 -8.384608 < 0.001 SDLI 2) ANOVA (lm) — robust SE Control Group vs Exp. Group -12.128571 1.8934694 -15.872535 -8.384608 < 0.001 SDLI 3) ANCOVA (baseline only) Control Group vs Exp. Group -12.128571 0.2667263 -12.656004 -11.601138 < 0.001 SDLI 4) ANCOVA (baseline only) — robust SE Control Group vs Exp. Group -12.128571 0.2667263 -12.656004 -11.601138 < 0.001 SDLI 5) ANCOVA (baseline + covars) Control Group vs Exp. Group -12.291287 0.2730362 -12.831496 -11.751078 < 0.001 SDLI 6) ANCOVA (baseline + covars) — robust SE Control Group vs Exp. Group -12.291287 0.2730362 -12.831496 -11.751078 < 0.001 Longitudinal trends show a notable improvement in the experimental group, whereas the control group's gains plateaued following the post-test. Post hoc analyses categorized by semester and gender found no significant interactions, which affirms the reliability of the intervention effects. Ancillary findings reinforce the validity of the primary results and highlight game-based self-directed learning as an effective educational strategy for nursing undergraduates. Discussion The randomized controlled trial validates the hypothesis that incorporating game-based learning (GBL) into a self-directed learning (SDL) framework significantly enhances knowledge acquisition and SDL skills among undergraduate nursing students compared to traditional SDL approaches. Over a 12-week period, participants who engaged with an Antimicrobial Stewardship (AMS) educational game demonstrated significant improvements in their understanding of antimicrobial resistance and stewardship, as well as notable increases in their Self-Directed Learning Instrument (SDLI) scores. These improvements remained significant even after controlling for baseline performance and other variables. Notable advancements were observed across various SDL dimensions, including motivation, planning, self-monitoring, and interpersonal communication, in addition to perceived cognitive, affective, and psychomotor learning. The study indicated no significant adverse events; minor technical difficulties encountered by certain GBL participants were promptly addressed and did not affect overall participation or data integrity. These findings align with existing research that supports innovative, student-centered teaching strategies aimed at better preparing nursing students for the challenges of modern healthcare. Our findings support and expand upon the existing literature regarding game-based learning (GBL) in health professions education. Previous systematic reviews by Xu et al. (2021), Tavares (2022), and Kuruca Ozdemir et al. (2022) have shown that GBL positively affects knowledge retention, motivation, and engagement among nursing students. [ 20 – 22 ] However, these studies primarily employed quasi-experimental designs and often lacked long follow-up periods or valid measures of self-directed learning. In contrast, our study utilized a rigorous randomized controlled trial (RCT) design and incorporated a psychometrically validated tool, the Self-Directed Learning Instrument (Cheng et al., 2009), within a 12-week longitudinal framework to address these methodological limitations. Additionally, our emphasis on process-oriented outcomes, such as self-monitoring and interpersonal communication, offers greater clarity about how GBL fosters self-directed learning (SDL), rather than simply confirming its existence. Enhancement of Knowledge Acquisition A key finding of the trial was the significant improvement in knowledge acquisition and long-term retention observed in the experimental group using game-based learning (GBL) compared to the control group. At the 12-week follow-up, the GBL group achieved notably higher knowledge scores and demonstrated a transition toward "adequate" knowledge levels, a milestone reached by only a small fraction of the control group. This finding supports existing literature that endorses GBL as an effective educational approach. For example, a longitudinal study by Samuel et al. found that nursing students who participated in digital learning games during anatomy and physiology courses scored higher on final exams, indicating better long-term retention. [ 29 ] Furthermore, research by Abumettleq et al. (2023) showed that a game-based instructional method enhanced understanding of Enhanced Recovery After Surgery (ERAS) protocols compared to standard lectures. [ 30 ] A systematic review of serious games also revealed that nursing students gained significant knowledge through these tools compared to traditional teaching strategies. [ 31 ] The GBL intervention created an engaging learning environment that improved cognitive processing and retention, unlike traditional lecture-based methods that encourage passive learning. These results suggest that GBL is an effective pedagogical tool for mastering complex clinical information, rather than a transient trend, underscoring its potential to enhance academic performance and critical thinking among nursing students. The development of Self-Directed Learning Abilities The trial demonstrated that GBL significantly improves students' self-directed learning capabilities. This is evidenced by higher scores on the Self-Directed Learning Instrument (SDLI), particularly in the areas of learning motivation, planning and implementation, self-monitoring, and interpersonal communication. This finding addresses the pressing need in nursing education for skills that can adapt to the changing healthcare landscape, as SDL principles are essential to learner-centered strategies. The GBL intervention was based on Self-Determination Theory (SDT), which highlights that satisfying the needs for autonomy, competence, and relatedness boosts intrinsic motivation—an essential aspect of Self-Directed Learning (SDL). Game elements provided learners with autonomy by granting them control over their learning pace and methods, enhanced competence through structured challenges and feedback, and fostered relatedness through collaborative teamwork. This study aligns with existing research, particularly the findings of Moon (2023), which indicate that motivation is a predictor of SDL capabilities. [ 32 ] The findings indicated that participants involved in GBL exhibited heightened learning motivation, evidenced by elevated scores on the SDLI. Furthermore, studies on gamification and flipped classrooms support the positive effects on motivation outcomes. Moreover, GBL improved SDL abilities, particularly in planning, implementation, and self-monitoring—key principles where learners assess their progress. Topcu (2023) identified similar gains in metacognitive self-regulation through GBL approaches. [ 33 ] Additionally, the improvement in interpersonal communication skills highlights how collaborative gaming sessions foster peer learning and encourage seeking assistance, both of which are essential educational strategies. These findings suggest that GBL not only enhances motivation but also equips students with the necessary skills for effective self-directed learning, thereby contributing to career adaptability, which is crucial for nursing professionals, as noted by Park (2021). [ 16 ] Comparison with Other Innovative Pedagogies The findings from our game-based learning (GBL) intervention align with existing research on innovative, student-centered teaching methods, such as flipped classrooms (FC) and problem-based learning (PBL). Liu et al. (2018) found that FC significantly enhances nursing students' SDL skills, including motivation and self-management, when compared to traditional pedagogical approaches. [ 34 ] Additionally, studies by Dadgari et al. (2020) and Khodaei et al. (2022) demonstrated that FC improves SDL readiness scores. [ 35 , 36 ] Furthermore, studies have demonstrated that blended learning strategies effectively enhance SDL readiness, particularly in the areas of self-management and self-control. [ 37 ] PBL, similar to GBL, emphasizes collaborative problem-solving and has been associated with enhanced SDL. A meta-analysis conducted by Chen et al. (2024) confirmed that PBL improves SDL performance and problem-solving abilities. Additionally, Wong and Kan (2022) found that an online PBL initiative led to lasting improvements in SDL readiness. [ 38 , 39 ] GBL's distinguishing factor is its ability to intrinsically motivate digital-native learners. While FC and PBL promote active learning, GBL incorporates game elements such as competition and instant rewards. This integration significantly enhances student enjoyment and engagement, as noted by Panesar-Aguilar et al. (2023). [ 40 ] The resulting increase in motivation is likely crucial to GBL's effectiveness in improving knowledge acquisition and SDL abilities. Implications, Limitations, and Future Directions The trial results highlight the significant advantages of the Game-Based Learning (GBL) strategy in nursing education, advocating for its incorporation into curricula to enhance lifelong learning skills in professional practice. The randomized controlled trial (RCT) effectively illustrates the positive impact of GBL on self-directed learning (SDL) among undergraduate nursing students. However, the study's limitations, particularly its single-center design, make it imperative to conduct future research in varied settings and populations. Furthermore, even though the trial did not report any adverse events, future implementations should consider potential challenges like technological stress. Long-term studies are recommended to evaluate the enduring effects of GBL on SDL and professional practice. Conclusion In conclusion, this trial provides strong evidence that a Game-Based Learning (GBL) strategy is an effective and superior alternative to conventional methods for improving knowledge acquisition and fostering self-directed learning skills in undergraduate nursing students. By creating an engaging, motivating, and autonomous learning environment, GBL encourages students to actively participate in their education, preparing them for the challenges of a constantly changing healthcare landscape. Abbreviations AMS: Antimicrobial Stewardship CAP: Cognitive, Affective, and Psychomotor FC: Flipped Classroom GBL: Game-based Learning PBL: Problem-based Learning RCT: Randomized Controlled Trial SDL: Self-Directed Learning SDLI: Self-Directed Learning Instrument SDT: Self-determination Theory Declarations Ethics approval and consent to participate: Approved by the Institutional Ethics Committee of Datta Meghe Institute of Higher Education & Research (DMIHER(DU)/IEC/2023/141C). Written informed consent was obtained from those willing to participate. Consent for publication: Not applicable Availability of data and materials: The datasets, statistical code, and other materials used during the current study will be made available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. The AMS gaming application for study was purchased in retail; Focus Game has no role in the study. Funding: The author(s) received no specific funding for this work. Authors' contributions: SC conceptualized the trial and drafted the initial manuscript, the CONSORT checklist and figure, the subsequent edits and revision of the manuscript, and the final manuscript. ALS offered suggestions on trial design, critically reviewed the initial draft, suggested comments and revisions and added the texts to the manuscript. Both authors contributed to refinement of the study and approved the final manuscript. Acknowledgements: The authors would like to acknowledge Chien-Lin Kuo for granting permission to use the SDLI tool and Dr. Mervyn J. Wighting for granting permission to use the CAP perceived learning scale in this study. The authors are grateful to Mr. Suman Sapkota for his expert execution of the statistical data analysis. Protocol and statistical analysis plan: It can be accessed in the study protocol published in PLOS One with the title "Impact of self-directed learning strategy, an innovative method in nursing undergraduates: Study protocol for a randomized controlled trial." DOI: https://doi.org/10.1371/journal.pone.0325300. [41] References Murad MH, Coto-Yglesias F, Varkey P, Prokop LJ, Murad AL. The effectiveness of self-directed learning in health professions education: a systematic review. Med Educ. 2010;44(11):1057–68. Cadorin L, Bressan V, Palese A. Instruments evaluating the self-directed learning abilities among nursing students and nurses: a systematic review of psychometric properties. BMC Med Educ. 2017;17(1):229. Tang LQ, Zhu LJ, Wen LY, Wang An-Shi, Jin YL, Chang WW. Association of learning environment and self-directed learning ability among nursing undergraduates: a cross-sectional study using canonical correlation analysis. BMJ Open. 2022;12(8):e058224. 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learning\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7801690/v1/6b24d23e62db0772ee597ff5.png"},{"id":99292093,"identity":"c96d68ba-c9a8-435c-bc41-493e922e1b12","added_by":"auto","created_at":"2025-12-31 10:39:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":151195,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of trial\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7801690/v1/21f74f9ca4d2939c22c8577b.png"},{"id":99321265,"identity":"9d47e5b8-f68f-460e-9823-c9c81a89a404","added_by":"auto","created_at":"2025-12-31 16:39:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":150778,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT participant flow diagram\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7801690/v1/8a138a5bc18a49a35151de57.png"},{"id":99292101,"identity":"975cd704-3925-488e-9fb2-7309b3495532","added_by":"auto","created_at":"2025-12-31 10:39:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":74528,"visible":true,"origin":"","legend":"\u003cp\u003eKnowledge over time by group\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7801690/v1/67d56bdb843ca4f98942a774.png"},{"id":99292094,"identity":"cbd00d46-2b7c-45ea-8c57-e9702c4c4666","added_by":"auto","created_at":"2025-12-31 10:39:57","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":75419,"visible":true,"origin":"","legend":"\u003cp\u003eSelf-directed learning score over time by group\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7801690/v1/21d8573be1a5124d756fd910.png"},{"id":99319742,"identity":"a49e2694-1ff4-40b1-ab00-bc909dfd190b","added_by":"auto","created_at":"2025-12-31 16:37:45","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":111548,"visible":true,"origin":"","legend":"\u003cp\u003eCAP perceived learning measures over time by group\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7801690/v1/c358f857b2b2e5d76f65e4a4.png"},{"id":102900245,"identity":"b7202012-4594-484a-b04f-4eee4374cc28","added_by":"auto","created_at":"2026-02-18 07:56:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2274043,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7801690/v1/b252e17f-823c-44e1-9b97-881f788b3b6b.pdf"},{"id":99321217,"identity":"04f1b813-fe6f-43ec-a7a4-7997494d8784","added_by":"auto","created_at":"2025-12-31 16:39:16","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":33056,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2025checklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-7801690/v1/f90e1dcf9f488cf473aaebaf.docx"},{"id":99321221,"identity":"966a2a7f-9481-44f0-a696-6a479507d989","added_by":"auto","created_at":"2025-12-31 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To adapt, nurses must prioritize continuous knowledge acquisition, with self-directed learning (SDL) as a key component. Relying solely on knowledge from formal education is insufficient; thus, enhancing SDL skills is vital for keeping pace with the expanding nursing knowledge and fostering lifelong learning. SDL empowers students to evaluate their learning needs, set goals, seek resources, and measure progress, thus encouraging critical thinking and professional autonomy. \u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003eThe goal is to shift students from being passive learners to becoming active participants in their educational journeys. However, studies indicate that nursing students' competencies in SDL, particularly in specific areas, are still lacking.\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSDL is an educational framework that is grounded in adult learning theories, particularly andragogy, and is gaining traction in nursing education. Knowles (1975) defines SDL as a process in which individuals recognize their learning needs, establish learning objectives, locate pertinent resources, choose and implement appropriate learning strategies, and evaluate their learning outcomes. This method positions the learner at the center of the educational process, highlighting the importance of personal responsibility, autonomy, and active involvement.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e As a result, the role of the educator evolves from being a content expert to that of a supportive facilitator.\u003c/p\u003e \u003cp\u003eSDL is based on a complex theoretical framework, reflecting John Dewey's educational philosophy that emphasizes personal development through educator facilitation. Zimmerman's self-directed learning model is based on Bandura's social cognitive theory, highlighting the interaction of behavioral, environmental, and personal factors.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e Garrison's model further elaborates SDL by focusing on motivation, self-management, and self-monitoring.\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e The goal of integrating SDL into nursing education is to develop skilled, self-reliant professionals capable of critical thinking and adaptability in patient care.\u003csup\u003e[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the field of educational innovation, SDL is a foundational competency that underpins numerous learner-centered strategies, particularly in nursing education. SDL is essential for preparing nurses for continuous professional development, enhancing learner autonomy, and boosting self-confidence and practical skills. It promotes critical thinking by involving students in analytical, reflective, and evidence-based practices necessary for complex patient care. Research indicates a strong positive correlation between SDL capabilities and academic performance as well as clinical proficiency.\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e Students skilled in SDL tend to exhibit superior clinical problem-solving and critical thinking skills, resulting in nurses who are adaptable, confident, and efficient in applying their knowledge in varied clinical scenarios.\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTraditional SDL methods may not adequately engage today's digital-native learners or effectively address motivational factors for sustainable SDL.\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e In nursing education, innovative teaching strategies such as problem-based learning (PBL), simulation-based learning, flipped classrooms, learning contracts, team-based learning, virtual reality, augmented reality, and game-based learning are enhancing self-directed learning by promoting critical thinking, lifelong learning, and professional development.\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGame-based learning (GBL) is an innovative pedagogical approach that incorporates play elements\u0026mdash;such as points, leaderboards, and interactive challenges\u0026mdash;to create engaging and motivating learning environments.\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e It enhances self-directed learning by encouraging active participation and improving knowledge retention. Evidence suggests GBL is more effective than traditional teaching, offering benefits like intrinsic motivation, independence, timely feedback, progress tracking, and personalized challenges.\u003csup\u003e[\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite its potential to improve knowledge retention and engagement in health-professional education, GBL has strategic gaps that must be addressed to effectively support SDL in nursing education.\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e Significant research gaps encompass the long-term effects of GBL, its efficacy across diverse student demographics, and its influence on emotional and behavioral learning outcomes. Furthermore, while existing literature emphasizes the general benefits of GBL, it falls short in examining its specific influence on SDL competencies and the development of lifelong professional skills. There is also a notable lack of randomized controlled trials assessing the effects of GBL on SDL competencies among undergraduate nursing students.\u003c/p\u003e \u003cp\u003eThe study explores the effectiveness of a game-based learning intervention that is aligned with self-directed learning principles, utilizing a randomized controlled trial (RCT) to address existing methodological and population gaps. Its goal is to enhance the relationship between GBL and SDL skills among nursing students, thereby providing a foundation for evidence-based curriculum development and educational policy. The findings could facilitate the creation of customized GBL resources designed to better assist nursing students in navigating specific challenges in their field.\u003c/p\u003e \u003cp\u003eThe research introduces a framework that integrates self-determination theory (SDT)\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e with gamification to improve self-directed learning. It asserts that fulfilling psychological needs for autonomy, competence, and relatedness via gaming elements can enhance intrinsic motivation and yield favorable educational results. By employing Lander's theory of gamified learning\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e in conjunction with Garrison's model of self-directed learning, educators can cultivate stimulating environments that enable learners to assume control of their educational experiences and enhance their self-directed learning competencies.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates a framework in which gaming features address the psychological needs identified in Self-Determination Theory (SDT) by promoting learners' autonomy, skill development, and social connections through teamwork and competition. Participation in activities that incorporate gaming elements nurtures feelings of autonomy, competence, and belonging. This, in turn, boosts motivation, leading to increased engagement and persistence in educational tasks, improved problem-solving abilities, and enhanced academic performance.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eObjective\u003c/h3\u003e\n\u003cp\u003eThe primary objective was to compare the effect of game-based learning as an innovative self-directed learning strategy with the conventional self-directed learning strategy on knowledge acquisition and self-directed learning abilities in nursing undergraduates through a randomized controlled trial comparing impacts at 12 weeks and determining game-based learning's superiority.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHypothesis:\u003c/h2\u003e \u003cp\u003eH\u003csub\u003e1\u003c/sub\u003e: The incorporation of game-based learning as an innovative self-directed learning strategy will be superior to the conventional learning method in improving self-directed learning abilities among nursing undergraduates.\u003c/p\u003e \u003cp\u003eH\u003csub\u003e2\u003c/sub\u003e: Nursing students in the game-based learning group will have higher knowledge scores than those in the conventional learning group.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eTrial design\u003c/strong\u003e \u003cp\u003e This study was designed and reported in accordance with the CONSORT 2025 guidelines for randomized trials.\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e The study protocol was prospectively registered (CTRI/2024/01/061599) and received approval from the Institutional Ethics Committee of Datta Meghe Institute of Higher Education \u0026amp; Research (DMIHER(DU)/IEC/2023/141C).\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThis research was a prospective, randomized, controlled, data analyst-blinded, single-center superiority trial involving two parallel groups with a 1:1 allocation ratio. The follow-up period lasted 12 weeks, with assessments conducted at four time points: baseline (pre-test), immediate post-intervention, 4 weeks post-intervention, and 12 weeks post-intervention.\u003c/p\u003e \u003cp\u003eA flow diagram illustrating the progress through the phases of the randomized trial, including enrollment, intervention allocation, follow-up, and data analysis for the two groups, is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSetting\u003c/strong\u003e \u003cp\u003eThe study was conducted at Smt. Radhikabai Meghe Memorial College of Nursing (SRMMCON), Wardha, Maharashtra, India, an institution affiliated with Datta Meghe Institute of Higher Education \u0026amp; Research.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eParticipants\u003c/strong\u003e \u003cp\u003eThe accessible population consisted of 200 first- and third-semester B.Sc. Nursing students at SRMMCON. The inclusion criteria included (1) enrollment in the B.Sc. Nursing program, (2) being in the first or third semester of study, (3) agreeing to informed consent, (4) basic proficiency in English, and (5) access to a device with internet connectivity. The exclusion criteria were (1) prior formal training in antimicrobial resistance/stewardship, (2) a record of irregular class attendance, and (3) an expressed desire to withdraw.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eIntervention and comparator\u003c/h3\u003e\n\u003cp\u003eFollowing a pretest, all participants from both semesters attended a 90-minute structured teaching session that focused on the concept, importance, and process of self-directed learning. This session served as a common co-intervention for both groups and was conducted before the random assignment.\u003c/p\u003e\n\u003ch3\u003eExperimental Group (AMS Game)\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIntervention Components and Materials\u003c/b\u003e: The experimental group was exposed to the Antimicrobial Stewardship (AMS) game, an educational tool developed by the Commonwealth Partnerships for Antimicrobial Stewardship Programme (CwPAMS) and Focus Games Ltd. The game is designed to teach the fundamentals of antimicrobial resistance, stewardship, and infection control, encouraging group discussion and behavior change.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAdministration and Duration\u003c/b\u003e: The intervention began with an initial in-person gaming session where participants were organized into small teams. Following this, four subsequent gaming sessions were conducted online, once a week, for four weeks. Participants received unique login credentials to access the online sessions.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eControl Group (Information Booklet)\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eComparator Components and Materials\u003c/b\u003e: The researcher developed a standardized information booklet for the control group. This booklet addressed the same topics as the game, including antimicrobial resistance, antimicrobial stewardship, and infection control.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eAdministration and Duration\u003c/b\u003e: Participants were allotted one hour for an initial self-study session using the booklet. They were then encouraged to pursue further self-learning with the provided material over the next four weeks.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eProhibited Co-interventions\u003c/h2\u003e \u003cp\u003eTo avoid confounding factors that could affect the outcomes, neither group received formal lectures or additional instruction on antimicrobial resistance, stewardship, or infection control during the four-week intervention period.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStrategies to Improve Adherence and Fidelity\u003c/h3\u003e\n\u003cp\u003eSeveral strategies were implemented to promote adherence to the intervention protocols and maintain the fidelity of the trial's execution.\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eParticipant Adherence\u003c/b\u003e: Weekly reminders were sent to participants through WhatsApp and email to promote consistent participation. The researcher conducted weekly Zoom meetings to support self-directed learning techniques and to address any questions related to the learning methods. Adherence to the program was assessed using attendance records from the initial session as well as login data from four online gaming sessions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFidelity and Contamination Prevention\u003c/b\u003e: To reduce communication risks and prevent contamination between groups, participants were required to maintain the confidentiality of their assignments. The control group was informed that they would have access to the AMS game after the study, while the experimental group received unique login codes for online sessions, which required webcam usage for identity verification.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe trial assessed both primary and secondary outcomes at four time points: baseline, immediately after the intervention, 4 weeks post-intervention, and 12 weeks post-intervention, utilizing consistent data collection tools. The primary outcomes included knowledge and the Self-Directed Learning Instrument (SDLI) score, with the goal of determining whether game-based learning is more effective than traditional self-directed learning (SDL) in enhancing nursing undergraduates' knowledge and SDL skills. The secondary outcomes focused on the development of critical process and performance skills, allowing for a thorough evaluation of the learning strategies' impacts across cognitive, affective, and psychomotor domains.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePrimary Outcomes\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eKnowledge acquisition: Knowledge acquisition was evaluated using a 15-item multiple-choice questionnaire that was developed by researchers (see Supplementary File S1) and validated for its focus on antimicrobial resistance, antimicrobial stewardship, and infection control. Scores on the questionnaire ranged from 0 to 15 and were classified into three categories: inadequate (\u0026le;\u0026thinsp;50%, score\u0026thinsp;\u0026le;\u0026thinsp;7.5), moderately adequate (51\u0026ndash;75%, score 7.6\u0026ndash;11.25), and adequate (\u0026gt;\u0026thinsp;75%, score\u0026thinsp;\u0026gt;\u0026thinsp;11.25). Content validity was established through an expert review, while reliability was confirmed with a Cronbach\u0026rsquo;s alpha of 0.78 and an intraclass correlation coefficient (ICC) of 0.80 from test\u0026ndash;retest evaluations. The English language version of the questionnaire has been uploaded as a supplementary file. To assess knowledge improvement and retention, the differences in pre- and post-intervention scores between groups were analyzed.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSelf-Directed Learning (SDL) Abilities: Self-Directed Learning (SDL) abilities were evaluated using the Self-Directed Learning Instrument (SDLI)\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e, which consists of 20 items rated on a five-point Likert scale, covering areas such as learning motivation, planning and implementing, self-monitoring, and interpersonal communication. Total scores range from 20 to 100, with higher scores indicating greater SDL ability. The SDLI exhibits strong reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.916) and has been validated through Delphi studies. The intervention's effectiveness was assessed by comparing pre- and postintervention SDLI scores between groups.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSecondary Outcomes\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCAP Perceived Learning Competency: This competency was assessed using the Cognitive, Affective, and Psychomotor (CAP) Perceived Learning Scale, which consists of nine items rated on a six-point Likert scale. Developed by Rovai et al. (2009)\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e, this scale provides sub scores for cognitive, affective, and psychomotor learning, with a maximum possible score of 54. Higher scores reflect a greater perceived level of learning. The scale has demonstrated internal consistency (α\u0026thinsp;=\u0026thinsp;0.79) and has established concurrent validity. Notable improvements in post-intervention scores in the experimental group compared to the control group underscore the effectiveness of the intervention.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eData collectors and outcome assessors were not involved in intervention delivery. The data analyst was blinded to group allocation throughout the analysis phase.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eHarms\u003c/h2\u003e \u003cp\u003eDuring the 12-week trial, we closely monitored and documented any negative effects reported by participants. Both interventions were non-pharmacological: the experimental group engaged in game-based self-directed learning, while the control group utilized conventional learning with printed materials. Therefore, we did not expect or observe any significant adverse events. We prioritized participant safety by encouraging students to share any discomfort during our weekly zoom meetings or through email and WhatsApp. We paid special attention to potential sources of stress, such as technical difficulties, time constraints, or feelings of inadequacy experienced while engaging in self-directed tasks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eThe target sample size for the trial was predetermined to ensure adequate statistical power to detect a significant difference between the experimental group utilizing game-based self-directed learning and the control group using conventional methods. This decision was informed by a meta-analysis by Bai et al. (2020)\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e, which indicated that gamification had a medium effect size (Cohen's d\u0026thinsp;=\u0026thinsp;0.5) on student learning outcomes. The study sought to determine similar effects on knowledge acquisition and self-directed learning (SDL) ability.\u003c/p\u003e \u003cp\u003eUsing G*Power version 3.1.9.7, a two-sample comparison of means was performed, establishing a required minimum of 64 participants per group at a two-sided alpha level of 0.05 with 80% power. To account for a potential 10% attrition rate during a 12-week follow-up, the sample size was increased to 70 participants per group, resulting in a total of 140 enrolled students. This calculation was in line with the main analytic plan, which aimed to use ANCOVA to compare adjusted mean differences in knowledge and SDL ability (SDLI) scores at the 12th week while taking into account baseline scores and covariates like age, semester, and previous exposure to game-based learning to avoid confounding variables.\u003c/p\u003e \u003cp\u003eAll participants were included in an intention-to-treat analysis with no follow-up losses, thereby achieving the desired sample size. The analysis confirmed that the sample was sufficient to detect the hypothesized effects, as evidenced by narrow confidence intervals and high model explanatory power (R\u0026sup2; = 0.877 for knowledge and R\u0026sup2; = 0.986 for SDLI) in the final ANCOVA models.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRandomization and allocation concealment\u003c/h2\u003e \u003cp\u003eParticipants were randomized in a 1:1 ratio into either a game-based self-directed learning (experimental) group or a conventional self-directed learning (control) group to ensure balanced allocation and minimize selection bias. Randomization was stratified by academic semester to address differences in baseline knowledge and self-directed learning (SDL) experience between junior and senior students. An independent researcher generated the allocation sequence using computer-generated random numbers from R software (version 4.4). A permuted block design with varying block sizes (4 and 8) was employed to reduce predictability while maintaining group balance throughout the enrollment process.\u003c/p\u003e \u003cp\u003eUpon confirming eligibility and obtaining informed consent, each participant was assigned a unique identification number. Allocation envelopes, which were sequentially numbered, opaque, and sealed, were prepared by the independent researcher and securely stored to remain inaccessible to the study team. These envelopes were opened only after baseline data collection and prior to the intervention. The success of the randomization process was verified by analyzing baseline demographic and outcome variables, which revealed no statistically significant differences between the groups (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), thereby affirming the integrity of the allocation process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBlinding\u003c/h2\u003e \u003cp\u003eIn a study comparing a game-based self-directed learning intervention to conventional self-study, blinding of participants and the researcher was not feasible. Nevertheless, two strategies were employed to ensure objective assessment: outcome measures were collected using self-administered electronic questionnaires, and the data analyst remained blinded throughout the analysis process. Datasets were de-identified and labeled by an independent researcher to prevent bias during statistical modeling and result reporting. Although a formal assessment of blinding success was not conducted, the combination of self-reported outcomes and blinded data analysis mitigated the risk of bias, in line with best practices for non-pharmacological randomized studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStatistical methods\u003c/h2\u003e \u003cp\u003eThe analysis was conducted using R software (version 4.4) with a significance level of α\u0026thinsp;=\u0026thinsp;0.05. It began with a verification of data completeness and an assessment of distribution using the Shapiro\u0026ndash;Wilk test. The majority of outcomes exhibited deviations from normality, necessitating the utilization of non-parametric methods for data summarization and comparisons. Continuous variables were reported as medians with interquartile ranges, while categorical variables were presented as frequencies and percentages. The Wilcoxon rank-sum test was employed to examine differences between groups for continuous outcomes, and Pearson's chi-square or Fisher's exact test was utilized for categorical variables. For the primary outcomes\u0026mdash;knowledge scores and SDLI scores at 12 weeks\u0026mdash;ANCOVA models were used to estimate adjusted mean differences, taking into account baseline values and covariates such as age, gender, academic semester, residential status, and prior exposure to game-based learning. Robust standard errors addressed heteroscedasticity, and model adequacy was evaluated through R\u0026sup2; values, which were found to be high for both outcomes.\u003c/p\u003e \u003cp\u003eSensitivity analyses confirmed the robustness of the findings across various model specifications. All participants who completed randomization were included in the intention-to-treat analysis, achieving complete follow-up with no exclusions for missing data. All analyses adhered to the original group allocation, and no interim analyses were conducted that could have influenced the trial\u0026rsquo;s conduct or interpretation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Flow\u003c/h2\u003e \u003cp\u003eThe trial, which took place from September to December 2024 at Smt. Radhikabai Meghe Memorial College of Nursing in Wardha, India, included 200 eligible undergraduate nursing students. Out of these, 140 students were randomly selected and assigned in a 1:1 ratio to either a game-based self-directed learning (experimental) group or a conventional self-directed learning (control) group. All participants completed the 12-week study without any dropouts and attended all assessments, which consisted of baseline, immediate post-test, 4-week follow-up, and 12-week follow-up, as detailed in the CONSORT flow diagram.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment\u003c/h2\u003e \u003cp\u003eThe recruitment process for the study occurred from September 10 to September 16, 2024, involving first- and third-semester B.Sc. Nursing students. Eligible participants needed to be enrolled in the nursing program, have basic English skills, possess internet access, and have no prior training in antimicrobial stewardship or infection control. Written informed consent was obtained before participation in the study. A stratified randomization method was employed to ensure balanced representation, selecting 70 students from each semester across the trial groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eIntervention and Comparator Delivery\u003c/h2\u003e \u003cp\u003e The experimental intervention consisted of a structured self-directed learning (SDL) program that was followed by the Antimicrobial Stewardship (AMS) educational game. This game was developed by the Commonwealth Partnerships for Antimicrobial Stewardship Programme (CwPAMS) in collaboration with Focus Games Ltd. Following a 90-minute orientation session focused on SDL principles, participants in the experimental group engaged in four weekly online sessions, each lasting 60 minutes, where they played the AMS game over a four-week period. These sessions were conducted via Zoom, allowing participants to collaborate in small teams. The researcher acted solely as a facilitator, providing technical support and encouraging peer discussion, without delivering any instructional content. Attendance was monitored through mandatory camera use and session logs.\u003c/p\u003e \u003cp\u003eThe participants in the control group received the same self-directed learning (SDL) orientation as those in the experimental group. Subsequently, they were given a detailed printed learning booklet that covered topics such as antimicrobial resistance, stewardship, and infection control. They were instructed to engage in self-study for one hour immediately following the orientation and to continue their independent study using the same materials over the next four weeks. Unlike the experimental group, this group did not have access to any interactive or gamified elements. To support the self-directed learning process, both groups were offered weekly Zoom check-ins to address logistical questions. However, it is important to note that these sessions did not include any content instruction to avoid potential contamination of the study.\u003c/p\u003e \u003cp\u003eBoth groups had a high level of adherence, with all participants attending all scheduled sessions and finishing all assessments. Technical support was provided to five participants in the experimental group who experienced brief connectivity issues during gaming sessions; these issues were resolved promptly without affecting participation or data completeness. There were no changes to the assigned interventions, and no participants switched groups. At the end of the 12-week follow-up, all participants in the control group were granted access to the AMS game as part of the post-trial benefit, in accordance with the study\u0026rsquo;s ethical commitment to equity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Data\u003c/h2\u003e \u003cp\u003eThe baseline characteristics are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The two groups exhibited a satisfactory balance concerning key demographic and academic variables. Most participants were female (70.0%) and aged 20 years or younger (85.7%), with equal representation from first- and third-semester cohorts (50% each). Additionally, residential status and prior experience with game-based learning were similarly distributed between the groups.\u003c/p\u003e \u003cp\u003eThe pre-intervention scores for all primary and secondary outcomes\u0026mdash;including knowledge, total and subscale scores from the Self-Directed Learning Instrument (SDLI), as well as perceived CAP learning scores (cognitive, affective, and psychomotor)\u0026mdash;revealed no statistically significant differences (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The median baseline knowledge scores were 7.0 [6.0\u0026ndash;9.0] for the experimental group and 7.0 [6.0\u0026ndash;8.0] for the control group (p\u0026thinsp;=\u0026thinsp;0.96), while the median SDLI scores were 55.0 [45.0\u0026ndash;66.0] for the experimental group and 55.0 [45.0\u0026ndash;64.0] for the control group (p\u0026thinsp;=\u0026thinsp;0.96). These results confirm successful randomization and establish a comparable foundation for assessing the effects of the intervention.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline demographic, academic, and outcome characteristics of participants by study group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eStratified\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN\u0026thinsp;=\u0026thinsp;140\u003c/b\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eExperimental Group\u003c/b\u003e \u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;70\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eControl Group\u003c/b\u003e \u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;70\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;= 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (85.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (49.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (51.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSemester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst semester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThird semester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith relatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlone in rented room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn college hostel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (22.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (59.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior exposure to GBL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-knowledge score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.0 (6.0, 9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.0 (6.0, 9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.0 (6.0, 8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-Learning motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.0 (19.0, 25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.0 (19.0, 26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.0 (19.0, 25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-Planning \u0026amp; implementing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.0 (9.5, 14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0 (9.0, 15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.0 (10.0, 14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-Self-monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0 (8.0, 12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0 (8.0, 12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.0 (9.0, 12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-Interpersonal communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.0 (8.0, 13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.0 (9.0, 13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.0 (8.0, 14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-SDLI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.0 (45.0, 65.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.0 (45.0, 66.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.0 (45.0, 64.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-Perceived cognitive learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0 (8.0, 10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.0 (8.0, 10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0 (8.0, 10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre_Perceived affective learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0 (8.0, 10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.0 (8.0, 11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0 (8.0, 10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre_Perceived psychomotor learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0 (8.0, 10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.0 (8.0, 10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0 (8.0, 10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre_CAP Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.0 (24.0, 30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.0 (25.0, 31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.0 (24.0, 30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest knowledge level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (59.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (50.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (49.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately adequate knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (40.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (49.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (50.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest SDL level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow SDL ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (63.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43 (48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate SDL ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (33.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh SDL Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003en (%); Median (Q1, Q3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003ePearson's Chi-squared test; Fisher's exact test; Wilcoxon rank sum test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eNumbers Analyzed, Outcomes, and Estimation\u003c/h2\u003e \u003cp\u003eAll 140 randomized participants completed the 12-week follow-up without any attrition or exclusions. The intention-to-treat analysis encompassed the entire cohort, with 70 participants in each group providing complete outcome data at four assessment points. No imputation was necessary, and the analyses preserved the original group allocations. At the 12-week follow-up, the experimental group demonstrated significantly greater improvements across all measured domains.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePrimary outcomes:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eKnowledge acquisition\u003c/strong\u003e \u003cp\u003eAt 12 weeks, the experimental group demonstrated significantly higher median knowledge scores [12.0 (11.0\u0026ndash;13.0)] compared to the control group [9.0 (7.0\u0026ndash;11.0); p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. No participants in the experimental group displayed inadequate knowledge, while 27.1% of the control group did. Furthermore, over 60% of the participants in the experimental group achieved adequate knowledge, in contrast to only 14.3% of those in the control group. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEndline knowledge outcomes at 12 weeks by study group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall \u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;140\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"A\" Group \u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;70\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"B\" Group \u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;70\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12th week Posttest knowledge score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.0 (9.0,12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0 (11.0,13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0 (7.0,11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12th week posttest level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (27.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately adequate knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (38.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (58.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequate knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (61.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003eMedian (Q1,Q3); n (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003eWilcoxon rank sum test; Pearson's Chi-squared test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe scores in the experimental group increased significantly from the baseline [7.0 (6.0\u0026ndash;9.0)] to the 12-week score [12.0 (11.0\u0026ndash;13.0)]. In contrast, the control group exhibited only a slight improvement, moving from 7.0 (6.0\u0026ndash;8.0) to 9.0 (7.0\u0026ndash;11.0). (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAs presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, after adjusting for baseline knowledge scores using ANCOVA, participants in the experimental group obtained significantly higher knowledge scores than those in the control group (adjusted mean difference \u0026minus;\u0026thinsp;3.1, 95% CI \u0026minus;\u0026thinsp;3.4 to \u0026minus;\u0026thinsp;2.8; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a strong effect of the game-based intervention. Baseline knowledge served as a significant predictor of the 12-week scores (β\u0026thinsp;=\u0026thinsp;0.92, 95% CI 0.83\u0026ndash;1.0; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, other covariates\u0026mdash;such as age, sex, semester, residence, and prior exposure to game-based learning\u0026mdash;did not exhibit a significant association with endline knowledge. The model demonstrated a satisfactory fit, with R\u0026sup2; = 0.877 and adjusted R\u0026sup2; = 0.868, accounting for nearly 88% of the variance in endline knowledge scores.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eANCOVA results for knowledge outcomes at 12 weeks (robust HC3 estimates)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge (Posttest3) ANCOVA \u0026mdash; robust (HC3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBeta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-3.4 to -2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre_Knowledge Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.83 to 1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;= 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.48 to 0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.44 to 0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSemester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst semester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThird semester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.49 to 0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith relatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.16 to 1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.77 to 0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlone in rented room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.32 to 0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn college hostel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.38 to 0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior exposure to Game based Learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.59 to 0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.877\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjusted R\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.868\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLog-likelihood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e429\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeviance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidual df\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. Obs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAbbreviation: CI\u0026thinsp;=\u0026thinsp;Confidence Interval\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSelf‑Directed Learning Abilities\u003c/strong\u003e \u003cp\u003eBy 12 weeks, participants in the experimental group demonstrated significantly higher Self-Directed Learning Inventory (SDLI) scores [72.0 (64.0\u0026ndash;78.0)] compared to the control group [59.0 (49.0\u0026ndash;67.0); p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Over 22.9% of the experimental group achieved the highest SDLI level, whereas only 2.9% of the control group did. Additionally, more than half of the control group (55.7%) remained at the lowest level, in contrast to 17.1% in the experimental group (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAll process-related outcomes favored the experimental group at 12 weeks. Median scores were significantly higher for learning motivation [28.0 (26.0\u0026ndash;30.0) vs 23.0 (20.0\u0026ndash;26.0)], planning and implementation [16.0 (13.0\u0026ndash;18.0) vs 13.0 (11.0\u0026ndash;15.0)], self-monitoring [13.0 (11.0\u0026ndash;15.0) vs 11.0 (9.0\u0026ndash;13.0)], and interpersonal communication [15.0 (13.0\u0026ndash;17.0) vs 12.0 (10.0\u0026ndash;14.0)]; all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEndline self-directed learning (SDLI) outcomes at 12 weeks by study group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall \u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;140\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental Group \u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;70\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003eGroup \u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;70\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12th week posttest SDLI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.0 (57.0,75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.0 (64.0,78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.0 (49.0,67.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12th week posttest SDLI level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow SDL abilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (55.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate SDL abilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (50.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (41.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh SDL abilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (22.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003eMedian (Q1,Q3); n (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003eWilcoxon rank sum test; Pearson's Chi-squared test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn longitudinal trend, the experimental group showed significant improvements from a baseline score of 55.0 to 72.0 over 12 weeks, while the control group experienced minimal increases, moving from 55.0 to 59.0. (see Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe ANCOVA results indicated that the experimental group had significantly higher SDLI scores compared to the control group, with an adjusted mean difference of \u0026minus;\u0026thinsp;12 (95% CI \u0026minus;\u0026thinsp;13 to \u0026minus;\u0026thinsp;12; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Baseline SDLI was identified as a strong predictor (β\u0026thinsp;=\u0026thinsp;0.86, 95% CI 0.84\u0026ndash;0.88; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, female gender was associated with lower scores (β = \u0026minus;\u0026thinsp;0.64, 95% CI \u0026minus;\u0026thinsp;1.2 to \u0026minus;\u0026thinsp;0.06; p\u0026thinsp;=\u0026thinsp;0.032), while living with relatives correlated with higher scores (β\u0026thinsp;=\u0026thinsp;1.3, 95% CI 0.16\u0026ndash;2.4; p\u0026thinsp;=\u0026thinsp;0.025). Other variables, such as age and previous exposure to game-based learning, did not show significant effects. The model fit was excellent (R\u0026sup2; = 0.986, adjusted R\u0026sup2; = 0.985), accounting for nearly 99% of the variance in SDLI outcomes. (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eANCOVA results for self-directed learning (SDLI) outcomes at 12 weeks (robust HC3 estimates)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDLI (Posttest3) ANCOVA \u0026mdash; robust (HC3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBeta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-13 to -12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre SDLI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.84 to 0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;= 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.50 to 1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.2 to -0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSemester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst semester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThird semester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.77 to 0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith relatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.16 to 2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.1 to 1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlone in rented room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.28 to 1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn college hostel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.62 to 0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior exposure to Game based Learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.19 to 1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjusted R\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e940\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLog-likelihood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e530\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e565\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeviance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidual df\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. Obs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAbbreviation: CI\u0026thinsp;=\u0026thinsp;Confidence Interval\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eSecondary outcomes:\u003c/h2\u003e \u003cp\u003e \u003cb\u003eCAP perceived learning outcome\u003c/b\u003e: The CAP perceived learning outcomes revealed significant differences at the 12th-week assessment. The experimental group outperformed the control group in several areas: perceived cognitive learning [12.0 (11.0\u0026ndash;13.0) vs 9.0 (8.0\u0026ndash;10.0)], perceived affective learning [11.0 (10.0\u0026ndash;12.0) vs 9.0 (8.0\u0026ndash;10.0)], perceived psychomotor learning [12.0 (11.0\u0026ndash;13.0) vs 9.0 (8.0\u0026ndash;10.0)], and the overall CAP perceived learning score [35.0 (31.0\u0026ndash;39.0) vs 27.0 (23.0\u0026ndash;30.0)]. All comparisons showed statistical significance with p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e illustrates the longitudinal trend of the CAP perceived learning outcomes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eHarms\u003c/h2\u003e \u003cp\u003eBoth interventions exhibited a low-risk educational nature, with no serious adverse events reported. Five participants experienced minor technical difficulties, but real-time support promptly resolved these issues. Furthermore, we observed no psychological distress or negative emotional responses, confirming the trial's minimal risk and eliminating the need for formal harm grading.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eAncillary Analyses\u003c/h2\u003e \u003cp\u003eSensitivity analyses indicated that experimental group participants outperformed the control group at 12 weeks across various statistical models, including ANOVA and ANCOVA, with significant results (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSensitivity analyses of knowledge and SDLI outcomes using alternative model specifications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContrast (Grp)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStd. Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCI Lower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCI Upper\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) ANOVA (lm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.057143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.3558943\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.760854\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.353432\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) ANOVA (lm) \u0026mdash; robust SE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.057143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.3558943\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.760854\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.353432\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3) ANCOVA (baseline only)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.057143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1575639\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.368715\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.745571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4) ANCOVA (baseline only) \u0026mdash; robust SE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.057143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1575639\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.368715\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.745571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5) ANCOVA (baseline\u0026thinsp;+\u0026thinsp;covars)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.103189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1681226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.435824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.770554\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6) ANCOVA (baseline\u0026thinsp;+\u0026thinsp;covars) \u0026mdash; robust SE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.103189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1681226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.435824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.770554\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) ANOVA (lm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-12.128571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.8934694\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-15.872535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-8.384608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) ANOVA (lm) \u0026mdash; robust SE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-12.128571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.8934694\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-15.872535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-8.384608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3) ANCOVA (baseline only)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-12.128571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2667263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-12.656004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-11.601138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4) ANCOVA (baseline only) \u0026mdash; robust SE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-12.128571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2667263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-12.656004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-11.601138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5) ANCOVA (baseline\u0026thinsp;+\u0026thinsp;covars)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-12.291287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2730362\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-12.831496\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-11.751078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6) ANCOVA (baseline\u0026thinsp;+\u0026thinsp;covars) \u0026mdash; robust SE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group vs Exp. Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-12.291287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2730362\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-12.831496\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-11.751078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLongitudinal trends show a notable improvement in the experimental group, whereas the control group's gains plateaued following the post-test. Post hoc analyses categorized by semester and gender found no significant interactions, which affirms the reliability of the intervention effects. Ancillary findings reinforce the validity of the primary results and highlight game-based self-directed learning as an effective educational strategy for nursing undergraduates.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe randomized controlled trial validates the hypothesis that incorporating game-based learning (GBL) into a self-directed learning (SDL) framework significantly enhances knowledge acquisition and SDL skills among undergraduate nursing students compared to traditional SDL approaches. Over a 12-week period, participants who engaged with an Antimicrobial Stewardship (AMS) educational game demonstrated significant improvements in their understanding of antimicrobial resistance and stewardship, as well as notable increases in their Self-Directed Learning Instrument (SDLI) scores. These improvements remained significant even after controlling for baseline performance and other variables. Notable advancements were observed across various SDL dimensions, including motivation, planning, self-monitoring, and interpersonal communication, in addition to perceived cognitive, affective, and psychomotor learning. The study indicated no significant adverse events; minor technical difficulties encountered by certain GBL participants were promptly addressed and did not affect overall participation or data integrity. These findings align with existing research that supports innovative, student-centered teaching strategies aimed at better preparing nursing students for the challenges of modern healthcare.\u003c/p\u003e \u003cp\u003eOur findings support and expand upon the existing literature regarding game-based learning (GBL) in health professions education. Previous systematic reviews by Xu et al. (2021), Tavares (2022), and Kuruca Ozdemir et al. (2022) have shown that GBL positively affects knowledge retention, motivation, and engagement among nursing students.\u003csup\u003e[\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e However, these studies primarily employed quasi-experimental designs and often lacked long follow-up periods or valid measures of self-directed learning. In contrast, our study utilized a rigorous randomized controlled trial (RCT) design and incorporated a psychometrically validated tool, the Self-Directed Learning Instrument (Cheng et al., 2009), within a 12-week longitudinal framework to address these methodological limitations. Additionally, our emphasis on process-oriented outcomes, such as self-monitoring and interpersonal communication, offers greater clarity about how GBL fosters self-directed learning (SDL), rather than simply confirming its existence.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eEnhancement of Knowledge Acquisition\u003c/h2\u003e \u003cp\u003eA key finding of the trial was the significant improvement in knowledge acquisition and long-term retention observed in the experimental group using game-based learning (GBL) compared to the control group. At the 12-week follow-up, the GBL group achieved notably higher knowledge scores and demonstrated a transition toward \"adequate\" knowledge levels, a milestone reached by only a small fraction of the control group. This finding supports existing literature that endorses GBL as an effective educational approach. For example, a longitudinal study by Samuel et al. found that nursing students who participated in digital learning games during anatomy and physiology courses scored higher on final exams, indicating better long-term retention.\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurthermore, research by Abumettleq et al. (2023) showed that a game-based instructional method enhanced understanding of Enhanced Recovery After Surgery (ERAS) protocols compared to standard lectures.\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e A systematic review of serious games also revealed that nursing students gained significant knowledge through these tools compared to traditional teaching strategies.\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003eThe GBL intervention created an engaging learning environment that improved cognitive processing and retention, unlike traditional lecture-based methods that encourage passive learning. These results suggest that GBL is an effective pedagogical tool for mastering complex clinical information, rather than a transient trend, underscoring its potential to enhance academic performance and critical thinking among nursing students.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eThe development of Self-Directed Learning Abilities\u003c/h2\u003e \u003cp\u003eThe trial demonstrated that GBL significantly improves students' self-directed learning capabilities. This is evidenced by higher scores on the Self-Directed Learning Instrument (SDLI), particularly in the areas of learning motivation, planning and implementation, self-monitoring, and interpersonal communication. This finding addresses the pressing need in nursing education for skills that can adapt to the changing healthcare landscape, as SDL principles are essential to learner-centered strategies.\u003c/p\u003e \u003cp\u003eThe GBL intervention was based on Self-Determination Theory (SDT), which highlights that satisfying the needs for autonomy, competence, and relatedness boosts intrinsic motivation\u0026mdash;an essential aspect of Self-Directed Learning (SDL). Game elements provided learners with autonomy by granting them control over their learning pace and methods, enhanced competence through structured challenges and feedback, and fostered relatedness through collaborative teamwork. This study aligns with existing research, particularly the findings of Moon (2023), which indicate that motivation is a predictor of SDL capabilities.\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003eThe findings indicated that participants involved in GBL exhibited heightened learning motivation, evidenced by elevated scores on the SDLI. Furthermore, studies on gamification and flipped classrooms support the positive effects on motivation outcomes.\u003c/p\u003e \u003cp\u003eMoreover, GBL improved SDL abilities, particularly in planning, implementation, and self-monitoring\u0026mdash;key principles where learners assess their progress. Topcu (2023) identified similar gains in metacognitive self-regulation through GBL approaches.\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e Additionally, the improvement in interpersonal communication skills highlights how collaborative gaming sessions foster peer learning and encourage seeking assistance, both of which are essential educational strategies. These findings suggest that GBL not only enhances motivation but also equips students with the necessary skills for effective self-directed learning, thereby contributing to career adaptability, which is crucial for nursing professionals, as noted by Park (2021).\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eComparison with Other Innovative Pedagogies\u003c/h2\u003e \u003cp\u003eThe findings from our game-based learning (GBL) intervention align with existing research on innovative, student-centered teaching methods, such as flipped classrooms (FC) and problem-based learning (PBL). Liu et al. (2018) found that FC significantly enhances nursing students' SDL skills, including motivation and self-management, when compared to traditional pedagogical approaches.\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e Additionally, studies by Dadgari et al. (2020) and Khodaei et al. (2022) demonstrated that FC improves SDL readiness scores.\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e Furthermore, studies have demonstrated that blended learning strategies effectively enhance SDL readiness, particularly in the areas of self-management and self-control.\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePBL, similar to GBL, emphasizes collaborative problem-solving and has been associated with enhanced SDL. A meta-analysis conducted by Chen et al. (2024) confirmed that PBL improves SDL performance and problem-solving abilities. Additionally, Wong and Kan (2022) found that an online PBL initiative led to lasting improvements in SDL readiness.\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGBL's distinguishing factor is its ability to intrinsically motivate digital-native learners. While FC and PBL promote active learning, GBL incorporates game elements such as competition and instant rewards. This integration significantly enhances student enjoyment and engagement, as noted by Panesar-Aguilar et al. (2023).\u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e The resulting increase in motivation is likely crucial to GBL's effectiveness in improving knowledge acquisition and SDL abilities.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImplications, Limitations, and Future Directions\u003c/h3\u003e\n\u003cp\u003eThe trial results highlight the significant advantages of the Game-Based Learning (GBL) strategy in nursing education, advocating for its incorporation into curricula to enhance lifelong learning skills in professional practice. The randomized controlled trial (RCT) effectively illustrates the positive impact of GBL on self-directed learning (SDL) among undergraduate nursing students. However, the study's limitations, particularly its single-center design, make it imperative to conduct future research in varied settings and populations. Furthermore, even though the trial did not report any adverse events, future implementations should consider potential challenges like technological stress. Long-term studies are recommended to evaluate the enduring effects of GBL on SDL and professional practice.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this trial provides strong evidence that a Game-Based Learning (GBL) strategy is an effective and superior alternative to conventional methods for improving knowledge acquisition and fostering self-directed learning skills in undergraduate nursing students. By creating an engaging, motivating, and autonomous learning environment, GBL encourages students to actively participate in their education, preparing them for the challenges of a constantly changing healthcare landscape.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAMS: Antimicrobial Stewardship\u003c/p\u003e\n\u003cp\u003eCAP: Cognitive, Affective, and Psychomotor\u003c/p\u003e\n\u003cp\u003eFC: Flipped Classroom\u003c/p\u003e\n\u003cp\u003eGBL: Game-based Learning\u003c/p\u003e\n\u003cp\u003ePBL: Problem-based Learning\u003c/p\u003e\n\u003cp\u003eRCT: Randomized Controlled Trial\u003c/p\u003e\n\u003cp\u003eSDL: Self-Directed Learning\u003c/p\u003e\n\u003cp\u003eSDLI: Self-Directed Learning Instrument\u003c/p\u003e\n\u003cp\u003eSDT: Self-determination Theory\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Approved by the Institutional Ethics Committee of Datta Meghe Institute of Higher Education \u0026amp; Research (DMIHER(DU)/IEC/2023/141C). Written informed consent was obtained from those willing to participate.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets, statistical code, and other materials used during the current study will be made available from the corresponding author on reasonable request.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests. The AMS gaming application for study was purchased in retail; Focus Game has no role in the study.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The author(s) received no specific funding for this work.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e SC conceptualized the trial and drafted the initial manuscript, the CONSORT checklist and figure, the subsequent edits and revision of the manuscript, and the final manuscript. ALS offered suggestions on trial design, critically reviewed the initial draft, suggested comments and revisions and added the texts to the manuscript. Both authors contributed to refinement of the study and approved the final manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors would like to acknowledge Chien-Lin Kuo for granting permission to use the SDLI tool and Dr. Mervyn J. Wighting for granting permission to use the CAP perceived learning scale in this study. The authors are grateful to Mr. Suman Sapkota for his expert execution of the statistical data analysis.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eProtocol and statistical analysis plan:\u003c/strong\u003e It can be accessed in the study protocol published in PLOS One with the title \"Impact of self-directed learning strategy, an innovative method in nursing undergraduates: Study protocol for a randomized controlled trial.\" DOI: https://doi.org/10.1371/journal.pone.0325300.\u003csup\u003e[41]\u003c/sup\u003e\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMurad MH, Coto-Yglesias F, Varkey P, Prokop LJ, Murad AL. The effectiveness of self-directed learning in health professions education: a systematic review. 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Educ Res Int. 2021;(2):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVisiers-Jim\u0026eacute;nez L, Palese A, Brugnolli Anna, Cadorin L, Salminen L, Leino-Kilpi Helena, L\u0026ouml;yttyniemi E, Nemcov\u0026aacute; J, et al. Nursing students\u0026rsquo; self-directed learning abilities and related factors at graduation: A multi-country cross-sectional study. Nurs Open. 2022;9(3):1688\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChakraborty S. Empowering and Engaging Adult Learners: Strategies to facilitate Self-directed learning in adult education. Int J Multidisciplinary Res. 2024;6(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTao Y, Li L, Xu Q, Jiang A. Development of a nursing education program for improving Chinese undergraduates\u0026rsquo; self-directed learning: A mixed-method study. 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BMJ. 2025;388:e081123.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng SF, Kuo CL, Lin KC, Lee-Hsieh J. Development and preliminary testing of a self-rating instrument to measure self-directed learning ability of nursing students. Int J Nurs Stud. 2010;47(9):1152\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRovai AP, Wighting MJ, Baker JD, Grooms LD. Development of an instrument to measure perceived cognitive, affective, and psychomotor learning in traditional and virtual classroom higher education settings. Internet High Educ. 2009;12(1):7\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBai S, Hew KF, Huang B. Does gamification improve student learning outcome? Evidence from a meta-analysis and synthesis of qualitative data in educational contexts. Educ Res Rev. 2020;30:100322.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamuel VM, Llaguno MBB, Mary Beth MR, Cabalsa MO, Mahmoud HM. Digital Gamification: An Innovative Pedagogy for Anatomy and Physiology Course Among Medical-Surgical Nursing Students. Assiut Sci Nurs J. 2022;10(28):1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbumettleq ISS, Bayraktar N, Dikmen B. Totur Effectiveness of Game-Based Teaching Method on Nursing Students\u0026rsquo; Knowledge of Enhanced Recovery After Surgery (ERAS). Iran Red Crescent Med J. 2024;26(1):e211817.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNascimento KGD, Ferreira MBG, Felix MMDS, Da Silva Garcia Nascimento J, Chavaglia SRR, Barbosa MH. Effectiveness of the serious game for learning in nursing: systematic review. Revista Ga\u0026uacute;cha De Enfermagem. 2021;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoon MY. Effects of online class satisfaction, Professor-Student interaction, and learning motivation on Self-Directed learning ability of nursing students applying the blended learning. JRTDD. 2023;6(1):19\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTopcu S. The Effect of Game-Based Learning on Motivation and Learning Strategies of Nursing Students in Occupational Health Nursing Course. BIK. 2023 Feb. 1;16(1):68\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu YQ, Li YF, Lei MJ, Liu PX, Theobald J, Meng LN, et al. Effectiveness of the flipped classroom on the development of self-directed learning in nursing education: A meta-analysis. Front Nurs. 2018;5(4):317\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDadgari A, Bagheri I, Salmani N. The Effect of Flipped Education on the Self-directed Learning Readiness of Nursing Students. Edu Stra Med Sci. 2020;13(4):287\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhodaei S, Hasanvand S, Gholami M, Mokhayeri Y, Amini M. The effect of the online flipped classroom on self-directed learning readiness and metacognitive awareness in nursing students during the COVID-19 pandemic. BMC Nurs. 2022;21(1):22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovindan SN, Singh HKD, Ling Lee W, Sekar M. Effect of blended self-directed learning on nursing students: Quasi-experimental approach. J Educ Health Promot. 2023;12(1):229.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen SL, Liao IC. Effectiveness of Using a Self-Directed Learning Program to Teach Physical Examination and Health Assessment Skills: A Quasi-Experimental Study. J Nurs Res. 2024;32(2):e320.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong FMF, Kan CWY. Online Problem-Based Learning Intervention on Self-Directed Learning and Problem-Solving through Group Work: A Waitlist Controlled Trial. Int J Environ Res Public Health. 2022;19(2):720.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanesar-Aguilar S, Margaret Trnka, Cale C. JFK School of Psychology and Social Sciences, Michelle McCraney. Improving Student Engagement in Nursing Education through Game-Based Learning. Res Humanit Social Sci. 2023;13(12):29\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaudhary S, Singh AL. Impact of self-directed learning strategy, an innovative method in nursing undergraduates: Study protocol for a randomized controlled trial. PLoS ONE. 2025;20(7):e0325300.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Game-based learning, Nursing education, Randomized controlled trial, Self-directed learning, Self-directed learning instrument (SDLI), CONSORT 2025","lastPublishedDoi":"10.21203/rs.3.rs-7801690/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7801690/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNursing education is adapting to advancing healthcare technologies and changing patient needs. Self-directed learning (SDL) is essential for fostering lifelong learning among nursing students. Game-based learning (GBL) has emerged as a novel approach to improve engagement and SDL skills, yet its effectiveness against traditional methods in nursing undergraduates is still not well studied.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study is a prospective, randomized, controlled trial aimed at evaluating the effectiveness of game-based learning (GBL) as an innovative self-directed learning strategy compared to conventional self-directed learning (SDL) in nursing education. Conducted at Smt. Radhikabai Meghe Memorial College of Nursing in India, it involved 140 nursing undergraduates who were randomly assigned to either an experimental group using an antimicrobial stewardship game or a control group utilizing traditional learning materials. Each participant attended a 90-minute orientation session before beginning a 12-week intervention period. The study focused on measuring SDL abilities through the Self-Directed Learning Instrument (SDLI) and knowledge acquisition with a questionnaire specifically targeting antimicrobial resistance and stewardship. Secondary outcomes included assessments of perceived cognitive, affective, and psychomotor learning via the CAP Perceived learning scale. Statistical analyses employed R software, utilizing nonparametric tests and ANCOVA models to adjust for baseline differences and covariates, with a significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAt the 12-week follow-up, the experimental group showed significantly higher median knowledge scores (12.0 vs. 9.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and SDLI scores (72.0 vs. 59.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to the control group. ANCOVA analysis indicated a significant adjusted mean difference for knowledge (-3.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and SDLI (-12.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). All secondary outcomes also demonstrated significant improvements in the experimental group (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with sensitivity analyses affirming the robustness of these findings across various statistical models.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eGame-based learning significantly improves knowledge acquisition and self-directed learning in undergraduate nursing students over traditional methods, and its incorporation into nursing curricula is advised to develop essential lifelong learning skills for the evolving healthcare sector.\u003c/p\u003e\u003ch2\u003eTrial registration number:\u003c/h2\u003e \u003cp\u003eTrial Registered Prospectively at Clinical Trials Registry - India [CTRI/2024/01/061599 (Registered on: 18/01/2024)] ; URL: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ctri.nic.in/Clinicaltrials/rmaindet.php?trialid=92950\u0026amp;EncHid=87481.96317\u0026amp;modid=1\u0026amp;compid=19\u003c/span\u003e\u003cspan address=\"https://ctri.nic.in/Clinicaltrials/rmaindet.php?trialid=92950\u0026amp;EncHid=87481.96317\u0026amp;modid=1\u0026amp;compid=19\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e","manuscriptTitle":"Impact of self-directed learning strategy, an innovative method in nursing undergraduates: A randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-31 10:39:51","doi":"10.21203/rs.3.rs-7801690/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"09f7e637-4242-4e01-aa8a-fb5cee1ef16c","owner":[],"postedDate":"December 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-18T07:56:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-31 10:39:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7801690","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7801690","identity":"rs-7801690","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}