Educational Card Games to Teach Pharmacotherapeutics in an Advanced Pharmacy Practice Experience

INTRODUCTION

Educational games have been incorporated in many fields of study to convey knowledge to students.^1-3 When employed properly, educational games build knowledge and skills and are enjoyable for the participants and appeal to students' competitive nature, which motivates them to play the game.^4-6 Educational games often promote higher-level discussions which help to enhance the communication, social interaction, and critical-thinking skills essential in health care. The games also allow health care educators to create real-life scenarios without real-life consequences. The format of educational games creates a setting that decreases student stress and facilitates student learning.^4-6

The majority of studies describing educational health care games show students enjoy playing them.^7-10 Unfortunately most of these studies do not evaluate student learning or the efficacy of the games. A Cochrane Review evaluated all published articles on health care-based educational games in which the participants were health care professionals or in postgraduate training identified 1156 papers, but only 1 was a randomized control trial.¹¹ The review committee concluded the systemic review did not confirm the use of games as a teaching strategy for health professionals and cited a need for additional high-quality research to explore the impact of educational games on patient and performance outcomes.

Methods of game development and student perceptions of games as an alternative learning technique have been published.^7-10 To create a successful game, developers must be cognizant of previous studies in order to replicate successes, and most importantly, to improve deficiencies. The objective of this study was to assess student learning after playing 2 card games, Cardiology Go Fish and Infectious Diseases Gin Rummy, during their APPEs. Secondary objectives of the study were to determine whether student learning preferences, as determined by VARK analysis,¹² were correlated with student assessment scores, and to assess student satisfaction with the learning experience.

VARK analysis, developed by Neil D. Fleming to improve teaching and learning, identifies 4 different learning preferences. A student's learning preference is indicative of how he/she wants to take in and give out information. The analysis was designed to determine whether students prefer to learn using 1 or a combination of the following modes: visual, aural, read/write, or kinesthetic (active). Students who have a combination of learning preferences are multimodal, whereas those who prefer only 1 learning method have a single-mode preference. The ability to identify students with a specific learning predilection allows educators to provide a more individualized teaching approach. By playing educational games with students, several learning preferences can be incorporated that traditional instructional teaching may not include.

VARK analysis has been used to determine learning preferences in nursing,^13-15 medical,^16-18 physiology,^19,20 and dental students²¹; however, only 2 studies have been published using VARK analysis in relationship to student performance. The first study investigated whether a curriculum was biased toward gender, learning preference, or pre-university experience in veterinary school.²² No differences in performance among students with multimodal, kinesthetic, or reading/writing learning preferences were found. Students with an auditory learning preference preformed worse than students with other learning preferences on all types of assessments. Conversely, another study that focused on the learning preferences and performance of dental school graduates in a biostatistics and research design course found graduates with an auditory learning preference had higher final examination scores in a multivariate analysis.²³ Prior to this study, VARK analysis has yet to be applied to pharmacy student performance.

DESIGN

Study participants included University of Southern Nevada College of Pharmacy students during a 6-week APPE from January 2010 through August 2010. Students could be admitted into the database only once. Student participation within the study was left to the discretion of their preceptor in accordance with usual APPE activities. Neither preassessment nor postassessment scores impacted students' APPE grades. This study was approved by the University of Southern Nevada Institutional Review Board.

In a separate study, pharmacy students at the university were surveyed to determine their interest in and the perceived difficulty of pharmcotherapeutics topics.²⁴ One hundred thirty-five students identified cardiology and infectious diseases as the 2 topics they found most interesting. After completion of their therapeutic blocks, infectious disease was identified as the second most difficult topic, and cardiology was identified as the third most difficult topic. Thus, the authors selected these 2 topics that the students found both interesting and challenging and developed cardiology and infectious diseases educational card games. The games were piloted with faculty members and students over a 6-month period and underwent revisions and refinements of play and rules prior to the enrollment of students in the study. Finalized versions of both games could accommodate groups of 2 to 8 students.

Cardiology Go Fish was intended to improve students' knowledge of cardiology-based medications and their role in several different disease states. The goal was to collect all 4 cards to complete a set: 2 mechanisms of action cards and 2 corresponding medication cards. Drug information was identified using multiple sources.^25,26

The second card game, Infectious Diseases Gin Rummy, centered on antimicrobial medications and the pathogens they treat. The object of the game was to form “melds” composed of 3 cards: an antibiotic card, a pathogen card, and a potpourri card consisting of site of infection; pharmacokinetic or pharmacodynamic parameter; or microbiologic information.

EVALUATION AND ASSESSMENT

Prior to playing the card games, students completed a 90-question preassessment (Appendix 1) that included 30 infectious disease questions, 30 cardiology questions, and 30 general pharmacy practice questions as a control. The preassessment was administered in the first week of the APPE and students were given 90 minutes to complete it. The 30 pharmacy practice questions were taken from various therapeutic sections of multiple North American Pharmacist Licensure Examination (NAPLEX) review resources.²⁷ Pharmacy practice questions were used as the control to eliminate reassessment bias and establish general learning over the 6-week APPE. Students were required to play each game for a minimum of 1 hour during at least 3 class sessions over a 6-week period under the observation of faculty members. At the end of the study, students completed a postassessment (same as the preassessment) and a survey instrument with 23 multiple-choice items and 6 open-ended questions, administered to gather feedback regarding the card games.

The VARK questionnaire (version 7.0), which consists of 16 multiple-choice questions, also was administered to students to determine their learning preferences.¹² All choices corresponded to the 4 learning preferences: visual, aural, read/write, and kinetic. Students could select 1 or more choices for each question. Students with a visual learning preference prefer to take in and give information holistically and often draw pictures and diagrams to explain concepts. Students with an aural learning preference prefer to listen and talk when learning. Students with a read-write learning preference prefer lists, handouts, and textbooks to understand new material. Students with a kinetic learning preference favor a hands-on approach, including trial and error, real-life examples, and application of new material. The VARK questionnaire can identify whether a student has a strong learning preference or if the student is a “flexible” learner who can take in information from multiple methods. Both Cardiology Go Fish and Infectious Diseases Gin Rummy incorporated all learning preferences throughout the course of a game.

The primary analysis compared the changes in preassessment scores with the postassessment scores of each question category. Secondary analyses included the changes in assessment scores for cardiology questions and infectious diseases questions in comparison to the pharmacy practice questions, relationships between student assessment scores and learning preferences, and student satisfaction.

Paired t test was used to analyze preassessment and postassessment scores. Linear regression was used to evaluate relationships between change in assessment scores and learning preferences categories. Independent t tests were used to compare changes in student assessment scores based on learning preferences. Alpha was set at 0.05.

All students enrolled in the study (N = 45) completed the preassessment and postassessment in the allotted time. Baseline characteristics of the students are presented in Table 1. Forty-two (93.3%) students' cardiology assessment scores increased (increase in scores ranged from 3.3% - 40.0%). Thirty-five (77.8%) students' infectious diseases assessment scores increased (range 3.3% - 33.3%). There were significant increases in postassessment scores in all 3 question categories: cardiology, 19.2% (p < 0.001); infectious diseases, 10.3% (p < 0.001); and pharmacy practice 5.1% (p < 0.001). Cardiology scores (19.2%) and infectious diseases assessment scores (10.3%) improved significantly as compared with improvement on pharmacy practice questions: 19.2% vs 5.1% (p < 0.001) and 10.3% vs 5.1% (p = 0.006), respectively. Assessment scores are summarized in Table 2.

Forty-three students (95%) completed a VARK analysis prior to playing either Cardiology Go Fish or Infectious Diseases Gin Rummy (Table 3). Linear regression to determine a correlation between visual, aural, reading/writing, or kinetic scores, and percentage improvement in cardiology or infectious diseases scores did not show strong correlations. The learning preference with the strongest correlation to cardiology improvement was kinetic (r = 0.2). Students with kinetic as their highest score (n = 12) had significantly higher increases in their cardiology assessment scores than other students (25.0% vs 16.5%, p = 0.010). The variable with the strongest correlation to improvement in infectious diseases assessment scores was visual (r value of 0.25). Conversely, students with visual as their highest score (n = 8) did not have higher increases in their infectious diseases scores (7.9% vs 10.2%, p = 0.563). No other learning preferences or multimodal learning preferences were associated with student performance.

Forty students (88.8%) completed the anonymous survey instrument. More than 90% of students strongly agreed or agreed playing Cardiology Go Fish and Infectious Diseases Gin Rummy was a valuable contribution to their learning; made them think about cardiology mechanisms or infectious diseases in new and different ways; promoted discussion relating to clinical practice; was an innovative method to understanding the material; helped them learn from their peers; and was appropriately challenging; and they would recommend the game to their peers (Table 4).

In response to open-ended questions, students stated their favorite aspects of Cardiology Go Fish included learning the specific drug mechanism of action and applying it to clinical cardiology topics. Favorite aspects of Infectious Diseases Gin Rummy included the review of drugs and bugs, topic discussions spurred by the game, and the critical thinking required. The least favorite features of both card games focused on the large number of participants and the resulting slow pace of the games. Suggested improvements for both games included limiting group size, expanding the game to other disease states, and setting a time limit per turn.

DISCUSSION

Cardiology Go Fish game play was competitive. Initially, students were confused with the rules and significant preceptor involvement was required. During the second and third sessions, students functioned more independently with decreased supervision by faculty members. Students often developed slight variations from the rules to facilitate game play. This improved peer facilitation of the game and increased interaction among students in the group. Infectious Diseases Gin Rummy game play was both cooperative and competitive. The first session was too challenging for students and time between play lagged. A variation of the game was developed and used to teach the fundamentals of creating melds which increased the speed of game play and whole group participation. Groups larger than 6 decreased the speed of game play and led to student frustration.

Pharmacy students learned from participating in both Cardiology Go Fish and Infectious Diseases Gin Rummy, regardless of their learning preference and the incorporation of these innovative active-learning tools enhanced their learning experience during APPEs. Common activities for students during APPEs include hands-on patient care, faculty-led topic discussions, journal clubs, and presentations. However, students need the basic pharmacology taught in previous lecture courses reinforced. These educational games provided a non-lecture approach to teaching cardiology and infectious diseases pharmacology. They also offered students another opportunity to organize and synthesize drug information differently, as shown in the survey results: 100% of students indicated that Infectious Diseases Gin Rummy made them think about the relationship between pathogens and antimicrobials in a new way, and 92.5% of students indicated that Cardiology Go Fish made them think about cardiac pharmacology in a new way.

One limitation of these educational games was the extensive time investment required by faculty members in creating and implementing the games and proctoring students. However, faculty members can recover this investment once students have mastered the basics and can self-facilitate, thereby increasing peer-to-peer learning. A methodological limitation of the study was that some students may have played longer than the mandatory 6 hours, as they were free to play the games anytime during their APPE. The additional time may have influenced their postassessment scores. A larger limitation of the study was the inability to correlate improvement in assessment scores with an improvement in student pharmacist patient care.

Results did not show a consistent and direct correlation between students' VARK scores and improvement in assessment scores. Although this may have been due to small sample size, it probably relates to the distinction between learning “preferences” and learning “style.” The purpose of the VARK analysis is to identify how students prefer to take in and give out information. Learning preferences do not take into consideration multiple confounding variables such as motivation or setting, which impact student learning.

These data show that students do learn from educational games and that the games were an effective adjunct to lecture material taught in previous courses. Future research could include randomized controlled studies comparing student learning from educational games versus lectures to determine whether differences in student learning exist. Further research should focus on the incorporation or addition of games to didactic teaching. Future studies also should consider evaluating multiple student learning preferences and other outside influences to better predict or identify whether associations exist with academic success.

SUMMARY

Significant increases were seen in cardiology, infectious diseases, and pharmacy practice assessment scores as a result of incorporating educational games into APPE instruction. Increases in pharmacy practice scores may be attributed to general knowledge gained during a 6-week APPE as well as the possibility of reassessment bias. However, larger increases in cardiology and infectious diseases assessment scores probably were secondary to playing the pharmacy education games. Although student learning occurred regardless of students' learning preferences, incorporating innovative learning tools like the card games enhanced their learning experience. Based on the results and feedback from students, incorporating games into APPEs will continue, and also may be included in small group teaching prior to student APPEs.