FEMS Microbiology Letters, 363, 2016, fnw045
doi: 10.1093/femsle/fnw045
Advance Access Publication Date: 23 February 2016
Research Letter
R E S E A R C H L E T T E R – Professional Development
Board game versus lecture-based seminar in the
teaching of pharmacology of antimicrobial drugs—a
randomized controlled trial
Michal S. Karbownik1,∗ , Anna Wiktorowska-Owczarek1 , Edward Kowalczyk1 ,
Paulina Kwarta2 , L ukasz Mokros3 and Tadeusz Pietras3
1
Department of Pharmacology and Toxicology, Medical University of Lodz, Zeligowskiego 7/9, Lodz 90–752,
Poland, 2 Department of Pediatrics and Allergy, Copernicus Memorial Hospital in Lodz, Pilsudskiego 71, Lodz
90–329, Poland and 3 Department of Clinical Pharmacology, Medical University of Lodz, Kopcinskiego 22, Lodz
90–153, Poland
∗
Corresponding author: Department of Pharmacology and Toxicology, Medical University of Lodz, Zeligowskiego 7/9, Lodz 90–752, Poland.
Tel: +48426393121; Fax: +48426393290; E-mail: [email protected]
One sentence summary: ‘AntimicroGAME’ is a promising didactic tool that has a potential to stimulate deeper understanding of the pharmacology of
antimicrobial drugs.
Editor: Laura Bowater
ABSTRACT
The effectiveness of an educational board game developed to teach the pharmacology of antimicrobial drugs to medical
students was compared with the lecture-based seminar as a supplemental tool to improve short- and long-term knowledge
retention and the perception of the learning method by students. A group of 124 students was randomized to board game
and control groups. Short-term knowledge retention was assessed by comparing differences in post- and pre-tests scores,
and long-term knowledge retention by comparing final examination scores. Both didactic methods seem to improve
short-term knowledge retention to similar extent. Long-term knowledge retention of board game seminar participants was
higher than those who attended the lecture-based seminar (ANCOVA, P = 0.035). The effect was most pronounced within
14 days after the intervention (ANOVA, P = 0.007). The board game was well perceived by the students. The board game
seems to be a promising didactic tool, however, it should be further tested to assess its full educational utility.
Keywords: basic medical pharmacology; antimicrobial drugs; medical education; board game
INTRODUCTION
Antimicrobial resistance has grown to represent a worldwide
public health crisis (Tanwar et al. 2014) and hence, there is an
urgent need for the development and implementation of an antimicrobial stewardship programme to secure our current antimicrobial drugs for future generations (Dixon and Duncan
2014). Adequate undergraduate education of medical students
has been recognized as one of the crucial factors in nurturing
the successful development of antimicrobial stewardship. It is
vitally important to train medical students to use antimicrobial drugs prudently and rationally as early as possible in their
education (Vickers 2011). Within the undergraduate curriculum,
Basic Medical Pharmacology serves as an introduction into the
complex world of antimicrobial drugs. The discipline deals with
such topics as mechanisms of action, toxicity profiles, drug interactions, routes of administrations of antimicrobial agents, as
Received: 21 December 2015; Accepted: 19 February 2016
C FEMS 2016. All rights reserved. For permissions, please e-mail: [email protected]
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FEMS Microbiology Letters, 2016, Vol. 363, No. 7
well as fundamental principles of rational antimicrobial therapy
(Pulcini and Gyssens 2013).
Medical pharmacology should be taught in the context of
real-life situations that students will meet in their future professional life (Gwee 2009). Passive education, e.g. classical formal lectures, are seldom considered successful in transferring
knowledge and fail to shape prudent and rational antimicrobial
prescribing attitudes in future health care professionals (Pulcini
and Gyssens 2013). Therefore, curricula should be enriched with
interactive clinically-oriented learning methods such as educational games. As summarized by Akl et al. (2013), educational
games create a risk-free environment for decision-making and
problem-solving learning. By promoting friendly competition,
and reducing stress and anxiety, such games have the potential to increase knowledge retention. They may enhance communication skills and social interaction. Moreover, educational
games have been found to positively impact cognitive abilities,
brain function and structure (Fissler, Kolassa and Schrader 2015).
Unfortunately, the available evidence concerning the relevance
of educational games as learning tools is of limited quality. The
findings only suggest but do not confirm nor refute the utility of
games as a teaching strategy for health care professionals (Akl
et al. 2013; Sipiyaruk and Khan 2014).
The aim of the present study was to compare the effects of
the use of a recently developed board game with a lecture-based
seminar in teaching the pharmacology of antimicrobial drugs,
with regard to the short- and long-term knowledge retention of
a group of medical students and their perception of the learning
method. Both educational interventions were assessed as supplemental to the formal learning of the subject, being ways to
complement and reinforce prior knowledge of the pharmacology of antimicrobial drugs.
METHODS
Participants
Polish-speaking third-year medical students of the Faculty of
Medicine and Faculty of Military Medicine, Medical University of
Lodz were recruited on a voluntary basis in the years 2013 and
2015.
Development of the board game
The concept of the board game termed ‘AntimicroGAME’ was
inspired by a game described by Valente et al. (2009), which
was designed to integrate bacteriology and mechanisms of
action of antimicrobial drugs. The factual content of the ‘AntimicroGAME’ was based around the existing Basic Medical
Pharmacology Syllabus for the undergraduate course in
Medicine (Medical University of Lodz 2012) and further revised
by an independent senior specialist in Medical Pharmacology.
The board of ‘AntimicroGAME’ is presented in Fig. 1. In the
game, students (four to five players) move their pawns along
the pathway in the board according to the number rolled on a
dice, starting at the square ‘CHORY’ (i.e. ill) and ending at the
square ‘ZDROWY’ (i.e. healthy). Therefore, the aim of the players
is to ‘cure their patients’. While moving along the board, a
player’s pawn may land on a square with a patient history (blue
squares), whereupon the player has to ‘treat his/her patient’
and move his/her pawn forwards or backwards depending on
the availability of a suitable antibiotic card. A player’s pawn may
also land on a square with a question mark (cherry squares). In
this situation, a student next to a player whose pawn landed on
a question mark square draws a question card for the classmate
and reads a clinical vignette question loudly. A total of 80 questions were developed by Basic Medical Pharmacology teachers
who were not familiar with the content of the final examination
questions (Table 1). Depending on the correctness of the answer,
a player moves his/her pawn forwards or backwards. Finally,
a player’s pawn may land on squares representing clinical
problems relevant to antimicrobial therapy, and a player moves
his/her pawn forwards (green squares) or backwards (orange
squares) as indicated on the board. The winner is the student
whose pawn lands at the ‘ZDROWY’ square first. The game was
piloted with a group of about 20 medical students, and further
modified according to the feedback received.
The lecture-based seminar
The factual content of the lecture-based seminar was outlined
according to the existing Basic Medical Pharmacology Syllabus
for the undergraduate course in Medicine (Medical University
of Lodz 2012). The form of the lecture-based seminar was constructed according to student opinions gathered earlier about a
typical seminar during pre-clinical studies at the Medical University of Lodz. The majority of participants (75.0%, i.e. 45 out of
60) agreed at the end of the lecture-based seminar that more
than 70% of the seminars in pre-clinical years of their medical studies were conducted in the same manner as the lecturebased seminar in this study. The seminar was prepared and
conducted by a qualified academic teacher of Basic Medical
Pharmacology. The seminar contained a PowerPoint presentation designed by the seminar leader enriched with a few case
studies extracted from the board game. The lecturer carrying out
the lecture-based seminar was familiar with factual content and
rules of the board game.
Research instruments
Cognitive pre- and post-tests were developed to assess student knowledge of the pharmacology of antimicrobial drugs
prior to and after educational intervention (short-term knowledge retention). The tests consisted of 20 ‘Yes’/’No’ clinical
vignette questions (one point per each correctly answered
question) representative of the basic medical pharmacology of
antimicrobial drugs, which had been piloted with a group of
about twenty medical students and modified according to the
feedback received. The questions from the two tests were different, however, they were prepared in the same manner and
of similar difficulty. None of the post-test questions was used
in the board game. The teacher carrying out the lecture-based
seminar remained blind to the post-test content.
Long-term knowledge retention was assessed in the antimicrobial part of the first attempt at the computer-based final
examination in Basic Medical Pharmacology. The examination
consisted of 60 theoretical and clinical vignettes multiple choice
questions (MCQs) with five possible answers. Only one answer,
the most suitable one, counted. The antimicrobial drug section
of the final examination consisted of 6–12 MCQs depending on
the academic year of the examination and the faculty. The questions were randomly chosen from a base of 309 MCQs on the
basic medical pharmacology of antimicrobial drugs held in the
examination database. Each day of the examination, another
set of randomly chosen questions was included to the examination question sheet. Long-term knowledge retention was expressed as the ratio of the total number of correctly answered
MCQs concerning the pharmacology of antimicrobial drugs to
Karbownik et al.
3
Figure 1. Representation of the ‘AntimicroGAME’ board.
Table 1. Example questions extracted from the board game question cards. Correct answers were also inserted in the cards for reference
purpose.
Question
1
2
3
Answer
A doctor considers administration of an oral extended-spectrum penicillin
antibiotic to his/her patient. This drug needs to be active against Streptococcus
sp., Haemophilus influenzae and Escherichia coli. This drug, however, is
susceptible for beta-lactamases action. Give the name of this drug.
A patient is treated with bisoprolol, furosemide and losartan due to
congestive heart failure. This patient has been admitted to the hospital with
the diagnosis of pyelonephritis, and gentamicin has been additionally
initiated. What is the potential influence of ‘cardiac’ drugs on the activity of
gentamicin?
A 47-year-old male patient has been diagnosed with oesophageal
candidiasis due to Candida albicans. Is the oral route of administration of
fluconazole suitable for this patient? Please explain.
the whole number of MCQs in that category in each examination
question sheet. An analogical ratio of the total number of correctly answered questions concerning the rest of pharmacology
to the whole number of MCQs in the remaining categories was
used to determine the knowledge of the rest of basic medical
pharmacology.
Amoxicillin
Furosemide increases nephro- and
ototoxicity of gentamicin.
Yes, fluconazole is active against
Candida albicans, is extensively
distributed to the target tissue and
has high oral bioavailability.
The VARK questionnaire was used to assess learning preferences. The Polish-language 13-question version of VARK was downloaded from http://www.varklearn.com/Polish/page.asp?p=questionnaire (15 May 2013,
date last accessed) and used with permission of the copyright
owner. The VARK questionnaire allows an individual to be
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FEMS Microbiology Letters, 2016, Vol. 363, No. 7
attributed to one of four categories based on their preferred
way of learning. The acronym VARK stands for Visual (V—
preference for depiction of information in graphical resources),
Aural (A—preference for information that is ‘heard or spoken’),
Read/Write (R—preference for information displayed as words)
and Kinaesthetic (K—perceptual preference related to the use
of experience and practice) (Fleming 2001). Each participant
was attributed with the learning preference which received
the highest score in the questionnaire. In case of an equal
score from two or more categories, the student was regarded as
having a multimodal (MM) learning preference.
The survey at the beginning of the study comprised questions on demographic characteristic of participants, learning
style questionnaire as well as previous academic performance
measured as the mean grade of final examinations in Biochemistry and Pathology (2.0—failed, 3.0—sufficient, 3.5—satisfactory,
4.0—good, 4.5—very good and 5.0—excellent), which were the
major final examinations in the previous year of the medical
studies. The opinion survey at the end of the study comprised six
items, which were rated on a 4-point Likert scale from 4 (strongly
agree) to 1 (strongly disagree) and the overall grade of the educational activity, which was rated on a 6-point Likert scale from
6 (excellent) to 1 (absolutely poor). Moreover, time dedicated
for self-study of the pharmacology of antimicrobial drugs was
recorded.
Procedure
The study was approved by the Bioethics Committee of the Medical University of Lodz (RNN/82/13/KE received on 12 March 2013).
The study was carried out in May–June 2013 and 2015 when
the students completed Basic Medical Pharmacology seminars
and were preparing for their final examination in the subject.
The study was conducted in two sessions separated within five
days. During Session I, all the participants were acquainted with
the rules of the study and informed consent was received. Participants randomly drew paper sheets with numbers and were
asked to complete blind pre- and post-tests, learning style questionnaires and opinion surveys according to their numbers. Demographic data, previous academic performance data and assessment of learning styles were recorded, then the cognitive
pre-test was carried out. Finally, the students received a reading assignment on the pharmacology of antimicrobial agents (8
pages. A4 format) and were asked to measure the time dedicated
for self-study between the Sessions.
Before Session II, participants were randomly assigned in a 1:1 ratio (GraphPad QuickCalcs web-based tool,
http://www.graphpad.com/quickcalcs/randomize1,
15
May
2013, date last accessed) to board game and lecture-based
seminar groups. The assignment to the groups was performed
with the numbers which students had drawn earlier. Both
tutors and students were blinded to the allocation process until
the very last minute before Session II. Both educational interventions were carried out during the same 90-min period, with
one group playing the game and the other taking part in the
lecture-based seminar. The board game session was preceded
with a 5-min explanation of the game rules. Then the students
played the game for 70 min or until the last student’s pawn
remained at the board not reaching the end box (‘ZDROWY’).
The control group participated in the lecture-based seminar
for 75 min. Immediately following Session II both groups were
asked to complete the cognitive post-test and the opinion
survey provided.
The first attempt at the final examination in Basic Medical
Pharmacology was performed 3–77 days after Session II (median
14 days), according to the Regulations of Basic Medical Pharmacology Course and the preferences of the students. The investigators had no role in students’ decision of when to first attempt
the final examination. After the final examinations were completed each year, the identity of the students was deblinded to
allow student characteristics and performance during the sessions to be matched with their final examination results. The
procedure timeline is illustrated in Fig. 2.
Statistical analysis
The normality of the distribution of continuous variables within
the groups of board game and lecture-based seminar was
checked with Shapiro–Wilk’s test, and the homogeneity of the
variance with Levene’s test. As long as the variables were found
to be normally distributed and of homogenous variance, Student’s t-test was used to compare the characteristics of the
groups, otherwise Mann–Whitney U test was used. Categorical
variables were compared between the groups with Pearson’s χsquare test. The variables in the text are described as means
and 95% confidence intervals (95% CI), if not stated otherwise.
In order to assess short-term knowledge retention, a two-way
repeated measures analysis of variance (ANOVA) was used with
pre-test and post-test scores as dependent variables and the
intervention group as a categorical predictor. Contrast analysis
was then performed to characterize the increase in test scores
in each group. In order to study long-term knowledge retention, an analysis of covariance (ANCOVA) was used with the
time which passed to the final examination as a confounding
factor. In order to assess the effect of learning preferences on
short- and long-term knowledge retention of the board game
and lecture-based seminar participants, suitable interactions
in ANOVA were assessed between VARK learning preference
category and intervention group. To assess the association between the variables Spearman’s rho was calculated. While testing the differences in the survey results, Bonferroni correction
was applied to account for multiple testing, and the similarity
of responses was identified with principal component analysis. P-values below 0.05 were considered statistically significant.
The analysis was performed using STATISTICA 12.5 Software
(StatSoft, Tulsa, OK, USA).
RESULTS
Characteristics of the sample
Although a total of 147 volunteer medical students were recruited, 124 of them were present during all the required
sessions and only these participants were included into the
analyses. A comparison of the demographic variables of the
participants between the intervention groups is presented in
Table 2. The comparison indicated that the groups were generally similar, apart from the distribution of learning preferences. However, due to the fact that two expected values in the
comparison of learning preferences frequencies are below five,
the significance of the chi-square test should be regarded with
caution.
Short-term knowledge retention
Participation in both the board game and the lecture-based seminar were found to increase short-term knowledge retention
Karbownik et al.
5
Figure 2. Illustration of the procedure timeline.
Table 2. Continuous and categorical variables of interest according to intervention group.
Board game (N = 63)
Lecture-based seminar (N = 61)
Variable
Mean
(SD)
Median
(25th –75th percentile)
Mean
(SD)
Median
(25th –75th percentile)
P-value
Age (years)
23.2 (1.1)
23 (22–24)
23.6 (1.7)
23 (22–24)
.3951a
Previous academic
performance (mean
of grades)
3.30 (0.47)
3.25 (2.96–3.62)
3.29 (0.50)
3.25 (3.00–3.50)
.8700b
Pre-test score
10.0 (3.1)
10 (8–12)
9.8 (3.2)
10 (7–12)
.7060b
Time dedicated for
self-study between
the sessions (hours)
2.59 (4.35)
0.62 (0.33–2.50)
3.06 (4.98)
1.00 (0.25–3.00)
.7749a
Time to the final
examination (days)
17.1 (16.2)
14 (3–29)
16.6 (13.6)
14 (3–29)
.9681a
n (%)
n (%)
Male
Female
24 (38.1)
39 (61.9)
20 (32.8)
41 (67.2)
Nationality
Polish
Non-Polish
63 (100)
0 (0)
61 (100)
0 (0)
Faculty
of Medicine
of Military Medicine
30 (47.6)
33 (52.4)
25 (41.0)
36 (59.0)
Sex
N/A
.4572c
.0497c
Learning
preferences
V
A
R
K
MM
.5368c
10 (15.9)
15 (23.8)
1 (1.6)
19 (30.2)
18 (28.6)
13 (21.3)
19 (31.2)
6 (9.8)
16 (26.2)
7 (11.5)
Notes: a Mann Whitney U test, b Student’s t-test, c Pearson’s χ -square test, N/A—not applicable. SD—standard deviation, VARK learning preferences involve: V—visual,
A—aural, R—read/write, K—kinaesthetic and MM—multimodal.
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FEMS Microbiology Letters, 2016, Vol. 363, No. 7
Figure 3. Short- and long-term knowledge retention in board game and lecture-based seminar groups. Short-term knowledge retention was expressed as mean posttest scores in relation to mean pre-test scores (whiskers represent 95% confidence intervals), while long-term knowledge retention was represented as the mean ratio
of correctly answered questions during the first attempt at the final examination in pharmacology of antimicrobial drugs to the whole number of questions in that
category in each exam question sheet (whiskers represent 95% confidence intervals). The final examination scores of students who sat the final examination not
later than 14 days after the educational intervention were included to the graphical presentation and the analysis. The short-term knowledge retention was assessed
with two-way interaction in repeated measures ANOVA between differences in post-test and pre-test scores and intervention group. Final examination scores were
compared between the groups with two-way block ANOVA, with the examination set as a blocking factor, n.s.—non-significant.
measured as mean differences in post-test and pre-test scores:
board-game by 3.5 points (95% CI 2.6–4.3), F(1,122) = 67.55, P
< 0.0001 and lecture-based seminar by 2.8 points (95% CI 1.9–
3.6), F(1,122) = 41.93, P < 0.0001. No statistically significant
two-way interaction was found between ‘differences in posttest and pre-test scores’ and ‘intervention group’, suggesting
that no difference existed between the board game and lecturebased seminar in increasing short-term knowledge F(1,122) =
1.32, P = 0.2527 (Fig. 3). Interestingly, no significant correlation was found between ‘differences in post-test and pre-test
scores’ and ‘time dedicated for self-study between the Sessions’
for the board game group (Spearman rho = 0.067, P = 0.6565)
nor the lecture-based seminar group (Spearman rho < 0.001,
P = 0.9989).
Long-term knowledge retention
As the students could sit the first attempt at the final examination partially according to their own preferences, it could be
assumed that the more knowledgeable students sat the final
examination first. In fact, there was no significant correlation
between the time which passed from the educational intervention to the first attempt at the final examination and previous
academic performance (Spearman rho = −0.079, P = 0.3866).
However, a significant negative correlation existed between the
time to final examination and pre-test scores (Spearman rho =
−0.224, P = 0.0122), as well as with post-test scores (Spearman
rho = −0.321, P = 0.0003), which suggests that our assumption
was legitimate.
Hence, ‘time to final examination’ was included as a confounding factor in the analysis of long-term knowledge retention. We found that the ‘ratio of correctly answered questions’
was inversely correlated with ‘time to final examination’ for
board game group: F(1,61) = 6.48, P = 0.0134, β = −0.004, but
not for the lecture-based seminar: F(1,59) = 0.56, P = 0.4562, β
= 0.001. Moreover, a significant interaction between the slopes
was found: F(1,120) = 4.75, P = 0.0312, indicating the model of
ANCOVA with different slopes to be used. The analysis revealed
that the mean ratio of correctly answered questions in the final
examination in pharmacology of antimicrobial drugs was significantly higher in the board game group as compared to lecturebased seminar: 0.673 (95% CI 0.625–0.720) versus 0.647 (95% CI
0.599–0.695), i.e. by 4.0%, F(1,120) = 4.57, P = 0.0346; however, the
full model explained only 5.8% of variance in the correctly answered questions. The effect was found to be most pronounced
for those students who sat the final exam not later than within
14 days after the educational intervention: board game 0.822
(95% CI 0.718–0.926) versus lecture-based seminar 0.703 (95% CI
0.599–0.806), i.e. by 16.9%, two-way block ANOVA with the examination set as a blocking factor, F(1,72) = 7.59, P = 0.0074. The
full model explained 22.5% of variance in the correctly answered
questions (Fig. 3).
No significant difference was found between the intervention groups with regard to the mean ratio of correctly answered
questions in the remaining part of the final examination: homogenous slopes ANCOVA with ‘time to final examination’ as
a confounding factor, F(1,121) = 0.25, P = 0.6180, indicating that
the game had a specific effect on the knowledge of the pharmacology of antimicrobial agents.
Karbownik et al.
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Table 3. Comparison of the answers to the survey concerning the educational activities between the intervention groups. Possible answers on
a 4-point scale: ‘I strongly agree’ (4), ‘I agree’ (3), ‘I disagree’ (2), ‘I strongly disagree’ (1). The answers are given as median (25th –75th percentiles).
Item
How much do you agree with the
following statements?
Board
game n = 61†
Lecture-based
seminar n = 61
Raw
P-value
Bonferroni adjusted
P-value
1
The knowledge of the pharmacology of
antimicrobial drugs as a subject is difficult.
3 (3–4)
3 (3–4)
.8134
1.0
2
Participation in the educational activity
improved my knowledge of the pharmacology of
antimicrobial drugs.
3 (3–4)
3 (3–3)
.0101
.0708
3
Participation in the educational activity
encouraged clinical thinking approach.
4 (3–4)
2 (2–3)
<.0001
<.0001
4
During the educational activity I was learning
from my peers.
4 (3–4)
2 (1–2)
<.0001
<.0001
5
Participation in the educational activity enabled
to look at the pharmacology of antimicrobial
drugs in a new, different way.
3 (3–4)
2 (2–2)
<.0001
<.0001
6
Participation in the educational activity was a
valuable element in the learning process of the
pharmacology of antimicrobial drugs.
3 (3–4)
3 (2–3)
<.0001
.0001
7
The overall grade of the educational activity.‡
5 (5–5)
4 (3–4)
<.0001
<.0001
†
Two of the students left the questions unanswered.
Possible grades: from ‘excellent’ (6) to ‘absolutely poor’ (1).
The answers to the questions 2–7 were found to be highly correlated with each other as principal component analysis revealed than 62.4% of the overall variance of
the answers could be explained by only one component.
‡
The effect of learning preferences on shortand long-term knowledge retention
Repeated measures ANOVA analysis found no statistically significant three-way interaction between ‘differences in posttest and pre-test scores’, ‘intervention group’ and ‘VARK learning preference category’, suggesting no difference existed between the learning preferences in short-term knowledge retention of the board game for lecture-based seminar participants
F(4,114) = 0.79, P = 0.5333. Students with each learning preference increased test scores to similar extent F(4,114) = 0.80, P =
0.5290. No statistically significant correlations were found between the scores in each VARK category and differences in posttest and pre-test scores for each of the intervention groups (P
> 0.05). Similar results were observed for long-term knowledge
retention. Neither statistically significant two-way interaction
between ‘intervention group’ and ‘VARK learning preference
category’ was observed in three-way block ANOVA with the
examination set as a blocking factor in long-term knowledge
retention F(4,107) = 1.27, P = 0.2864. Similarly, no statistically
significant correlations were found between the scores in each
category of VARK learning preferences scales and ratio of correctly answered examination questions (P > 0.05).
Student perception of learning methods
The two groups of students reported the difficulty of the pharmacology of antimicrobial drugs to be similar, and both activities improved short-term knowledge retention to a similar extent. However, although the board game was initially found to
be significantly preferable in regard of the latter comparison,
this difference did not survive Bonferroni correction. The game
was generally better perceived by the students than the lecturebased seminar (Table 3).
DISCUSSION
The ongoing curricular reform in Poland and the need to upgrade
current teaching standards to more context-based approaches
(Janczukowicz 2013) have placed great emphasis on the implementation of more interactive methods of teaching medical students. ‘AntimicroGAME’ may well be the first such educational
game developed for medical students in Poland, and only few
educational games exist worldwide to cover the field of pharmacology of antimicrobial drugs (Valente et al. 2009; Buur, Schmidt
and Barr 2013).
In combination with a reading assignment, the game seems
to be equally effective in reinforcing short-term knowledge as
a traditional lecture. The opinion of students partially supports
these findings, as the survey of student perceptions appears to
suggest that the game improves knowledge to higher extent
than the lecture-based seminar. It is possible that this is associated with the substantially better overall grade of the board
game. Interestingly, after adjusting for the effect of time which
passed from the intervention to the exam, the board game was
found to be more effective in increasing long-term knowledge
retention in pharmacology of antimicrobial drugs. The difference, although statistically significant, was modest, possibly because of the presence of other multiple confounders affecting
the final examination results and the educational intervention
occurring at only a single time-point: such a short contact time
may have prevented it from exerting its full effect. Nevertheless,
the results may suggest that participation in the game, by evoking clinical thinking as well as the need of interactions between
the peers stimulates a more contextualized and deeper learning
approach, which translates later into better cognitive outcomes.
Consequently, the game may also shape the awareness and
adherence to antimicrobial stewardship standards as well as
prudent and rational prescribing patterns in future health care
professionals.
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FEMS Microbiology Letters, 2016, Vol. 363, No. 7
Current scientific data neither confirm nor refute the utility of educational games as a teaching strategy for health professionals. This is mainly due to low quality of the overall evidence (Akl et al. 2013; Sipiyaruk and Khan 2014). The ambiguity
of the findings may also be attributed to a diversity of game formats and setups (Bochennek et al. 2007), as well as the purpose
of use, either as a basic or supplemental learning tool. Some
gaming strategies implemented to teach medical subjects were
found to be superior than traditional methods (Khan et al. 2011;
Boeker et al. 2013; Aljezawi and Albashtawy 2015), whereas others have been found to be similar (Shiroma, Massa and Alarcon
2011; Rondon, Sassi and Furquim de Andrade 2013) or even inferior (Selby, Walker and Diwakar 2007; Charlier and De Fraine
2013).
The present study reports an interesting phenomenon of ‘delayed effect’ of the board game on knowledge reinforcement.
The game did not significantly surpass the lecture-based seminar in the immediate cognitive post-test, but exerted its effect
in the knowledge retention test carried out, on average, 14 days
later. A similar observation was reported by Khan et al. (2011),
who explained the ‘delayed effect’ by the innovation an educational game brings. They claimed that ‘game format of learning is a rarity for the students’, it is ‘their first experience, and
therefore it stuck in their minds’. A similar explanation may
be attributed to our findings, as 88.5% (i.e. 54 out of 61) of the
board game participants admitted that less than 10% of the seminars during their pre-clinical years of studies were carried out
in a format similar to the board game (detailed data not shown).
The time before the retention test used in the present study
differs from that of Khan et al. (2011), who report using a period of as long as two months between educational intervention and the long-term knowledge retention test. The fact that
the knowledge is preserved over such a long period could be explained by the active involvement of the students in the subject
as they attended regular classes between educational intervention and retention test. Contrarily, in the present study, the time
between the intervention and retention test coincided with the
summer examination session and any post-intervention selflearning was not recorded.
Knowledge retention favouring the board game in this study
was observed to be particularly pronounced within 14 days after the educational intervention and disappearing later. The
disappearance of the effect may be explained by the wellestablished phenomenon of memory decline in time, which is
illustrated with Ebbinghaus’ forgetting curve (Murre and Dros
2015). Another explanation for this fact may be that the more
knowledgeable students could have sat the examination earlier and it was the group which benefited most from the board
game.
In the present study, no differences were found between the
educational interventions in the degree of knowledge retention
between students with various learning preferences measured
with VARK questionnaire. This may indicate that the board game
is not biased toward a particular learning preference. Currently,
the effect of learning preferences on learning outcomes is being challenged (Norman 2009). For example, Barclay, Jeffres and
Bhakta (2011) found that students learned from participating in
the educational games regardless of their learning preference
as determined by the VARK. On the other hand, it should be
borne in mind that learning preferences do not take multiple
confounding factors into consideration and a learning ‘preference’ is not a ‘strength’ (Fleming 2001). Therefore, the results
do not preclude the importance of learning preferences in the
learning process.
The present study does have some limitations that warrant
mention while interpreting the results. First, the sample of the
students was in fact not random. The students were recruited as
volunteers. Volunteer bias may threaten the generalizability and
utility of the findings (Jordan et al. 2013). Second, the professional
qualification of the tutor carrying out the lecture-based seminar
was not evaluated, although this factor could have affected the
outcome of learning (Matthes et al. 2002). Finally, the students’
knowledge of the subject was measured simply with the number of correct answers to the test questions. Although the correctness of the answers can be regarded as a standard measure
of knowledge, it has serious deficiencies (Hunt 2003). Especially
the low number and random nature of questions on antimicrobial drugs during the final examination may hardly constitute a
fair and representative measure of the knowledge of the pharmacology of antimicrobial drugs.
CONCLUSIONS
The educational board game ‘AntimicroGAME’ developed as a
supplemental tool to teach pharmacology of antimicrobial drugs
to medical students allowed better performance in the antimicrobial part of the final examination in Basic Medical Pharmacology as compared to a traditional lecture. The game was warmly
welcomed by the students and in their opinion facilitated clinical thinking and peer communication. The game has a potential
to stimulate deeper understanding of the pharmacology of antimicrobial drugs and may contribute to more rational prescribing patterns in future health care professionals. Further studies examining repeated board game sessions, involving a more
representative long-term knowledge retention test and longterm perspective measurement of attitudes towards antimicrobial stewardship should be carried out to further assess the utility of the game.
FUNDING
This work was supported by the Medical University of Lodz with
the grant for young scientists [ 502-03/5-108-03/502-54-157]. The
funder had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
Conflict of interest. None declared.
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