Educational Game : A Fun and team based learning in psychiatric course and its effects on Learning

Background: Using traditional and inactive methods in medical education can cause fatigue, lack of attention, frustration, lack of motivation and decrease the level of students’ learning. games in education is one of the interactive, active and fun methods that has its own educational purpose that translates the special features and highlights the special capabilities by deepening the skills . In this article, the effect of the instructional game as a educational puzzles and the effect of this program on students ‘ self-regulation and team learning has been investigated. Method: This research is a pre test – post test semi experimental study. The population of this study was Jahrom University of Medical Sciences students and samples were 39 nursing students which studied psychiatric course. Sample was selected from available class to the teacher. Initially, the content of the course was presented as a presentation of the main content of the lecture. After the completion of the lessons, contents prepared through puzzle and this program was given to small groups in all sessions. The groups, while answering the questions, checked the collection of information and the searched for the answers, and then the correct answer was provided by the teacher. The combination of teamwork with small groups and solving puzzles which contained learned lessons provided an attractive environment in the form of teamwork. Four questionnaires included : self-directed learning readiness scale (SDLRS), Burrfurd’s self-regulatory questionnaire and a Questionnaire for assessing the value of team work and then a questionnaire of self-reflection were used in two stages (before and after) of intervention. Results: The results of the study showed that self-regulatory indicators (p = 0.17) and self-directed (including self-control motivation) and self-management (p=0.15, p=0.0, p=0.001) were meaningful after improving intervention respectively. Other results show that intervention has affected team-based learning scales (including attitudesteam learning and team-learning skills (0.73, 046, 0.62) although it is not significant. Also, the mean increase in all subdomain of selfreflection were significant (p <0.05). Other results indicated that the intervention increased the mean scores of self-regulation and self-directed of students. But it is only in self-management was significant.Conclusion:The results of the study showed that the use of instructional al game can affect the individual and participation learning by creating entertaining and interactive environment. Therefore, it is recommended that the mentioned method be used in medical science education


Introduction
Using traditional and inactive methods in medical education can cause fatigue, lack of attention, frustration, lack of motivation and decrease the level of students' learning.Nowadays, traditional and old methods of teaching and learning, with the advent of new technologies and methods, lose their effectiveness.Learners need to look for new ways and means to transfer knowledge and increase learning to keep pace with the changing environment around Bangladesh Journal of Medical Science Vol. 17 No.04 October '18.Page : 631-637 DOI: http://dx.doi.org/10.3329/bjms.v17i4.38328them.They have to work with new approaches to build their knowledge and play a valuable role in their learning 1 .
Using problem-based methods in an effective and efficient manner can contribute to the development of self-directed learning.This type of learning is accompanied by active learning experience, self-direction, motivation, critical thinking, and learning from the search and research path.Also, using problem-based methods as methods based on personal experience has the greatest effect on student learning.choosingthe appropriate teaching method is one of the effective factors in student progress and acquisition of professional skills 2 .Active learning enhances students' ability to study their learning needs, gain an active role in the learning process, enhance critical thinking ability, increase decision-making ability in different clinical settings and strengthen problem-solving skills 3 .The ever-increasing changes in science and technology have already made it necessary to take advantage of the new ways of problem-based teaching and the use of an inclusive-oriented approach.Therefore, it is recommended that a suitable learning environment be created, and the new skills of training methods developed and current methods improved 4 .Theinstractional and game based learning method is one of the active learning methods.In this method, using a learning strategy in small groups, learners are trying to achieve a common goal, in order to improve their learning ability and other members of the group 5 .
The advantages of this educational method can be to reduce students' fatigue, increase their participation in learning and develop deeper learning 6 .One of the active learning methods is using of instructional game.Breuer (2011) in his study on digital game based learning emphasizes the necessity to integrate the evaluation of both; the learning objectives or learning content in this method 7 .Games can help to change the roles by providing alternative,it makes novel environments where the regular roles of students "dissolve"; they can become just players and learners in a game that engages them all in topics that can help to create funny environments in which they, can co-exist and co-create together as a team 8 .Learning"reportedthat thismethod decreases distraction in team based learningand the more they were engaged in group competition and team based learning.Also, the more students learned about topic 12 .Domingue,et al expanded Gamifying Learning Experiences.They showed that the Students who completed the gamified experience got better scores in practical assignments and in final score in course 13 Today, the need of using active learning methods that deepens student learning should be considered in medical science education.Applying active methods helps to strengthen critical thinking and reinforce problem-solving skills in students and helps them to cope with clinical decisions in professional settings 14,15 .The use of interactive and collaborative approaches is also an active approach to the perceived need for medical education, and in contrast to the usual methods, students take an active part in the learning process and take on the responsibility of learning for themselves and their friends 16,17 .Regarding the relationship between active and student-centered learning on self-regulatory and self-directed development, application of the game based learningmethod(one pf board game learning as a puzzle based learning ) can be effective in enhancing these dimensions in learners.Educational game related with many learning indictors as a self regulated learning and self directedlearning .Also it may be related to team based learning and student self reflection.We will continue to define and briefly illustrate these two issues: self-directed learning is a process in which studentsIngeniouslyshare their learning in identifying needs, formulating and compiling learning goals, identifying resources for learning, selecting and implementing learning strategies, learning, and evaluating learning outcomes.The role of educating the movement from a wise person in the learning scene.It is guided by its learning environment 18 .Self-Regulatory Learning: It is a multi-faceted structure that involves complex interactions between the use of cognitive, meta-cognitive and motivational strategies and is a type of learning that results from the effects of students 'self-production thoughts, emotions, strategies and behaviors that are directed towards achieving goals 19 .In this article, the effect of the instructional game and the effect of this program on students 'self-regulation,self directedlearning,self reflectionand value of team learning has been investigated.Methods:This is a descriptive study.The population of this study was Jahrom University of Medical Sciences students and samples were 39 nursing students with psychological disorders course study.Samples were selected from class available to the teacher.The purpose of this study was designing, implementing and evaluating the instructional game (role -goal attribution )inteaching process of psychiatric course.Initially, the content of the course was presented as a presentation.After the completion of the lessons, thequestions (board game as a role -goal attribution ) were given to small groups.The groups answering the tables,while reviewing the content collection and the searching for answers and then the correct answer was told by the teacher.Combining teamwork with small groups and educational game that contained the learned lessons provided an attractive environment in the form of teamwork to allow students to review the contents of the coursework at the same session.Teamwork score (as midterm score) was givento every single student according to the sum correct answers.In order to complete students' learning and develop ofself-reflection, in each topic, cases of disorders were placed in the forum.Its management was also arranged in such a way that the individual first responded to the questions individually, and then other students could access them.This process provided self-reflection and interactive environment to complete and consoled of students 'learning.At the end of each topic, the related short films that were previously prepared by the students were broadcasted and the necessary explanations were presented by the teacher.The questionnaires were given to the students at the appropriate time, regarding not to interference with the educational programs and considering the students' satisfaction in the study, at the beginning or end of the classroom.In each case,after initial justification and explanation of how to respond to the questionnaires, the students answer the questions , and the ambiguities wereresolved.Then, enough time to answer was given to them, and at the end the completed questionnaires were collected.Four questionnaires including: the self-directed learning readinessquestionnaire, the self-regulatory learningquestionnaire, a questionnaire on evaluating the value of team working (value of work in the group and working with peers)and self-reflection were used in this study.Standard questionnaires were used for measuring the rate of students' readiness for self-directed and self-regulatory learning.The S-SDLRS( A short questionnaire about selfdirected learning):The Gagliimino Self-Directed readiness scale is a self-report questionnaire with 41 items in 5-part Likert type (rarely to always) that includes three domains : self-management, self-control and learning motivation.The internal correlation of the questions was 0.95 and the reliability of the present method was 0.68.Scores for each field are calculated from 100 and scores less than 33.3were low, between 33.3.To 66.7 is considered moderate and more than that were high.Cronbach's alpha coefficient for self-management subscales was 0.81, learning motivation was 0.78, and self-control was 0.84.This questionnaire was assessed byNadi andSajjadian in 2013 on 1135 medical and dental students and thereliability and validity of the questionnaire were confirmed.The maximum score of this tool was 205 and at least 41 [20][21] .Self-Regulatory Questionnaire( Buffard's Self-Regulatory Questionnaire): Buffard 's Self-Regulatory Learning Questionnaire was used to measure the amount of participants' (students')use of self-regulatory learning strategies.This scale has 14 items by Buffard, etal (1995).In this test, for each question, there are 5 options that include fully agree, agree, disagree, disagree, and completely disagree, which has 1 to 5 points, respectively.Meanwhile, the scoring of questions 5, 13, and 14 is inversely.This questionnaire has standardized by kadivar.The total reliabilitycoefficient of the questionnaire that obtained on the basis of Cronbach's alpha of was 0.71.In the research of Talebzadeh-Nobariyan et al., Its reliability was obtained through an experimental test on 30 students and using Cronbach's alpha (which equaled 0.76).The results of factor analysis showed that the correlation coefficient between questions was appropriate and the measurement tool was composed of two factors 22 .
In the current research, thetotal reliability coefficient of the questionnaire was obtained by Cronbach's alpha (0.72).Two of the questions in this questionnaire are as follows: "When I study, I clearly identify my goals."And, "When I do not understand a story, I do not know how to myself out to trouble (1 23 .Value ofTeamwork Questionnaire (VTs) was first developed by Haidate, etal, (in2002) in 17 on a 5-point scale(absolutely agree the absolutely disagree).It also concludes two sub-scales of team working and work with peers.Cronbach's alpha coefficient for the entire questionnaire was 0.79 to 0.8 [24][25] .Other results indicated that the intervention increased the mean scores of self-regulatory and self-directed of students but only in self-management had mean value.Therefore, it can be concluded that in general, intervention can promote self-directed feature of students (Table 3).

Discussion
This research has designed, implemented and evaluated instructional game in psychiatric course.
Results from this method showed that this method effect to learning indicators as a self reflection, self regulation and self directed learning.
The positive effect of instructional game reported by some researcher.As a research by Vogel et al.,  2006, instructional game lead to greater cognitive outcomesamong participant.It may be related to learners more engaged inthe learning process when they are required to interact with it 26 .
It is necessary to apply such methods as instructional game in this courses and also engage students more in active learning methods because the psychological disorders' intangibility and similarities of signs and symptoms.Also teamwork and learning from peers make exciting learning environment for learning and sufficient reflection of what the students learned.
It is clear that today the traditional role of teachers and learners has changed in the learning process and active participation of learners is emphasized 27 .Also evidence showinstructional game may lead to greater cognitive, attitudinal gainsand skill-based over traditional instructional methods.Also when informational content combines with the appropriate gaming characteristics, the combination of the two increase learner motivation 28 .
When informational content combines with the appropriate gamingcharacteristics, the combination of the two elicits a motivated learner 29 .Our study the effect of instructional game in promotion of students' self regulation.The findings from Tominey,et al showed that the efficacy of the game in terms of improving behavioral self-regulation and improving specific skills in preschool 30 .The results of many studies showed that students tended to participate in environments where attention was paid to individual characteristics of learners, interaction, collaboration, innovation and creativity 31 .Hays in the investigating effectiveness of instructional game as a review showed that (1) there are varied empirical research on the effectiveness of games (2) Some games provide effective for some tasks (3)  No evidence confirmed that games are the preferred in all situations.(4) It is more effective if they are embedded in instructional programs that students give feedback from teacher (5) Instructional support by teacher has main roleduring play game 32 .The results of study bySweygnir et al showed thepositive effect of the game method on learners' learning, which is consistence with the results of the present study 33 .However, in contrast the results of this study and the studies above, the findings of Maskowitz et al showed that the use of the game doesn't have a positive effect on learners' learning because of teachers' weakness in implementing of this method 6 .Also Jürgen,et al study did not show a significant difference in the performance of trained students with participatory learning and the students who trained with traditional method 34 .The study of Payami et al showed that the students feel more satisfied with this method because of their activeness and relevance in the classroom.Therefore, they expressed more interest and motivation in learning process, and they described this method as a more attractive and exhilarating method of learning 35 .Game method leads to the enhancement of the students' interest in and positive feelings about the study subjects 36 .Salomon et al.Reported positive effects of this type of learning on interpersonal attitudes, behaviors, values, and skills of learners.These results are consistent with the findings of the present study37.Other evidence showed that that games can help prepare students to create deeper, more robust understanding while improving their perceptions of learning concept, also this method for teaching SCRUM in computing courses was an engaging way, keeping students immersed in the learning task 38 .Guillen etal to investigating Sirius game and effectiveness reported that the relation between in the creation of serious games and instructional content, game dimensions, debriefing, perceived educational value, and role this method to transfer of learned skills in students through intrinsic motivation 36 .
Limitations of research include the lack of team learning culture and the need for specific planning.Also, due to the need for full-time student engagement in learning, this method requires the teacher's time and energy more that traditional ones to implement it.Educational game methodface classroom management and traditional teaching curriculum (which for many years has been managed by teachercenter method andstudent learned their subjects by this method for a long time) challenges.

Conclusion:
Considering the positive effects of the mentioned method, and also the importance of new methods in learning, the use of these teaching methods in medical education courses is recommended so that it can be used to improve the quality of learning, team learning abilities and features.

Table 3 :
The effect of educational game on the features of self-directed learning subscale