INTRODUCTION

The traditional teaching model began with illuminism, or Age of Enlightenment, in the 18^th century¹, having the teacher as the mentor of the educational process and placing the entire mission of disseminating knowledge on this figure. Students, in turn, behaved as passive individuals in the learning process, being presented with extensive content in expository classes and periodically evaluated through tests, which served to measure the absorption of a given subject². Thus, students graduated tending not to take full advantage of their potential and having difficulty correlating the studied content with professional practice.

This scenario can be considered incongruent with the new technological era and the new way of thinking, linked to this panorama³, resulting from the emergence of the Internet in 1947. From then on, the process of disseminating information became increasingly easier, which opened several doors for the modernization of teaching, especially in the medical field⁴.

Within this context, the term ‘gamification’ was coined in 2002 by Nick Pelling, which is defined as the application of game strategies in everyday activities, aiming at increasing the participants’ engagement. The psychological motivation behind gamification shows that the goal and the dispute move a good part of human beings, and competition is often the basis of the knowledge acquisition process⁵.

In this context, although it is currently possible to access any information via cell phone, as well as participate in online meetings, take part in competitions, games, and quizzes, most educational institutions, at different levels of education, still adopt the traditional teaching model, which does not stimulate students’ autonomy, analytical skills, and critical reasoning⁶.

Therefore, aiming to avoid the educational flaws inherent to traditional methodologies, such as lack of attention and interest and, consequently, lower knowledge absorption, it would be appropriate to use an active methodology, also placing the student as the protagonist in the teaching and learning process³. From this perspective, gamification would be perfect for the occasion, and could use, as TAKENAMI et al.⁷ did, board games, which were part of many people’s childhood and adolescence and have many attractive features that are the reason for countless hours spent among groups of friends and family.

Certainly, some of the particular features of board games include attention, enthusiasm, motivation, dynamics, fun, attractiveness, competitiveness and interaction between participants⁸, which are considered extremely valuable for the learning process, especially in relation to broader subjects, such as renal physiology. This subject is indispensably important for medical training but is often classified by students as difficult because it requires a lot of study and individual commitment to understand it correctly.

Because of these facts, it is often not possible to achieve the learning objectives using only the traditional teaching methodology, thus suggesting the complementary use of active methodologies to facilitate learning. Therefore, the present study aimed to analyze the perception of students attending the 2^nd semester of a medical course regarding the use of a game about the main concepts of renal physiology.

METHOD

This is a descriptive, prospective study, based on the experiences of medical students. The board game was applied to 104 students attending the second semester of 2022 and supervised by a physiology professor. The project was evaluated and approved by the Human Research Ethics Committee, and students only participated in the research after signing the Free and Informed Consent Form (TCLE).

Planning meetings were held to adapt the renal physiology content to the practical activity. The board game called Perfil^ⓡ served as inspiration for the production and creation of the game, to address contents about the nephron structure and function, in addition to the hormones and medications that are involved in renal physiology.

The game structure was defined for an audience of 4 to 60 participants in each game match, containing 25 question cards, each with 5 tips regarding concepts of the renal system physiology, and five guess cards at any time (Figure 1).

Source: prepared by the authors, 2022.

Figure 1 Representative figure of some cards present in the game, including structures correlated to the nephrons and the guess card at any time. 

Regarding the distribution of students in the game, the gamification activity was carried out in four different shifts, lasting around 100 minutes (90 minutes for the game and 10 minutes for filling out the questionnaire), with a group of no more than 30 people in each shift, totaling 104 participants.

The classroom consisted of six tables with five chairs each, where the students were divided into groups of up to five students, randomly, and each table received a dice. The nephron-shaped board was designed using the Canva^® website and was projected on the board. It contains 18 squares that go from the glomeruli, passing through each tubular segment until reaching the collecting duct (Figure 2). Some squares had consequences that could be burdens or bonuses for the players who stopped on them. For example, we have the 10^th square with the bonus of winning a guess card at any time and the 17^th square with the burden of having to go back two squares.

Source: prepared by the authors, 2022.

Figure 2 Representative figure of the nephron-shaped board used during the practical class. 

Six pegs were used, each representing one of the six tables, numbered from 1 to 6. They were differentiated by color and, at first, were positioned on the glomeruli, as this was the starting point for all participants in the game (Figure 2). As the players advanced on the board, the pegs were moved with the help of the mouse along the 18 squares.

Before starting the game, the game dynamics were presented to the students, following the steps below:

At the end of the game, a QR code was made available so that students could answer a questionnaire using Google Forms, giving their opinion on the activity.

The questionnaire consisted of 11 questions (9 objective and 2 subjective ones). The variables investigated were: age, gender, previous experience with gamification, the contribution of the theoretical class to practice, the suitability of the duration of the practical class, the change in stimulus to study after practice, whether the practice facilitated the understanding of the subjects, whether the students would like to have more subjects covered in this way, which method would be the best to assimilate the content (traditional class, traditional class followed by gamification or gamification alone), how they perceived the use of gamification in the practical class (good, excellent, average or indifferent) and whether they had any additional comments to make about the activity.

The data obtained were stored in Google Forms spreadsheets for future analysis. In this same location, the graph was generated automatically, the percentage data were obtained through Microsoft Excel Software and the tables were created using Microsoft Word Software.

RESULTS

A total of 104 students participated in the study, the majority of which were female (72). The most prevalent age group was 19 to 20 years old, corresponding to 54% of all participants. The data obtained through the questionnaire revealed that the experience with gamification was new for 45.2% of the students. Furthermore, 93.3% stated that after this type of activity they felt more stimulated to study the content, in addition to considering the duration of the activity adequate, without it becoming tiring (Table 1).

The results showed the importance of this method to facilitate understanding of the subject, reinforced by 94.2% of the students. However, 96.3% of them also recognized the importance of theoretical classes to support group discussion during practice.

When asked about the addition of theoretical subjects addressed using gamification, 91.3% answered that they would like to have more subjects addressed in this way (Table 1). Moreover, when asked about which would be the best method to assimilate the studied content between the traditional method alone, gamification alone, traditional class followed by gamification, and indifferent, the following results emerged: 61.5% of the students considered the traditional class followed by gamification to be the best and 30.8% considered gamification alone to be the best way to improve the learning process (Graph 1).

Source: prepared by the authors, 2023.

Graph 1 Figure representing the students’ opinions on the best way to assimilate the content. 

Regarding the use of gamification in practical classes, only 3.9% of the respondents considered the use of this tool to be regular or indifferent, while 96.3% perceived it as good or excellent (Table 2).

When asked if they had any additional comments to make about the activity, 45 (43%) students gave their opinion. Of these, the majority wrote comments similar to the following: “Very good, very useful”, “It was a great way to put the theoretical lesson into practice”, “Very good class, very dynamic, a relaxed and fun way to assimilate the subject!” and “It was very interactive and helped us a lot with understanding”.

It is important to emphasize that none of the comments made indicated dissatisfaction by the students regarding the activity.

DISCUSSION

Introducing new learning strategies in medical education is of great importance for the students’ academic training. The gamification strategy aims to stimulate memory, create cognitive bridges with previous learning, and foster many other skills that are extremely important for future medical professionals, such as insight and teamwork^9),(10.

The results of this study showed that gamification was very well received. Most students said they were more motivated to study the content, understanding the subject more easily. This information is consistent with studies in the literature that show that gamification improves students’ knowledge, skills, and satisfaction^11),(12.

Another important factor is that the practice was not considered tiring; on the contrary, it was considered dynamic, with an adequate duration, interactive, and aroused the students’ interest in more approaches like this. Certainly, a time-consuming practice without many steps that move the game forward can increase the students’ dropout and/or dispersion from the activity, that is, the duration of the gamification application is an essential factor to consider when investigating the effectiveness of these methods in student learning¹³. Moreover, a meta-analysis study demonstrated that learning with gamification has an ideal maximum effect achieved when the practice lasts less time¹⁴.

In this context, it is relevant to mention that the organizers of the practical activity were also able to identify in students, during the day of the experiment, more attention, interactivity and enthusiasm without dispersion, as seen in a previous study, also carried out with board and card games⁷. PAIVA. et al. explains that this is due to gamification that complements and optimizes learning, in addition to increasing interest and desire to study².

These data demonstrate how gamification, as well as other active methodologies that, unfortunately, are still scarce in medical education, are desired by students, as they have several characteristics that are extremely useful for the learning process, which makes them more frequently used as tools for consolidating content and increasing interest in opportune situations.

It is also worth noting that, unlike previously cited studies^2),(7),(15, this study has a larger sample size and assesses students’ perceptions through something more concrete, in this case, the questionnaire at the end of the practical activity, which allows a more objective documentation of the results.

Furthermore, in a systematic study of more than 40 articles on gamification in the education of health professionals, no negative results were reported due to the use of gamification. It has also been suggested that it is possible to improve learning outcomes in health professions education using gamification, especially when games that stimulate the search for learning are used¹¹. This information corroborates our data, since none of the students expressed a negative opinion about the class, and 93.3% of the students reported feeling more motivated to study the content after having completed this type of activity.

In fact, although the sample size is significant, since it only included one class, it does not represent the student population as a whole, suggesting that the study could be extended to more semesters in possible future implementations. Furthermore, it was not possible to analyze the effectiveness of gamification through a pre- and post-test comparing the traditional teaching method with the active methodology, which would provide greater amplitude to the results. The analysis of this study was a subjective one, through our perception of the students’ reactions during the practice and, later, their answers in the questionnaire.

Within this bias, another limitation observed was the need to constantly update the cards used in the dynamics, since the students wrote down the questions and answers during the practice, which allows the transfer of these data from one semester to the next. Such an event requires updating the information described in the cards between semesters. A promising way to minimize this damage would be to create a question bank and use a different set of cards each semester.

Finally, although gamification has proven to be effective, this study also revealed that, for students to have a complete experience, prior exposure to the subject is necessary, whether through a traditional theoretical class or through prior personal study. This shows that, within the teaching-learning process, active methodologies, in fact, have the important role of complementing the traditional method, and not replacing it.

FINAL CONSIDERATIONS

In conclusion, gamification has proven to be an excellent ally for traditional theoretical classes, serving as a mechanism for sedimentation and increased interest, and its use can be suggested more frequently. Moreover, it is a method that can be easily adapted to numerous teaching areas.

More experiments are needed to improve the method, and pre- and post-tests are suggested for a more objective and comparative assessment.