This study sought to answer the question of to what extent puzzle game-based training can improve.
the knowledge and cognitive function of surgical technology students in CABG surgery. The results showed that surgical technology students’ knowledge and cognitive function improved significantly after playing the CABG surgery puzzle game. This study was the first one that examined the effectiveness of using the puzzle game-based teaching method in CABG surgery for surgical technology students.
Previous studies have shown that adding elements such as in-game advice and feedback, adding prompts for players to explain or reflect during the game, and creating competition (by showing the player’s score compared to other players) improves learning [64, 65]. In the CABG surgery puzzle game, elements such as a heartbeat avatar provide feedback to the player by providing positive and negative points, guidance, and explanation to achieve the puzzle.
the solution, showing the player’s score at the end game. Moreover, his rank among other players were used.
One of the main reasons for supporting the potential of digital games for learning are there ability to engage in cognitive interaction with learners [66, 82], in which the learner engages in cognitive processes during learning, including selecting relevant information from the game and mentally sorting it into a coherent structure. Moreover, integration is related to previous knowledge and improvement . In the CABG surgery puzzle game, to solve the puzzle, the player must analyze in his mind different pieces of the puzzle. Each of them showed a stage of the CABG surgery and merged it with his previous knowledge about this surgery and chose the puzzle pieces correctly in He placed the right place.
The results of a semi-experimental single-group pre-test-post-test study by Hannani et al. (2019) showed that the mean knowledge scores of surgical technology students in the post-intervention phase (spinal fusion surgery training using games) (17.47) were significant. It is more than the stage before the intervention (10.93) (P = 0.001) .
The semi-experimental study of Amir Alavi et al. (2016) The results showed the average scores of knowledge of tracheobronchial anatomy of anesthesiology resident students of Gilan University of Medical Sciences. Before the intervention in the control group (traditional bronchoscopy training), it was equal to 17.82 ± 55.83 in the intervention group (bronchoscopy training). Using simulation web software) it was equal to 66.33 ± 13.71; The scores after the intervention in control and intervention groups were 90.83 ± 10.84 and 119.17 ± 14.43, respectively. There was a significant difference between the average scores of tracheobronchial anatomy knowledge of anaesthesia resident students after the intervention in the intervention group (bronchoscopy training using web-based software similar to compared to the control group (bronchoscopy training by traditional method) (P < 0.0001) .
In the semi-experimental study of Akbari et al. (2021), the results showed the average knowledge scores of surgical technology students in the intervention group (teaching surgical table arrangement using games). (6.70 ± 0.72) were significantly higher than the control group (teaching surgical table arrangement using the speech method was (5.90 ± 1.71) (P = 0.040) .
In a systematic review by Tavares (2022), the results of a review of 17 articles examined interventions and topics with increased educational complexity that required increased levels of knowledge retention and critical thinking, such as nursing theory and complex clinical skills. Furthermore, topics including game-based learning approaches, student experience and participation, the impact of game-based learning on students’ learning and knowledge retention, and the use of a wide range of learning assessment methods such as quizzes, escape rooms, and serious games, showed that, the game-based teaching method was accepted by the students. They confirmed its widespread use in the nursing curriculum. Most studies reported increased student knowledge and learning when using game-based learning, although time-limited games can often increase student anxiety. In the end, the researchers concluded that game-based learning is an essential alternative to traditional teaching methods; however, the frequent use of game elements and their limited long-term effects may limit their widespread use in nursing education .
In a systematic review by Ozdemir et al. (2022), the results of the review of 46 articles showed that game-based learning is used for many different subjects in nursing education. Simulation games are the most widely used type of game, and game-based learning facilitates the achievement of learning outcomes mainly in the cognitive domain (including knowledge, understanding, application, analysis, synthesis, and evaluation). In the end, the researchers concluded that game-based learning is a helpful method to achieve learning results, mainly in the cognitive domain, with some positive and negative aspects. Further research should investigate the effects of games on emotional and behavioural learning outcomes and the use of games to evaluate learning outcomes .
The results of Gudadappanavar et al.‘s study (2021) showed that the average post-test scores of second-year MBBS students in the intervention group (teaching using games) (33.17 ± 2.93) were significantly higher than the control group (teaching by lecture method) (2.82). ±28.66) was (P < 0.001) .
In the study of McCarroll et al. (2009), the results showed that the average scores of the students in the intervention group (teaching muscle anatomy through lectures and games) that was 5.82% higher than those of the control group (teaching by lectures). However, the difference is that there is no statistical significance (P > 0.05) .
Huang et al. (2017) showed that mobile and computer video games improve undergraduate students’ cognitive performance, learning, and memory . The results of Farzad et al.‘s study (2021) showed the average post-test scores of organizational performances (one of the areas of cognitive performance) of preschool children in the intervention group (teaching using Kiko’s Thinking Time game) (56.10) was significantly higher than the control group (teaching Russian to speak) (25.17) (P < 0.001) .
Using the puzzle game, as a new educational tool, aims to make creative decisions, create and improve self-confidence in solving problems, stimulate comprehensive memory to consolidate and better understand concepts, highlight the main concepts, and acquire and improve cognitive skills and functions .
The results of Padmaja et al.‘s study (2019) also showed that the average comprehension scores of students in the intervention group (teaching concepts of pathology using visual puzzles) (4.46) are significantly higher than the control group (teaching by traditional lecture method) (3.58). P = 0.001) , as well as the study of Haripriya et al. (2019), in which the average comprehension scores of students in the intervention group (teaching concepts of pathology using a bingo puzzle game) it was significantly higher than the control group (3.65 ± 0.85 vs. 2.64 ± 0.91) (P < 0.05) .
According to Mikhailovich, educational puzzles should include at least one of the four criteria of generality (through the puzzle and solving it, the reader can solve future problems and riddles in real life), simplicity (puzzles and their solutions are easy to remember) fixed and easy to remember), Eureka (the puzzle being exciting and having simple solutions so that solving the puzzle is interesting for the learner) and entertainment (the environment of the puzzle and solving it should be fun and enjoyable) have an impact on applying comprehensive learning . The CABG surgery puzzle game was also designed to have a fun environment and a simple solution for learners to fix the game the solution in their memory and use it in the future to help the CABG surgery team in the hospital environment.
The results of the present study also showed that education based on the puzzle game has significantly led to the improvement of one of Bloom’s cognitive skill areas, that is, the knowledge of surgical technology students in CABG surgery, and with the study’s results by Plant et al. (2019) showed that anatomy education with a 3D puzzle in a virtual reality environment, it can be a valuable complementary tool for traditional anatomy teaching and learning because solving a 3D puzzle in a virtual environment and receiving feedback from solving each part of the puzzle, the student can improve The level of self-knowledge should help ; Patrick et al.‘s study (2018) in which the average knowledge scores of pharmacy students who used the word puzzle game for self-learning the basics of pharmacy was 52.69 ,
Cardozo et al.‘s study (2016) showed that the average knowledge scores of medical students in the intervention group (teaching the heart physiology cycle using puzzles) were higher than those in the control group. (teaching the heart physiology cycle using the lecture method)  and Barclay’s study and colleagues (2011) in which the knowledge scores of pharmacy students in the field of cardiac drugs (19.2 vs. 5.1 per cent) (P < 0.001). Infectious diseases (10.3 vs. 5.1 per cent) (P = 0.006) ) in the stage after playing card games, Cardiology Go Fish and Infectious Diseases Gin Rummy was significantly higher than the stage before playing the game .
Among the reasons for adaptation, visual education, along with the gasification approach, leads to a better and deeper understanding of learning. Students’ knowledge is improved by discovering the relationships between the components of each phenomenon (surgery, anatomy). The student is stabilized, and their recall is facilitated when applying the material in the natural environment and when taking the test. The concept of the brain’s cognitive function has been the focus of neuroscientists and neuropsychologists. However, recently, researchers have been drawn to the function of the brain in the learning process. Studies have shown that learning takes place during the change in the organization of cognitive functions of the brain, and Quality education leads to better cognitive performance and effective inclusive learning [12,13,14,15]. Cognitive performance has different dimensions and scopes based on the level of complexity, including feeling (multi-sensory), perception, movement, and construction skills (copying, drawing), and attention and concentration (selective attention, sustained attention/awareness). Memory (working memory, episodic/declarative memory, procedural memory, semantic memory, and prospective memory), executive function (critical thinking, reasoning, problem-solving), processing speed (mastery, encoding, and tracking), and language/verbal skills (Naming, reading, and understanding [83, 84]. Cognitive performance is the second dependent variable in the present study and the results showed that the use of the CABG surgery puzzle game has significantly improved the cognitive performance of surgical technology students, and with the results of the study by Molyana et al. (2022), which showed that 32 knowledge In the stage before the intervention (playing the puzzle game), the student had low cognitive performance, and eight students had sufficient cognitive performance, and after the intervention, One student had good cognitive performance, 26 students had high cognitive performance, and 13 had very high cognitive performance. Students’ cognitive performance in the stage after the intervention (playing the puzzle game) was significantly higher than in the stage before the intervention. (P < 0.01)  a double-blind, a randomized controlled trial study by Nunci et al. (2013) showed that the brain training game improved executive functions, working memory, and processing speed in young people and the Tetris puzzle game led to the improvement of attention and ability. It becomes auditory-spatial. Also, this study provided scientifically evidence that the brain training game has beneficial effects in improving cognitive functions, including executive function, working memory, and processing speed in young people.
The results of the study by Chang et al. (2021) showed that the bingo puzzle game had more effects on increasing the learning motivation of 86 third-year undergraduate students in the field of business, while the so creative mobile application promoted knowledge sharing and critical thinking. In addition, both teaching methods positively affected learning outcomes through common mechanisms, including focused attention, brainstorming, active participation, interaction, and logical thinking. There was a significant interaction between motivation, knowledge sharing, and critical thinking . Kobal et al.‘s (2015) study showed that students who experienced the puzzle game course, they have developed their problem-solving strategies and basic reasoning skills. The average scores of their problem-solving and reasoning skills in the post-intervention stage (using a reasoning puzzle game) were better than the pre-intervention stage , Bruker et al.‘s study (2019) in which the average cognitive performance scores of healthy people aged 50–93 in all domains (reasoning, focused and sustained attention, information processing, executive function, working memory, and episodic memory) after playing the number puzzle game is significantly higher than before playing the game (P < 0.0004) .
Among the reasons for adaptation, visual education, along with the principles of gamification, leads to improving reasoning, perception, cognitive and problem-solving skills. The use of puzzle games for education, as a new visual educational method, can also Encourage learners to think critically. Improve this skill instead of covering the content, encouraging analogical reasoning and clinical reasoning, increasing focus on the topic and the concept of learning, encouraging the students to apply the knowledge learned in practice, improving problem-solving skills and improving organizational performance (due to the need for Formulation of strategy, reorganization, and planning) help.
Overall, results of the study showed that the puzzle game-based training approach could be used in teaching sensitive and important surgeries such as CABG surgery for surgery and surgical technology students.
The strategy of the research team to reduce the effect of eight factors that threaten the internal validity of the quasi-experimental study is as follows:
Lack of history of attending and working in the CABG operating room and not watching the CABG surgery video were among the inclusion criteria for our study. Also, the students in our study did not receive any training about CABG surgery except for the intervention of our study (puzzle game); Therefore, the history factor as a threatening factor for the internal validity of the quasi-experimental study has been controlled in our study.
Since the interval between the pre- and post-tests in our study was short (14 days) and the students in the study did not receive any training about CABG surgery except the intervention of our study (puzzle game); Therefore, the maturation factor as a threatening factor for the internal validity of the quasi-experimental study has been controlled in our study.
Since we used a type of test with similar questions to conduct pre- and post- tests; Therefore, the instrumentation factor as a threatening factor for the internal validity of the quasi-experimental study has been controlled in our study.
Since we did not provide the students with the score of the test before the intervention and also the correct answers to the questions of this test, as well as the interval between the test before and after the intervention, in order to reduce the possibility of remembering the content of the questions of the test before the intervention (Recall Bias) was 14 days; Therefore, the testing factor as a threatening factor for the internal validity of the quasi-experimental study has been controlled in our study.
Since we conducted a single-group study without a control group, there is no problem of differences between study groups in terms of study variables; But we have used a non-random sampling method (because our statistical population was limited and all students did not want to participate in the study, and according to the principles and rules of ethics in medical research, we were able to force students to attend We were not in the study); Therefore, the current research team has done as much as possible to control the selection bias factor as a risk factor of quasi-experimental study.
Regression to the mean
This factor did not exist in our study, because we did not consider a specific score as a criterion in the analysis of the results of the students’ tests before and after the intervention, as well as the score of each student from the test after the intervention compared to the test before the intervention had increased.
We had stated in the study contract with the students that after entering the study and until the end of the study, the student cannot read the CABG surgery training material and share it with others, and also the students cannot play the puzzle game and answer the questions get guidance and advice from others on the questions of the tests before and after the intervention and raise any problems in playing the game or answering the questions of the tests before and after the intervention only with the research team; Therefore, the social interaction factor as a risk factor for the validity of the quasi-experimental study has been controlled in our study.
18 students participated in the test before our intervention, and during the study period, 2 students who met one of the exclusion criteria (unwillingness to continue cooperation and play the puzzle game for 1 time), were withdrawn from our study, and 16 students participated in the post- test. In order to avoid the effect of the Austrian factor, the effect of the scores of the two students who were excluded from the study on the average scores of the pre-test was controlled using the covariance test so that it does not have a confounding effect on the results of our study; Therefore, the Austrian factor as a risk factor for the validity of the quasi-experimental study has been controlled in our study.
Based on the results of this study, the CABG surgery puzzle game can be used as a complementary tool for conventional training of CABG surgery principles. Since this game is online and can be used at any time and place and on Laptops, tablets and mobile phones are included and have the lowest cost. Therefore, a wide range of universities and students can use it to train surgical students and surgical technology as well as novice surgical technologists and establish educational justice to a large extent in the country. Also, this game can be used in situations where it is impossible to be present in the clinical environment, such as the Covid-19 pandemic. However, studies to evaluate the generalizability and the effect of using the CABG surgery puzzle game on the skills and clinical performance of students and comparing the puzzle game-based training method with the traditional training method in acquiring knowledge and skills, as well as the amount of consolidation of the learned material in the memory Learners are needed.
Among the strengths of the present study are the use of the puzzle game-based training method and gamification in CABG surgery to train the scrub surgery technologists’ duties in each stage of the surgery mentioned above and the use of a particular standardized researcher-made test to measure knowledge and performance. The knowledge of surgical technology students about the clinical of scrub surgical technologists in each of the stages of CABG surgery, the use of a new, low-cost, online training method that can be used at any place and time and with any smart device (laptop, tablet and mobile phone) ) Cited.
Among the study’s limitations, we can mention the lack of a control group, the small sample size due to limited access to students and the use of virtual exams due to the closure of universities due to the Covid-19 pandemic (despite the creation of virtual exam security).