Crossword Puzzle as a Learning Tool to Enhance Learning about Anticoagulant Therapeutics

Crossword Puzzle as a Learning Tool to Enhance Learning about Anticoagulant Therapeutics | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Crossword Puzzle as a Learning Tool to Enhance Learning about Anticoagulant Therapeutics Ghada Bawazeer, Ibrahim Sales, Abdullah Alhammad, Ahmed Aldemerdash, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1078884/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Apr, 2022 Read the published version in BMC Medical Education → Version 1 posted 9 You are reading this latest preprint version Abstract Background Educational games make the learning process more enjoyable, fun, and create a competitive classroom environment that can positively affect learning. This study sought to implement and evaluate pharmacy students’ perceptions towards using crossword puzzles (CWPs) as a learning tool in the pharmacotherapy cardiovascular module focusing on the therapeutics of anticoagulants. Methods Clues for the puzzle were developed, validated, and piloted by course faculty. A free internet puzzle generator was used to create puzzles with 10 to 20 clues. Students were given 30 minutes to solve the puzzle following the completion of the didactic topic. An 8-item survey instrument and Pharmacists’ Inventory of Learning Styles (PILS) questionnaire were administered to examine students’ perceptions of the game and their learning style preference, respectively. Results Over three consecutive course offerings, 267 students participated in the activity from both undergraduate programs (Bachelor of Pharmacy (BPharm) and Doctor of Pharmacy (PharmD). Most students expressed favorable perceptions of the puzzle. Female and BPharm students had significantly more favorable perceptions than male students and PharmD students on several perception items. There was no association between student perceptions and their learning styles. Conclusion CWP presented an innovative, creative, and easy active learning tool to enhance students’ learning and engagement. Internal Medicine crossword game pharmacy anticoagulation therapeutics learning style active learning. Figures Figure 1 Background Old habits are hard to break. Didactic lectures continue to resemble the school days of Charlie Brown and his schoolteacher in the classroom. The COVID-19 pandemic has further complicated effective delivery of didactic lectures with the absence of the visual confirmation that students are actively participating and understanding the information. Such barrier has led to a lack of learner engagement objectively exemplified by an increase in absenteeism in pharmacy school lectures, students underestimating the importance of lectures, and a corresponding decrease in performance, particularly in therapeutics courses 6 , 7 . Contrarily, students who are stimulated by effective learning methods are more likely to attend lectures than their colleagues 8 . On average, the first 10 minutes of a lecture are associated with the peak of student attention and highest retention of information 9 – 11 . Student interest declines from that point and is barely salvaged in the last 5 to 10 minutes. In totality, students are disengaged for approximately 75% of the lecture. This is not surprising since millennials have been weaned upon technological advances and various means of communication and entertainment 12 , 13 . This has resulted in both reality and an absence of consistent stimulation becoming something that is no longer considered intriguing. Evidence supports the positive impact of using innovative educational tools to benefit the teaching and learning process for health professions, and pharmacy education is no exception 14 . The Accreditation Council for Pharmacy Education (ACPE) placed high emphasis in “Standard 10: Curriculum Design, Delivery, and Oversight” on student engagement through teaching and learning activities that promote self-directed learning and accommodate the diverse learning needs of students 15 . Gleason and colleagues categorized classroom-based active learning methods into five types: Cooperative Learning, Problem-Based Learning, Team-Based Learning, Case-Based Learning, and Ability-Based Education and Assessment-as-Learning 16 . Stewart et al. surveyed 114 US colleges and schools of pharmacy faculty members to evaluate the extent and the promoting factors for using active learning techniques 17 . Eighty-seven percent of the faculty members reported using active learning activities such as case-based learning (71%), deliberative discussion (50%), team-based learning (47%), clickers (45%), simulation (25%), Interactive Web-based learning (19%) and process-oriented guided inquiry learning (12%). Promoters for active learning techniques include younger faculty age, lower faculty rank, and departments of pharmacy practice or social/behavioral/administrative sciences. In the Middle Ease, Alruthia et al. surveyed faculty members in health colleges from 17 countries throughout the region 18 . The majority of pharmacy colleges respondents (n=202) acknowledged utilizing various active learning strategies including class discussions (87%), small group discussions (56.9%), learning by teaching (49.5%), case studies and problem-based learning (41.1%). Several other studies have also described the incorporation of active learning techniques into pharmacy curriculum 17,19−23 . Gamification or serious games have gained popularity recently 24 – 26 . In their overview of game implementation in the classroom, Biehle and Jeffres provided four essential fundamentals toward game development and use: (1) Motivation for participating should initially be external with the objective of internally motivating the student to master the material, (2) students should benefit from the material whether they win or lose, (3) all students should equally be engaged in participating, and (4) the objective of the game should be clearly explained to the students 26 . Several systematic reviews concluded that gamification can possibly improve the learning outcomes of health professions education including pharmacy 27 , 28 . The published literature includes descriptions of a lengthy list of the different types of games used to aid students in learning 5,22,29−45 . The use of crossword puzzle (CWP) has been used occasionally in the literature with studies conducted in several pharmacy courses. Gaikwad et al. reported a significant improvement between CWP pre- and post-test scores when used in a pharmacology course covering antihypertensive and antiepileptic drugs for second-year Bachelor of Medicine and Bachelor of Surgery (MBBS) medical students 41 . Medical students in their fifth year of the MBBS degree indicated satisfaction with a CWP covering hormonal contraceptives 42 . Student perceptions toward the activity were also positive. Shah and colleagues developed a CWP during a pharmacology and medicinal chemistry module about anti-ulcer agents 5 . A post-activity survey revealed that most students over a two-year period enjoyed the CWPs and felt as if it enhanced their learning. Although it is assumed that active learning strategies will increase student engagement for most participants, there is scarce of literature that investigated whether there is an association between student learning styles and their preference for active learning strategies in the classroom. Conversely, when a mismatch occurs in the instructor’s teaching style and a student’s learning style, student learning may be impacted 46 . A study describing millennial students in the Philippines found that most students are application-oriented, focusing on applying what they studied to what they learned in practice 47 . This finding is important given that modern pharmacy curricula include more application courses and experiential education. Crawford et al. compared the dominant learning styles of pharmacy students and faculty members and found no significant differences between faculty members and student learning styles 48 . However, the study found that learning styles differed by gender and faculty track (tenure vs clinical). Studies evaluating the use of CWPs as an educational tool for learning therapeutics aspects of drugs in Saudi Arabia are limited. The objective of this study was to evaluate students’ perception toward the use of CWPs as an educational tool for enhancing their learning about anticoagulant therapeutics taught in the pharmacotherapy courses in the Doctor of Pharmacy (PharmD) and the Bachelor of Pharmacy (BPharm) undergraduate programs. In addition, we sought to determine whether students’ learning style preferences influenced their perception of this active learning technique. Methods The CWP was implemented as an active learning tool in therapeutic courses for the PharmD and BPharm programs. These courses are covered in the seventh level (third professional year), and the content included module on cardiovascular diseases including the use of anticoagulant drugs. Didactic lectures on the management of venous thromboembolism and atrial fibrillation with overview of anticoagulant drugs were discussed over 6 contact hours. The learning objectives related to anticoagulant therapy are presented in Table 1 . CWP was developed using a free online CWP generator ( TheTeachersCorner.net ). The course instructors developed the puzzle clues (questions and answers) based on the material covered during the lectures and designed to cover Bloom taxonomy of knowledge, comprehension, and application levels. The content validity of these CWPs was mapped to the intended learning outcomes of the modules and was peer-reviewed by another course instructor. Additionally, the CWP was also piloted among a group of student interns in their advanced pharmacy practice experiential training. Printed copies of the CWP were provided to the students to solve immediately after the lecture (BPharm group, 10 clues CWP) or during pharmacy practice lab (PharmD group, 20-clues CWP). During these sessions, students were divided into groups, and 30 minutes was allocated for solving each CWP. Although students were expected to self-correct the answers to solve the puzzle, a debriefing session was provided to discuss any confusing points or misconceptions related to the topic. An example puzzle is shown in Fig. 1 . At the end of the activity, students were asked to complete two post-activity surveys administered via SurveyMonkey. The first survey was the Pharmacists’ Inventory of Learning Styles (PILS), a survey tool validated for pharmacy practice 49 . The second survey was an 8-item questionnaire to measure students’ attitudes towards the use of games in learning developed by Shah et al 5 . No extra marks were given to the students for completing the puzzle or the survey. Students were also informed that their grade in the course would not be impacted by their participation, or lack thereof, in the activity. We implemented the CWP over three consecutive years using different puzzles. The study was approved by institutional review board at King Saud University and was granted an exemption status ( Project # E-21-6205 ). Table 1 Specific Learning Objectives for Lectures Covering Anticoagulation therapeutics. PHCL 412 and PHCL 416 Anticoagulation Therapy Lectures Objectives: 1. Compare and contrast between the different anticoagulant therapies about: a. Place of therapy b. Mechanisms of action c. Advantages and disadvantages in terms of their pharmacokinetic and pharmacodynamic properties (e.g. dosing, onset of action, drug & food interaction, etc) d. *Key pivotal clinical trials of anticoagulant drugs e. Side effects and management f. Monitoring of drug therapy g. Patient education h. *Use in selected population (e.g. cancer patients, pregnancy, morbid obesity, renal impairment, and pediatrics) 2. Apply evidence-based guideline recommendation for the use of anticoagulants in the: a. Prevention and treatment of venous thromboembolism b. Stroke prevention in Atrial fibrillation c. *Perioperative management of anticoagulant therapy * not included in the learning objectives for PHCL 416 Statistical analysis: The data were analyzed using IBM SPSS Statistic version 22. The data was presented in frequencies (N) and percentages (%). The continuous data were expressed by the mean and standard deviation (SD). A normality test (Kologrove-Smirnov and Shapiro-Wilk test) was conducted for the dependent variables (student perceptions of CWPs) and the independent variables (gender and education degree) to determine whether students' perceptions were normally distributed among gender categories (i.e. male and female) and education degree categories (i.e. PharmD and BPharm). As data were not normally distributed, the Mann-Whitney U test was used to test for the differences in perception among the independent groups. Results Data were available on 267 students who participated in the game. The mean age of the students was (21.34 ±1.21), the majority were females (67%), and two-thirds (71%) were enrolled in the PharmD program. Table 2 summarizes the student demographics. On the PILS survey, the most preferred learning styles among all students were convergers (35.6%) and assimilators (25.3%), while 15.7% of students were multimodal. Learning style order of preference based on gender showed a significant difference ( p <0.05), with female students preferring assimilator and converger learning styles, while male students’ preference was higher for accommodator and diverger learning styles. Less than 10% of students were able to complete the puzzle in 30 minutes and fewer number have correct answers. On the perception survey, students perceived that CWPs helped them to identify the most important topics to focus on (82.4%), served as a good review of the lecture material (81.3%), enjoyed classmate interaction, and reviewing material while solving puzzle (79.1%), enhanced their learning (77.2%), found the material pertinent (74.2%) and learned more from the class because of CWP (67.4%). Most of the students perceived the amount of time given was sufficient (73.1%) and most of them expressed preference to have extra credits for such activities (67.4%). Table 3 summarizes students’ perceptions of CWP as a learning tool. Table 2 Demographic Characteristics (N=267) Characteristics N(%) Age (years)* 21.34 ±1.21 Gender Male 88 (33) Female 179 (67) Learning style ¥ Accommodator 28 (10.7) Assimilator 66 (25.3) Converger 93 (35.6) Diverger 34 (13.1) multimodal 41 (15.7) Educational degree PharmD 191(71.5) BPharm 76 (28.5) *mean ± SD, ¥ (6 students did not answer this question) Table 3 Student Perceptions of CWPs as a Study Tool (N=267)* Question Mean (SD) Strongly Disagree N (%) Disagree N (%) Neutral N (%) Agree N (%) Strongly Agree N (%) The CWP provided enhanced my learning 4.1(0.9) 7(2.6) 9(3.4) 45(16.9) 119(44.6) 87(32.6) Enjoyed classmate interaction and reviewing material while solving puzzle 4.1(0.9) 5(1.9) 9(3.4) 42(15.7) 104(39) 107(40.1) CWPs oriented us to the topics we should focus on 4.1(0.8) 5(1.9) 7(2.6) 35(13.1) 121(45.3) 99(37.1) Length of time provided for solving the puzzles was sufficient 3.9(0.9) 5(1.9) 18(6.7) 49(18.4) 100(37.5) 95(35.6) The material on the puzzles was pertinent 3.9(0.8) 5(1.9) 3(1.1) 61(22.8) 118(44.2) 80(30) Learned more in class because of the CWPs 3.8(0.9) 5(1.9) 18(6.7) 64(24) 115(43.1) 65(24.3) Solving CWPs are good reviews of material covered 4.0(0.8) 4(1.5) 9(3.4) 37(13.9) 125(46.8) 92(34.5) Extra credit should be associated with activities such as CWPs 4.0(0.9) 6(2.2) 13(4.9) 52(19.5) 94(35.2) 102(38.2) *Survey adapted with permission from Ref 36. There was a significant difference in students' perception of CWPs among gender groups. Female students had a significantly higher mean score for the statement "length of time provided for solving the puzzles was sufficient" than their male counterparts ( p = 0.001) (Table 4 ). Furthermore, there was also a significant difference in student perceptions about CWPs among the two different undergraduate programs. The BPharm students' mean score was significantly higher on several perception questionnaire items compared to PharmD students, specifically on statement items “CWPs oriented them to the topics they should focus on” ( p =0.003), “the length of time provided for solving the puzzles was sufficient” ( p = 0.001), and “the material on the puzzles was pertinent” ( p = 0.038). There was no association observed between learning style and student’s perception of CWP (p =0.19). Student feedback and suggestions about using the CWP in the teaching and learning process are summarized in Table 5 . Overall, students found the method enjoyable and helpful to memorize and retain the newly learned information; however, several students urged that it would be much better if they had the chance to check their spelling or use their reference books. Students also believed that CWP is an effective way to teach confusing subjects prior to exams and suggested to extend the use of CWP for other topics such as antibiotics, drug-drug interactions, microbiology and medicinal chemistry. Table 4 Association of Student Perceptions of CWPs with demographic Characteristics Question Gender P value* Education degree P value* Male Female PharmD BPharm Mean (SD) Mean (SD) Mean (SD) Mean (SD) The CWP provided enhanced my learning 4.0(0.98) 3.9(0.90) 0.462 3.9(0.91) 4.0(0.97) 0.463 Enjoyed classmate interaction and reviewing material while solving puzzle 4.0(0.94) 4.1(0.91) 0.416 4.1(0.91) 4.1(0.94) 0.840 CWPs oriented us to the topics we should focus on 4.0(0.93) 4.1(0.84) 0.741 4.0(0.85) 4.3(0.90) 0.003 Length of time provided for solving the puzzles was sufficient 3.7(1.02) 4.1(0.95) 0.001 3.8(0.98) 4.2(0.96) 0.001 The material on the puzzles was pertinent 3.8(0.88) 4.0(0.85) 0.163 3.9(0.82) 4.1(0.95) 0.038 Learned more in class because of the CWPs 3.7(1.01) 3.8(0.91) 0.668 3.7(0.91) 3.9(1.01) 0.086 Solving CWPs are good reviews of material covered 4.1(0.83) 4.0(0.87) 0.971 4.0(0.86) 4.1(0.86) 0.146 Extra credit should be associated with activities such as CWPs 4.1(0.87) 3.9(1.03) 0.051 3.9(0.99) 4.2(0.93) 0.008 *Mann− Whitney U test Table 5 Students’ free comments on the CWP activity Feedback about using the game in the teaching-learning process Suggestions for future use ● Change the narration style and create a stimulating learning environment for students. ● “It is much better studying in game format rather than normal assignments.” ● “I liked how we did not use any reference to answer it was a mind refreshing activity.” ● “I like the idea it is creative and fun, it made me focus more on the spelling which is important.” ● Improve thinking and memorizing. ● “Made my brain thinks faster” ● “A good change in the routine it made me want to pay mor attention in class” ● “It was good, but I wish we were able to check spell.” ● Puzzles to solve in shorter time ● It should be implemented after each pharmacotherapy block. ● Assigning grades/bonus will be also rewarding. ● Use it to teach confusing subjects. ● Use it as a review before the exam. ● Let students know before hands about the puzzle Discussion The pathophysiology and therapeutic of cardiovascular diseases, specifically topics about thromboembolism and atrial fibrillation are essential topics taught in the Pharm.D. and Bachelor programs in King Saud University, Riyadh, Saudi Arabia. These cardiovascular topics are usually introduced in the first therapeutic course series, and they require students to use critical thinking and clinical decision-making skills when implementing guideline recommendations, which most student perceive it to be challenging. The courses also rely on student’s prior knowledge on the pharmacology of cardiovascular drugs. Feedback from students and course faculty showed students’ knowledge about anticoagulant drugs pharmacology was suboptimal due to misalignment of some topics in the curriculum. To ease out student’s trepidation, the course instructors utilized variety of active learning pedagogy to engage students in this first therapeutic course, including CWP activity. To the best of our knowledge, this is the first study conducted to evaluate the pharmacy’ students’ perceptions about the use of CWP for enhanced learning about the anticoagulating therapeutics in Saudi Arabia. In the present study, student perceptions about the value of CWP was generally positive. Overall, most of the students agreed that CWP enhanced their learning, oriented them to key information they need to focus on, improved retention of information and was a good review for the material covered in the lectures. These findings in consistent with other published studies 1 , 3 , 50 . Shah et al. reported higher agreement on the same survey items compared to the present results. Ninety percent of students indicated positive perceptions such as CWPs enhanced their learning, helped them focus on important topics in the lectures, and served as a good review of the lecture material 5 . Mirroring the results from other studies about the recreational and fun aspects of the puzzles, most students enjoyed the classroom interactions while solving the puzzle. They felt the puzzle was interactive, enjoyable, and encouraged a competitive environment within the classroom 2,3,42,51−55 . In the current study, students from the BPharm program reported statistically significant positive perceptions compared to PharmD students specifically on the following items: “CWP oriented us to the topics we should focus on” and “the material on the puzzle was pertinent”. This difference could be explained by the fact that traditional teaching is more predominant in BPharm curriculum. Crawford et al. found significant differences between tenure track and clinical track learning styles among faculty at the University of Illinois at Chicago Pharmacy college 48 . The tenure track had a predominantly abstract sequential learning style that focuses on theoretical concepts and analytical approaches. The clinical faculty have a more concrete sequential learning style that focuses on application and practicality of information. The use of active learning is reported to be higher in clinical faculty members and faculty members in the social/behavioral/administrative sciences 17 . In KSU, BPharm curriculum is focused predominantly on pharmaceutical sciences, with only two therapeutic courses. On the perception item about “the length of time provided for solving the puzzle was sufficient”, students from the BPharm program have a significantly higher agreement than the PharmD students ( p =0.001). We attributed this difference to the shorter puzzle administered to the BPharm group (10 clues) compared to the PharmD group (20 clues). Nonetheless, different studies reported described variable clues numbers ranging from 12 to more than 50 and completion time from 5 to 60 minutes, and all showed favorable agreement that the allocated time was adequate regardless of the size of the puzzle or completion time 2,5,42,50–52,56−59 . Notably, in the current study male students were less satisfied with the time provided for solving the puzzles than female students. Two factors could have produced such difference. First, active learning, specifically games, are less utilized by male faculty. This is supported by a recent study that found that female faculty are more likely to implement active learning strategies in classroom teaching than male faculty 18 . Furthermore, faculty from different generations could be differ in their interaction, learning, and teaching skills regardless of gender 13 . Second, gender variation in learning styles could have affected their perceptions about the time. Although some studies have reported more men being divergers and women have an assimilator learning style, others did not find such differences 48,60−62 . The present study found that the predominant learning style in our student population is consistent with the learning styles of pharmacists and pharmacy students reported in the literature 47 – 49 , 60 , 63 – 65 . The learning styles primarily reported with the pharmacy profession are assimilators and convergers. Similarly, in this current study, the converger learning style was predominant in both male (35%) and females (36%). The second most prominent learning style was assimilator in female students (33%) and divergent in male students (26%). It is worth noting that male representation in this study is only one third of the sample studied. No significant difference was found between student perceptions about CWP and their learning styles. Studies on the relationship between pharmacy students learning styles and academic performance are scarce and with divergent conclusions. A study conducted in medical students in Thailand showed that students’ learning styles differed between pre-clinical and clinical years. Furthermore, the learning style is only associated with students’ academic achievement during the pre-clinical years, with the reflective learning style associated with high academic success 66 , 67 . Another study found a similar correlation between reflective abilities and academic success in undergraduate pharmacy education 68 . Both assimilators and divergers on the Kolb learning style inventory possess reflective abilities 69 . On the other hand, several other studies did not find an association between learning styles and academic achievement 61 . Millennials (those born between 1981 and 1996), represented by students participating in the current study, could have different approaches to learning and different preferences of learning styles, hence, different perceptions towards the variable approaches of learning. Corrido et al showed that based on Vermunt’s Inventory of Learning Styles (ILS), millennial Filipino pharmacy students have a predominantly application-directed learning style (i.e. those who try to discover relationships between things and apply what they learned); followed by a reproduction-directed learning style (i.e. those who memorize the learning content in order to be able to reproduce it in a test) 47 , 70 . Eng et al. also concluded that learning styles inventory could influence the learning environment during experiential education of millennial pharmacy students 71 . The previous studies and others raise an important issue to consider for both educators as well as students about identifying learning styles to improve learning experience rather than to stigmatize. Student’s self-awareness about their learning styles can help them refine their study habits and encourage them to reach out to faculty members when struggling academically due differences in teach and learning styles; therefore, the learning environment can be catered to maximize students’ gain, confidence, and ability to transfer learning. At the same time, for faculty and preceptors, self-awareness of their own learning style and that of their students could help improve teaching styles and promote better approaches to better facilitate teaching and assessment. The open comment section of the survey highlighted how the students valued the puzzle activity as a learning and self-assessment tool. One of the interesting comments repeated by several students is the fact that spelling was an obstacle while solving the puzzle. Other researchers reported similar spelling challenges surfaced while solving CWPs 3 , 55 , 72 , 73 . For pharmacy students, such accuracy is vital to patient and medication safety. The positive reception toward this tool encourages faculty members to develop creative tool that carry low burden (such as the CWP) to engage students especially in large class-size, which can be deterrent to incorporating active learning in teaching 74 . This study had several limitations. First, due to logistic reasons, administering the puzzle in relation to the lecture delivery was variable among the cohorts (right after the lecture, during the same week, or two weeks later). Although this might have affected the recall of information, the several open comments about spelling difficulties could be the main reason for not getting the right answers. Secondly, there was only one BPharm cohort group compared to three PharmD cohort groups. Thirdly, the length of the puzzle used for the BPharm group was shorter (10 questions and clues vs 20 for the PharmD group); this is mainly because the content material for the BPharm is less than the PharmD and the need to deliver the puzzle in the short break after the lecture immediately. The learned information could have still been fresh and easy to retrieve. Hence, the perception of time sufficiency was satisfactory. Lastly, we did not assess the impact of the game on short- or long-term retention of the information, nor on student’s final grade in the course or pre- and post-testing examination; however, the activity was purposely implemented to guide students towards the most important information about the topic and assist them to identify any gaps in knowledge or understanding. Conclusion The study demonstrated that students valued active learning engagement in the class environment using the CWPs. CWPs presented an easy and versatile tool that can be customized in difficulty to enhance students' educational experience and promote more self-awareness of the teaching and learning trends for both students and faculty. Providing students with a self-learning tool and engaging them during the learning process may lead to better understanding, retention, and application of the learned material and eventually in academic performance. Future studies should investigate the impact of CWPs on both short- and long-term retention of the lecture material. Abbreviations ACPE Accreditation Council for Pharmacy Education BPharm Bachelor of Pharmacy CWP Crossword Puzzle KSU King Saud University PharmD Doctor of Pharmacy PILS Pharmacists’ Inventory of Learning Declarations Ethics approval and consent to participate The activity described in this study was conducted as part of the course delivery, no consent form provided. The study was approved by institutional review board at King Saud University and was granted an exemption status ( Project # E-21-6205 ). Consent for publication Not applicable Availability of data and material Data are available upon request Competing interests none Funding This research was funded by Deanship of Scientific Research at King Saud University, research group number (RD-1441-367) Authors' contributions Conceptualization, and Methodology, G.B.; Validation, G.B., A.D.; Formal Analysis, M.M.; Investigation, G.B. I.S.; Resources, M.J. H.B.; Data Curation, H.B., M.J.; Original Draft Preparation, G.B., I.S., M.M.; Writing – Review & Editing, G.B., I.S., A.A. A.D.; Visualization, G.B.; Project Administration, G.B., I.S. A.H., A.D.; Funding Acquisition, I.S. All authors approved the final manuscript prior to submission. Acknowledgements The authors would like to thank Dr. Zuhair Al Qahtani for helping in running the session to implement the game. 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Currents in pharmacy teaching & learning. 2017;9(1):155-159. Cain J, Piascik P. Are Serious Games a Good Strategy for Pharmacy Education? Am J Pharm Educ. 2015;79(4):47. Biehle L, Jeffres M. Play games and score points with students. The clinical teacher. 2018;15(6):445-450. Van Gaalen AB, J; Schönrock-Adema, J; Bouwkamp-Timmer, T; Jaarsma, ADC; Georgiadis, JR. Gamification of health professions education: a systematic review. Advances in Health Sciences Education. 2020:1-29. Shawaqfeh MS. Gamification as a learning method in pharmacy education. J Pharma Care Health Sys S2-004 doi. 2015;10(2). Oliver CH, P.; Beavers, M.; Gibbs, E.; Goeckner, B. and Miller K. Experiential Learning About the Elderly: The Geriatric Medication Game. Am J Pharm Educ. 1995;59(6):155-158. Rose TM. A board game to assist pharmacy students in learning metabolic pathways. Am J Pharm Educ. 2011;75(9):183. Smith CR, P. Blais, M. Schneck, R. Evaluation of two different poverty simulations with professional phase pharmacy students. Currents in pharmacy teaching & learning. 2017;9(5):903-910. Clarke C, Sedlacek RK, Watson SB. Impact of a Simulation Exercise on Pharmacy Student Attitude toward Poverty. Am J Pharm Educ. 2016;80(2):21. Ee RWX, Yap KZ, Yap KY. Herbopolis - A mobile serious game to educate players on herbal medicines. Complementary therapies in medicine. 2018;39:68-79. Plakogiannis RS, A.; Hernandez, N.; Nogid, A. A heart failure themed escape room approach to enhance pharmacy student learning. Currents in pharmacy teaching & learning. 2020;12(8):940-944. Cain J. Exploratory implementation of a blended format escape room in a large enrollment pharmacy management class. Currents in pharmacy teaching & learning. 2019;11(1):44-50. Clauson AH, L.; Frame, T.; Hagan, A.; Bynum, L. A.; Thompson, M. E.; Kiningham, K. An innovative escape room activity to assess student readiness for advanced pharmacy practice experiences (APPEs). Currents in pharmacy teaching & learning. 2019;11(7):723-728. Eukel HN, Frenzel JE, Cernusca D. Educational Gaming for Pharmacy Students - Design and Evaluation of a Diabetes-themed Escape Room. Am J Pharm Educ. 2017;81(7):6265. Tietze KJ. A bingo game motivates students to interact with course material. Am J Pharm Educ. 2007;71(4):79. Kennedy D, Fanning K, Thornton P. The Age Game : An Interactive Tool to Supplement Course Material in a Geriatrics Elective. American Journal of Pharmaceutical Education. 2004;68:115. Chavez BG, Eric H.; Pathak, Rolee; Volino, Lucio R. Popular game shows as educational tools in the pharmacy classroom. Currents in Pharmacy Teaching and Learning. 2012;4(2):146-149. Gaikwad N, Tankhiwale S. Crossword puzzles: self-learning tool in pharmacology. Perspectives on medical education. 2012;1(5-6):237-248. Patrick SV, K.; Giri, V. P.; Datta, D.;Kumawat, P.; Singh, P.; Matreja, P. S. The usefulness of crossword puzzle as a self-learning tool in pharmacology. Journal of advances in medical education & professionalism. 2018;6(4):181-185. Rahim ASA, Ziden AA, Yap BK. Gamified Online Quizzes: Pharmacy Student Perceptions of Learning in an Undergraduate Medicinal Chemistry Course. Malaysian Journal of Pharmacy. 2020;6(1):6-12. Frey KM. Structure activity relationship (SAR) maps: A student-friendly tool to teach medicinal chemistry in integrated pharmacotherapy courses. Currents in Pharmacy Teaching and Learning. 2020;12(3):339-346. Yuriev E, Capuano B, Short JL. Crossword puzzles for chemistry education: learning goals beyond vocabulary. Chemistry Education Research and Practice. 2016;17(3):532-554. Romanelli F, Bird E, Ryan M. Learning styles: a review of theory, application, and best practices. Am J Pharm Educ. 2009;73(1):9. Carrido DI, Ramirez R-LF. Learning styles of millennial students at a pharmacy school in the Philippines. Pharmacy Education. 2020;20:265-272. Crawford SY, Alhreish SK, Popovich NG. Comparison of learning styles of pharmacy students and faculty members. American journal of pharmaceutical education. 2012;76(10):192-192. Austin Z. Learning styles of pharmacists: impact on career decisions, practice patterns and teaching method preferences. Pharmacy Education. 2004;4(1). Mohan BN, Vinod; Gowda, Shivaraj; Arvindakshan, Rajeev. Crossword puzzle: a tool for enhancing medical students' learning in microbiology and immunology. International Journal of Research in Medical Sciences. 2018;6(3):756-759. Gilani RN, Priyanka; Daigavane, Pallavi; Bajaj, Pavan; Mankar, Nikhil; Vishnani, Rozina. Crossword puzzle: An effective self-learning modality for dental undergraduates. Journal of Datta Meghe Institute of Medical Sciences University. 2020;15(3):397. Malini M, Sudhir G, Narasimhaswamy K. Crossword puzzle as a tool to enhance learning among students in a medical school. National Journal of Physiology, Pharmacy and Pharmacology. 2019;9(8):793-797. Nazeer MS, Razia; Ahmed, Mohammad Muzammil; Asad, Mohammad Rehan; Sami, Waqas; Hattiwale, Haroon Rasheed; Sreekanth, T. Crossword puzzles as an active learning mode for student directed learning in anatomy teaching: Medical undergraduate perceptions. International Journal of Medical Research & Health Sciences. 2018;7(10):12-19. Saxena AN, Raenelle; Pahwa, Punam; Mills, Sheryl. Crossword puzzles: active learning in undergraduate pathology and medical education. Archives of pathology & laboratory medicine. 2009;133(9):1457-1462. Crossman EK, Crossman SM. The crossword puzzle as a teaching tool. Teaching of Psychology. 1983;10(2):98-99. Mueller ST, Veinott ES. Testing the effectiveness of crossword games on immediate and delayed memory for scientific vocabulary and concepts. Paper presented at: CogSci2018. Raines DA. An innovation to facilitate student engagement and learning: Crossword puzzles in the classroom. Teaching and Learning in Nursing. 2010;5(2):85-90. Rajyaguru KA, MN Mohd; Nadiawati, AR; Reddy, SC. An Innovative Crossword Puzzle Tool to Evaluate the Undergraduate Medical Student’s Knowledge in Forensic Medicine. Journal of Advances in Medicine and Medical Research. 2016:1-7. Saran R, Kumar S. Use of crossword puzzle as a teaching aid to facilitate active learning in dental materials. Indian Journal of Applied Research. 2015;5(4):456-457. John EMN, Chin Fen; Ming, Long Chiau; Hong, Yet Hoi; Hassan, Yahaya. Learning style preferences of undergraduate pharmacy students in a Malaysian public university. Indian Journal of Pharmaceutical Education and Research. 2016;50(3):330-334. Willis SCP, Mrs Harsha; Silkstone, Victoria; Austin, Zubin. Unpacking links between learning gains, learning styles and achievement amongst 1 st year pharmacy students at Manchester Pharmacy School : Social Pharmacy, Manchester Pharmacy School; 2015. Alonso-Martín PC-D, Rocío; Granado-Alcón, Carmen; Lago-Urbano, Rocío; Martínez-García, Concha. Variability of Higher Education Students’ Learning Styles Depending on Gender, Course, Degree and Institutional Context. Sustainability. 2021;13(4):1659. Bell B, Koch J, Green B. Assessing Learning Styles of Pharmacy Students Using the VARK Questionnaire. 2014. Pungente MD, Wasan KM, Moffett C. Using Learning Styles to Evaluate First-Year Pharmacy Students' Preferences Toward Different Activities Associated with the Problem-Based Learning Approach. Am J Pharm Educ. 2003;66:119-124. Williams B, Brown T, Etherington J. Learning style preferences of undergraduate pharmacy students. Currents in Pharmacy Teaching and Learning. 2013;5(2):110-119. Jiraporncharoen WA, C; Chockjamsai, M; Euathrongchit, J. Learning styles and academic achievement among undergraduate medical students in Thailand. Journal of educational evaluation for health professions. 2015;12. Kolb AD. Individual learning styles and the Massachusetts: Sloan School of Management. 1971. Tsingos C, Bosnic-Anticevich S, Smith L. Does a learning style preference for processing information through reflection impact on the academic performance of a cohort of undergraduate pharmacy students? Pharmacy Education. 2015;15. Kolb AD. The Learning Style Inventory: Technical Manual. Boston, MA1971. Vermunt JD. Inventory of learning styles (ILS). Tilburg, The Netherlands: Tilburg University, Department of Educational Psychology. 1994. Eng M. Experience applying the Pharmacist Learning Styles Inventory (PILS) to experiential clerkships as a preceptor: A reflection. Currents in Pharmacy Teaching and Learning. 2013;5(1):62-67. Abuelo A, Castillo C, May SA. Usefulness of crossword puzzles in helping first-year BVSc students learn veterinary terminology. Journal of veterinary medical education. 2016;43(3):255-262. Kumar L, Bangera S, Thalenjeri P. Introducing innovative crossword puzzles in undergraduate physiology teaching- learning process. Archives of Medicine and Health Sciences. 2015;3(1):127-130. Oyler DRR, F.; Piascik, P.; Cain, J. Practical Insights for the Pharmacist Educator on Student Engagement. Am J Pharm Educ. 2016;80(8):143. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Apr, 2022 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Major revision 28 Feb, 2022 Reviewers agreed at journal 07 Dec, 2021 Reviews received at journal 25 Nov, 2021 Reviewers agreed at journal 25 Nov, 2021 Reviewers invited by journal 25 Nov, 2021 Editor assigned by journal 25 Nov, 2021 Editor invited by journal 25 Nov, 2021 Submission checks completed at journal 25 Nov, 2021 First submitted to journal 14 Nov, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1078884","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":65834148,"identity":"c5c75bd4-bd41-4526-8bd5-0b1d113a119c","order_by":0,"name":"Ghada Bawazeer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDACCRiDvQ1MMTYQr4XnGMlaJNKI1CIf3fxM4scfGznzmc+SP/Mw2MhuOMD+8AM+LYZ3jplJ9vCkGcvcTjsmzcOQZrzhAI+xBF4tMxLMbvBIHE6cIZ3exszDcDgRqIWBgJb0bzf/GPyvnyF5vBnosP9ALeyPf+D1i0SO2W2ehAMJEhJsB4AOOwDUwmCG1xYDmTPlv2UOJBvO4ElLk5xjkGw88zCPmQVeW2a3bzZ888dOXoL9mPGHNxV2sn3H2x/fwGvLAVQuEDPjUw+ypYGAglEwCkbBKBgFDAAv20lkj/dl0wAAAABJRU5ErkJggg==","orcid":"","institution":"King Saud University","correspondingAuthor":true,"prefix":"","firstName":"Ghada","middleName":"","lastName":"Bawazeer","suffix":""},{"id":65834149,"identity":"fd60f771-a8cb-4341-8eb0-3cf46c360397","order_by":1,"name":"Ibrahim Sales","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Sales","suffix":""},{"id":65834150,"identity":"4324e86a-1e7e-4b2d-8178-0238bd312a14","order_by":2,"name":"Abdullah Alhammad","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"","lastName":"Alhammad","suffix":""},{"id":65834151,"identity":"e285b9a5-c238-43c2-bf12-9036dbe2a334","order_by":3,"name":"Ahmed Aldemerdash","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Aldemerdash","suffix":""},{"id":65834152,"identity":"6b9a5bad-f474-4bd3-9128-f53e2e272c6b","order_by":4,"name":"Mansour Mahmoud","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Mansour","middleName":"","lastName":"Mahmoud","suffix":""},{"id":65834153,"identity":"3b96326e-7538-4d65-b03b-3dc49f64f68c","order_by":5,"name":"Majeda Aljuhani","email":"","orcid":"","institution":"King Saud Medical City","correspondingAuthor":false,"prefix":"","firstName":"Majeda","middleName":"","lastName":"Aljuhani","suffix":""},{"id":65834154,"identity":"585b0c61-adfb-4803-9b22-c76f7ccb85c6","order_by":6,"name":"Huda Albogumi","email":"","orcid":"","institution":"Pharmaceutical Care Services, Ministry of National Guard Health Affair","correspondingAuthor":false,"prefix":"","firstName":"Huda","middleName":"","lastName":"Albogumi","suffix":""}],"badges":[],"createdAt":"2021-11-14 11:29:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1078884/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1078884/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-022-03348-0","type":"published","date":"2022-04-11T09:49:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":16028986,"identity":"eeb31728-e64a-46e6-9fb0-527a397f851d","added_by":"auto","created_at":"2021-11-30 16:58:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69130,"visible":true,"origin":"","legend":"An Example of a CWP Clues","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-1078884/v1/5fe7f5a333e1d34515de81eb.png"},{"id":20180054,"identity":"774b7d1a-c976-44cc-8427-3e172ef3bf25","added_by":"auto","created_at":"2022-04-11 09:49:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":462385,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1078884/v1/d99fe2fc-6d5f-490e-9a93-608748eace60.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Crossword Puzzle as a Learning Tool to Enhance Learning about Anticoagulant Therapeutics","fulltext":[{"header":"Background","content":"\u003cp\u003eOld habits are hard to break. Didactic lectures continue to resemble the school days of Charlie Brown and his schoolteacher in the classroom. The COVID-19 pandemic has further complicated effective delivery of didactic lectures with the absence of the visual confirmation that students are actively participating and understanding the information. Such barrier has led to a lack of learner engagement objectively exemplified by an increase in absenteeism in pharmacy school lectures, students underestimating the importance of lectures, and a corresponding decrease in performance, particularly in therapeutics courses \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Contrarily, students who are stimulated by effective learning methods are more likely to attend lectures than their colleagues \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. On average, the first 10 minutes of a lecture are associated with the peak of student attention and highest retention of information \u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Student interest declines from that point and is barely salvaged in the last 5 to 10 minutes. In totality, students are disengaged for approximately 75% of the lecture. This is not surprising since millennials have been weaned upon technological advances and various means of communication and entertainment \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. This has resulted in both reality and an absence of consistent stimulation becoming something that is no longer considered intriguing.\u003c/p\u003e \u003cp\u003eEvidence supports the positive impact of using innovative educational tools to benefit the teaching and learning process for health professions, and pharmacy education is no exception \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The Accreditation Council for Pharmacy Education (ACPE) placed high emphasis in \u0026ldquo;Standard 10: Curriculum Design, Delivery, and Oversight\u0026rdquo; on student engagement through teaching and learning activities that promote self-directed learning and accommodate the diverse learning needs of students \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Gleason and colleagues categorized classroom-based active learning methods into five types: Cooperative Learning, Problem-Based Learning, Team-Based Learning, Case-Based Learning, and Ability-Based Education and Assessment-as-Learning \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Stewart et al. surveyed 114 US colleges and schools of pharmacy faculty members to evaluate the extent and the promoting factors for using active learning techniques \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Eighty-seven percent of the faculty members reported using active learning activities such as case-based learning (71%), deliberative discussion (50%), team-based learning (47%), clickers (45%), simulation (25%), Interactive Web-based learning (19%) and process-oriented guided inquiry learning (12%). Promoters for active learning techniques include younger faculty age, lower faculty rank, and departments of pharmacy practice or social/behavioral/administrative sciences. In the Middle Ease, Alruthia et al. surveyed faculty members in health colleges from 17 countries throughout the region \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. The majority of pharmacy colleges respondents (n=202) acknowledged utilizing various active learning strategies including class discussions (87%), small group discussions (56.9%), learning by teaching (49.5%), case studies and problem-based learning (41.1%). Several other studies have also described the incorporation of active learning techniques into pharmacy curriculum \u003csup\u003e17,19\u0026minus;23\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGamification or serious games have gained popularity recently \u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. In their overview of game implementation in the classroom, Biehle and Jeffres provided four essential fundamentals toward game development and use: (1) Motivation for participating should initially be external with the objective of internally motivating the student to master the material, (2) students should benefit from the material whether they win or lose, (3) all students should equally be engaged in participating, and (4) the objective of the game should be clearly explained to the students \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Several systematic reviews concluded that gamification can possibly improve the learning outcomes of health professions education including pharmacy \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. The published literature includes descriptions of a lengthy list of the different types of games used to aid students in learning \u003csup\u003e5,22,29\u0026minus;45\u003c/sup\u003e. The use of crossword puzzle (CWP) has been used occasionally in the literature with studies conducted in several pharmacy courses. Gaikwad et al. reported a significant improvement between CWP pre- and post-test scores when used in a pharmacology course covering antihypertensive and antiepileptic drugs for second-year Bachelor of Medicine and Bachelor of Surgery (MBBS) medical students \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Medical students in their fifth year of the MBBS degree indicated satisfaction with a CWP covering hormonal contraceptives \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. Student perceptions toward the activity were also positive. Shah and colleagues developed a CWP during a pharmacology and medicinal chemistry module about anti-ulcer agents \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. A post-activity survey revealed that most students over a two-year period enjoyed the CWPs and felt as if it enhanced their learning.\u003c/p\u003e \u003cp\u003eAlthough it is assumed that active learning strategies will increase student engagement for most participants, there is scarce of literature that investigated whether there is an association between student learning styles and their preference for active learning strategies in the classroom. Conversely, when a mismatch occurs in the instructor\u0026rsquo;s teaching style and a student\u0026rsquo;s learning style, student learning may be impacted \u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e. A study describing millennial students in the Philippines found that most students are application-oriented, focusing on applying what they studied to what they learned in practice \u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. This finding is important given that modern pharmacy curricula include more application courses and experiential education. Crawford et al. compared the dominant learning styles of pharmacy students and faculty members and found no significant differences between faculty members and student learning styles \u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. However, the study found that learning styles differed by gender and faculty track (tenure vs clinical).\u003c/p\u003e \u003cp\u003eStudies evaluating the use of CWPs as an educational tool for learning therapeutics aspects of drugs in Saudi Arabia are limited. The objective of this study was to evaluate students\u0026rsquo; perception toward the use of CWPs as an educational tool for enhancing their learning about anticoagulant therapeutics taught in the pharmacotherapy courses in the Doctor of Pharmacy (PharmD) and the Bachelor of Pharmacy (BPharm) undergraduate programs. In addition, we sought to determine whether students\u0026rsquo; learning style preferences influenced their perception of this active learning technique.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe CWP was implemented as an active learning tool in therapeutic courses for the PharmD and BPharm programs. These courses are covered in the seventh level (third professional year), and the content included module on cardiovascular diseases including the use of anticoagulant drugs. Didactic lectures on the management of venous thromboembolism and atrial fibrillation with overview of anticoagulant drugs were discussed over 6 contact hours. The learning objectives related to anticoagulant therapy are presented in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. CWP was developed using a free online CWP generator (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTheTeachersCorner.net\u003c/span\u003e). The course instructors developed the puzzle clues (questions and answers) based on the material covered during the lectures and designed to cover Bloom taxonomy of knowledge, comprehension, and application levels. The content validity of these CWPs was mapped to the intended learning outcomes of the modules and was peer-reviewed by another course instructor. Additionally, the CWP was also piloted among a group of student interns in their advanced pharmacy practice experiential training. Printed copies of the CWP were provided to the students to solve immediately after the lecture (BPharm group, 10 clues CWP) or during pharmacy practice lab (PharmD group, 20-clues CWP). During these sessions, students were divided into groups, and 30 minutes was allocated for solving each CWP. Although students were expected to self-correct the answers to solve the puzzle, a debriefing session was provided to discuss any confusing points or misconceptions related to the topic. An example puzzle is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. At the end of the activity, students were asked to complete two post-activity surveys administered via SurveyMonkey. The first survey was the Pharmacists\u0026rsquo; Inventory of Learning Styles (PILS), a survey tool validated for pharmacy practice \u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e. The second survey was an 8-item questionnaire to measure students\u0026rsquo; attitudes towards the use of games in learning developed by Shah et al \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. No extra marks were given to the students for completing the puzzle or the survey. Students were also informed that their grade in the course would not be impacted by their participation, or lack thereof, in the activity. We implemented the CWP over three consecutive years using different puzzles. The study was approved by institutional review board at King Saud University and was granted an exemption status (\u003cb\u003eProject # E-21-6205\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSpecific Learning Objectives for Lectures Covering Anticoagulation therapeutics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHCL 412 and PHCL 416 Anticoagulation Therapy Lectures Objectives:\u003c/p\u003e \u003cp\u003e1. Compare and contrast between the different anticoagulant therapies about:\u003c/p\u003e \u003cp\u003ea. Place of therapy\u003c/p\u003e \u003cp\u003eb. Mechanisms of action\u003c/p\u003e \u003cp\u003ec. Advantages and disadvantages in terms of their pharmacokinetic and pharmacodynamic properties (e.g. dosing, onset of action, drug \u0026amp; food interaction, etc)\u003c/p\u003e \u003cp\u003ed. *Key pivotal clinical trials of anticoagulant drugs\u003c/p\u003e \u003cp\u003ee. Side effects and management\u003c/p\u003e \u003cp\u003ef. Monitoring of drug therapy\u003c/p\u003e \u003cp\u003eg. Patient education\u003c/p\u003e \u003cp\u003eh. *Use in selected population (e.g. cancer patients, pregnancy, morbid obesity, renal impairment, and pediatrics)\u003c/p\u003e \u003cp\u003e2. Apply evidence-based guideline recommendation for the use of anticoagulants in the:\u003c/p\u003e \u003cp\u003ea. Prevention and treatment of venous thromboembolism\u003c/p\u003e \u003cp\u003eb. Stroke prevention in Atrial fibrillation\u003c/p\u003e \u003cp\u003ec. *Perioperative management of anticoagulant therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"1\"\u003e\u003csup\u003e\u003cem\u003e* not included in the learning objectives for PHCL 416\u003c/em\u003e\u003c/sup\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis:\u003c/h2\u003e \u003cp\u003eThe data were analyzed using IBM SPSS Statistic version 22. The data was presented in frequencies (N) and percentages (%). The continuous data were expressed by the mean and standard deviation (SD). A normality test (Kologrove-Smirnov and Shapiro-Wilk test) was conducted for the dependent variables (student perceptions of CWPs) and the independent variables (gender and education degree) to determine whether students' perceptions were normally distributed among gender categories (i.e. male and female) and education degree categories (i.e. PharmD and BPharm). As data were not normally distributed, the Mann-Whitney U test was used to test for the differences in perception among the independent groups.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eData were available on 267 students who participated in the game. The mean age of the students was (21.34 \u0026plusmn;1.21), the majority were females (67%), and two-thirds (71%) were enrolled in the PharmD program. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the student demographics. On the PILS survey, the most preferred learning styles among all students were convergers (35.6%) and assimilators (25.3%), while 15.7% of students were multimodal. Learning style order of preference based on gender showed a significant difference (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05), with female students preferring assimilator and converger learning styles, while male students\u0026rsquo; preference was higher for accommodator and diverger learning styles. Less than 10% of students were able to complete the puzzle in 30 minutes and fewer number have correct answers. On the perception survey, students perceived that CWPs helped them to identify the most important topics to focus on (82.4%), served as a good review of the lecture material (81.3%), enjoyed classmate interaction, and reviewing material while solving puzzle (79.1%), enhanced their learning (77.2%), found the material pertinent (74.2%) and learned more from the class because of CWP (67.4%). Most of the students perceived the amount of time given was sufficient (73.1%) and most of them expressed preference to have extra credits for such activities (67.4%). Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes students\u0026rsquo; perceptions of CWP as a learning tool.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic Characteristics (N=267)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.34 \u0026plusmn;1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e179 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLearning style\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAccommodator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAssimilator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConverger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiverger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emultimodal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational degree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePharmD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e191(71.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBPharm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76 (28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003csup\u003e\u003cem\u003e*mean \u0026plusmn; SD, \u0026yen; (6 students did not answer this question)\u003c/em\u003e\u003c/sup\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStudent Perceptions of CWPs as a Study Tool (N=267)*\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuestion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStrongly Disagree\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDisagree\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAgree\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe CWP provided enhanced my learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7(2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9(3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45(16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119(44.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87(32.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnjoyed classmate interaction and reviewing material while solving puzzle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9(3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42(15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104(39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e107(40.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCWPs oriented us to the topics we should focus on\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7(2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35(13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e121(45.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99(37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of time provided for solving the puzzles was sufficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18(6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49(18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95(35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe material on the puzzles was pertinent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9(0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3(1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61(22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118(44.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80(30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLearned more in class because of the CWPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.8(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18(6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64(24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115(43.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65(24.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSolving CWPs are good reviews of material covered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9(3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37(13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125(46.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92(34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExtra credit should be associated with activities such as CWPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6(2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13(4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52(19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94(35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102(38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cem\u003e*Survey adapted with permission from Ref 36.\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThere was a significant difference in students\u0026apos; perception of CWPs among gender groups. Female students had a significantly higher mean score for the statement \u0026quot;length of time provided for solving the puzzles was sufficient\u0026quot; than their male counterparts (\u003cem\u003ep\u003c/em\u003e = 0.001) (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Furthermore, there was also a significant difference in student perceptions about CWPs among the two different undergraduate programs. The BPharm students\u0026apos; mean score was significantly higher on several perception questionnaire items compared to PharmD students, specifically on statement items \u0026ldquo;CWPs oriented them to the topics they should focus on\u0026rdquo; (\u003cem\u003ep\u003c/em\u003e =0.003), \u0026ldquo;the length of time provided for solving the puzzles was sufficient\u0026rdquo; (\u003cem\u003ep\u003c/em\u003e = 0.001), and \u0026ldquo;the material on the puzzles was pertinent\u0026rdquo; (\u003cem\u003ep\u003c/em\u003e = 0.038). There was no association observed between learning style and student\u0026rsquo;s perception of CWP \u003cem\u003e(p\u003c/em\u003e=0.19). Student feedback and suggestions about using the CWP in the teaching and learning process are summarized in Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e. Overall, students found the method enjoyable and helpful to memorize and retain the newly learned information; however, several students urged that it would be much better if they had the chance to check their spelling or use their reference books. Students also believed that CWP is an effective way to teach confusing subjects prior to exams and suggested to extend the use of CWP for other topics such as antibiotics, drug-drug interactions, microbiology and medicinal chemistry.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation of Student Perceptions of CWPs with demographic Characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eQuestion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eP value*\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eEducation degree\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eP value*\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePharmD\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBPharm\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe CWP provided enhanced my learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9(0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9(0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.463\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnjoyed classmate interaction and reviewing material while solving puzzle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.840\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCWPs oriented us to the topics we should focus on\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.741\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.3(0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of time provided for solving the puzzles was sufficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.7(1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.8(0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.2(0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe material on the puzzles was pertinent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.8(0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9(0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLearned more in class because of the CWPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.7(1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.8(0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.668\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.7(0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9(1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSolving CWPs are good reviews of material covered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.971\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0(0.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.146\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExtra credit should be associated with activities such as CWPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1(0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9(1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9(0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.2(0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003csup\u003e\u003cem\u003e*Mann\u0026minus; Whitney U test\u003c/em\u003e\u003c/sup\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab5\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStudents\u0026rsquo; free comments on the CWP activity\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFeedback about using the game in the teaching-learning process\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSuggestions for future use\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● Change the narration style and create a stimulating learning environment for students.\u003c/p\u003e\n \u003cp\u003e● \u0026ldquo;It is much better studying in game format rather than normal assignments.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e● \u0026ldquo;I liked how we did not use any reference to answer it was a mind refreshing activity.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e● \u0026ldquo;I like the idea it is creative and fun, it made me focus more on the spelling which is important.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e● Improve thinking and memorizing.\u003c/p\u003e\n \u003cp\u003e● \u0026ldquo;Made my brain thinks faster\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e● \u0026ldquo;A good change in the routine it made me want to pay mor attention in class\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● \u0026ldquo;It was good, but I wish we were able to check spell.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e● Puzzles to solve in shorter time\u003c/p\u003e\n \u003cp\u003e● It should be implemented after each pharmacotherapy block.\u003c/p\u003e\n \u003cp\u003e● Assigning grades/bonus will be also rewarding.\u003c/p\u003e\n \u003cp\u003e● Use it to teach confusing subjects.\u003c/p\u003e\n \u003cp\u003e● Use it as a review before the exam.\u003c/p\u003e\n \u003cp\u003e● Let students know before hands about the puzzle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe pathophysiology and therapeutic of cardiovascular diseases, specifically topics about thromboembolism and atrial fibrillation are essential topics taught in the Pharm.D. and Bachelor programs in King Saud University, Riyadh, Saudi Arabia. These cardiovascular topics are usually introduced in the first therapeutic course series, and they require students to use critical thinking and clinical decision-making skills when implementing guideline recommendations, which most student perceive it to be challenging. The courses also rely on student\u0026rsquo;s prior knowledge on the pharmacology of cardiovascular drugs. Feedback from students and course faculty showed students\u0026rsquo; knowledge about anticoagulant drugs pharmacology was suboptimal due to misalignment of some topics in the curriculum. To ease out student\u0026rsquo;s trepidation, the course instructors utilized variety of active learning pedagogy to engage students in this first therapeutic course, including CWP activity. To the best of our knowledge, this is the first study conducted to evaluate the pharmacy\u0026rsquo; students\u0026rsquo; perceptions about the use of CWP for enhanced learning about the anticoagulating therapeutics in Saudi Arabia.\u003c/p\u003e \u003cp\u003eIn the present study, student perceptions about the value of CWP was generally positive. Overall, most of the students agreed that CWP enhanced their learning, oriented them to key information they need to focus on, improved retention of information and was a good review for the material covered in the lectures. These findings in consistent with other published studies \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. Shah et al. reported higher agreement on the same survey items compared to the present results. Ninety percent of students indicated positive perceptions such as CWPs enhanced their learning, helped them focus on important topics in the lectures, and served as a good review of the lecture material \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Mirroring the results from other studies about the recreational and fun aspects of the puzzles, most students enjoyed the classroom interactions while solving the puzzle. They felt the puzzle was interactive, enjoyable, and encouraged a competitive environment within the classroom \u003csup\u003e2,3,42,51\u0026minus;55\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the current study, students from the BPharm program reported statistically significant positive perceptions compared to PharmD students specifically on the following items: \u0026ldquo;CWP oriented us to the topics we should focus on\u0026rdquo; and \u0026ldquo;the material on the puzzle was pertinent\u0026rdquo;. This difference could be explained by the fact that traditional teaching is more predominant in BPharm curriculum. Crawford et al. found significant differences between tenure track and clinical track learning styles among faculty at the University of Illinois at Chicago Pharmacy college \u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. The tenure track had a predominantly abstract sequential learning style that focuses on theoretical concepts and analytical approaches. The clinical faculty have a more concrete sequential learning style that focuses on application and practicality of information. The use of active learning is reported to be higher in clinical faculty members and faculty members in the social/behavioral/administrative sciences \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. In KSU, BPharm curriculum is focused predominantly on pharmaceutical sciences, with only two therapeutic courses.\u003c/p\u003e \u003cp\u003eOn the perception item about \u0026ldquo;the length of time provided for solving the puzzle was sufficient\u0026rdquo;, students from the BPharm program have a significantly higher agreement than the PharmD students (\u003cem\u003ep\u003c/em\u003e=0.001). We attributed this difference to the shorter puzzle administered to the BPharm group (10 clues) compared to the PharmD group (20 clues). Nonetheless, different studies reported described variable clues numbers ranging from 12 to more than 50 and completion time from 5 to 60 minutes, and all showed favorable agreement that the allocated time was adequate regardless of the size of the puzzle or completion time \u003csup\u003e2,5,42,50\u0026ndash;52,56\u0026minus;59\u003c/sup\u003e. Notably, in the current study male students were less satisfied with the time provided for solving the puzzles than female students. Two factors could have produced such difference. First, active learning, specifically games, are less utilized by male faculty. This is supported by a recent study that found that female faculty are more likely to implement active learning strategies in classroom teaching than male faculty \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Furthermore, faculty from different generations could be differ in their interaction, learning, and teaching skills regardless of gender \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Second, gender variation in learning styles could have affected their perceptions about the time. Although some studies have reported more men being divergers and women have an assimilator learning style, others did not find such differences \u003csup\u003e48,60\u0026minus;62\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe present study found that the predominant learning style in our student population is consistent with the learning styles of pharmacists and pharmacy students reported in the literature \u003csup\u003e\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e,\u003cspan additionalcitationids=\"CR64\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e. The learning styles primarily reported with the pharmacy profession are assimilators and convergers. Similarly, in this current study, the converger learning style was predominant in both male (35%) and females (36%). The second most prominent learning style was assimilator in female students (33%) and divergent in male students (26%). It is worth noting that male representation in this study is only one third of the sample studied. No significant difference was found between student perceptions about CWP and their learning styles. Studies on the relationship between pharmacy students learning styles and academic performance are scarce and with divergent conclusions. A study conducted in medical students in Thailand showed that students\u0026rsquo; learning styles differed between pre-clinical and clinical years. Furthermore, the learning style is only associated with students\u0026rsquo; academic achievement during the pre-clinical years, with the reflective learning style associated with high academic success \u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e,\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e. Another study found a similar correlation between reflective abilities and academic success in undergraduate pharmacy education \u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e. Both assimilators and divergers on the Kolb learning style inventory possess reflective abilities \u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e. On the other hand, several other studies did not find an association between learning styles and academic achievement \u003csup\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMillennials (those born between 1981 and 1996), represented by students participating in the current study, could have different approaches to learning and different preferences of learning styles, hence, different perceptions towards the variable approaches of learning. Corrido et al showed that based on Vermunt\u0026rsquo;s Inventory of Learning Styles (ILS), millennial Filipino pharmacy students have a predominantly application-directed learning style (i.e. those who try to discover relationships between things and apply what they learned); followed by a reproduction-directed learning style (i.e. those who memorize the learning content in order to be able to reproduce it in a test) \u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e. Eng et al. also concluded that learning styles inventory could influence the learning environment during experiential education of millennial pharmacy students \u003csup\u003e\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe previous studies and others raise an important issue to consider for both educators as well as students about identifying learning styles to improve learning experience rather than to stigmatize. Student\u0026rsquo;s self-awareness about their learning styles can help them refine their study habits and encourage them to reach out to faculty members when struggling academically due differences in teach and learning styles; therefore, the learning environment can be catered to maximize students\u0026rsquo; gain, confidence, and ability to transfer learning. At the same time, for faculty and preceptors, self-awareness of their own learning style and that of their students could help improve teaching styles and promote better approaches to better facilitate teaching and assessment.\u003c/p\u003e \u003cp\u003eThe open comment section of the survey highlighted how the students valued the puzzle activity as a learning and self-assessment tool. One of the interesting comments repeated by several students is the fact that spelling was an obstacle while solving the puzzle. Other researchers reported similar spelling challenges surfaced while solving CWPs \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e. For pharmacy students, such accuracy is vital to patient and medication safety. The positive reception toward this tool encourages faculty members to develop creative tool that carry low burden (such as the CWP) to engage students especially in large class-size, which can be deterrent to incorporating active learning in teaching \u003csup\u003e\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study had several limitations. First, due to logistic reasons, administering the puzzle in relation to the lecture delivery was variable among the cohorts (right after the lecture, during the same week, or two weeks later). Although this might have affected the recall of information, the several open comments about spelling difficulties could be the main reason for not getting the right answers. Secondly, there was only one BPharm cohort group compared to three PharmD cohort groups. Thirdly, the length of the puzzle used for the BPharm group was shorter (10 questions and clues vs 20 for the PharmD group); this is mainly because the content material for the BPharm is less than the PharmD and the need to deliver the puzzle in the short break after the lecture immediately. The learned information could have still been fresh and easy to retrieve. Hence, the perception of time sufficiency was satisfactory. Lastly, we did not assess the impact of the game on short- or long-term retention of the information, nor on student\u0026rsquo;s final grade in the course or pre- and post-testing examination; however, the activity was purposely implemented to guide students towards the most important information about the topic and assist them to identify any gaps in knowledge or understanding.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study demonstrated that students valued active learning engagement in the class environment using the CWPs. CWPs presented an easy and versatile tool that can be customized in difficulty to enhance students' educational experience and promote more self-awareness of the teaching and learning trends for both students and faculty. Providing students with a self-learning tool and engaging them during the learning process may lead to better understanding, retention, and application of the learned material and eventually in academic performance. Future studies should investigate the impact of CWPs on both short- and long-term retention of the lecture material.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eACPE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAccreditation Council for Pharmacy Education\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBPharm\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBachelor of Pharmacy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCWP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrossword Puzzle\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eKSU\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKing Saud University\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePharmD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDoctor of Pharmacy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePILS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePharmacists\u0026rsquo; Inventory of Learning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe activity described in this study was conducted as part of the course delivery, no consent form provided. The study was approved by institutional review board at King Saud University and was granted an exemption status (\u003cstrong\u003eProject # E-21-6205\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr /\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available upon request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr /\u003e none\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e \u003cbr /\u003e This research was funded by Deanship of Scientific Research at King Saud University, research group number (RD-1441-367)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, and Methodology, G.B.; Validation, G.B., A.D.; Formal Analysis, M.M.;\u003c/p\u003e\n\u003cp\u003eInvestigation, G.B. I.S.; Resources, M.J. H.B.; Data Curation, H.B., M.J.; Original Draft Preparation, G.B., I.S., M.M.; Writing \u0026ndash; Review \u0026amp; Editing, G.B., I.S., A.A. A.D.; Visualization, G.B.;\u003c/p\u003e\n\u003cp\u003eProject Administration, G.B., I.S. A.H., A.D.; Funding Acquisition, I.S. All authors approved the final manuscript prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Dr. Zuhair Al Qahtani for helping in running the session to implement the game.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZamani P, Diparva Haghighi S, Ravanbakhsh M. The use of crossword puzzles as an educational tool. \u003cem\u003eJournal of advances in medical education \u0026amp; professionalism. \u003c/em\u003e2021;9(2):102-108.\u003c/li\u003e\n\u003cli\u003eMshayisa VV. 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Learning styles of millennial students at a pharmacy school in the Philippines. \u003cem\u003ePharmacy Education. \u003c/em\u003e2020;20:265-272.\u003c/li\u003e\n\u003cli\u003eCrawford SY, Alhreish SK, Popovich NG. Comparison of learning styles of pharmacy students and faculty members. \u003cem\u003eAmerican journal of pharmaceutical education. \u003c/em\u003e2012;76(10):192-192.\u003c/li\u003e\n\u003cli\u003eAustin Z. Learning styles of pharmacists: impact on career decisions, practice patterns and teaching method preferences. \u003cem\u003ePharmacy Education. \u003c/em\u003e2004;4(1).\u003c/li\u003e\n\u003cli\u003eMohan BN, Vinod; Gowda, Shivaraj; Arvindakshan, Rajeev. Crossword puzzle: a tool for enhancing medical students' learning in microbiology and immunology. \u003cem\u003eInternational Journal of Research in Medical Sciences. \u003c/em\u003e2018;6(3):756-759.\u003c/li\u003e\n\u003cli\u003eGilani RN, Priyanka; Daigavane, Pallavi; Bajaj, Pavan; Mankar, Nikhil; Vishnani, Rozina. Crossword puzzle: An effective self-learning modality for dental undergraduates. \u003cem\u003eJournal of Datta Meghe Institute of Medical Sciences University. \u003c/em\u003e2020;15(3):397.\u003c/li\u003e\n\u003cli\u003eMalini M, Sudhir G, Narasimhaswamy K. Crossword puzzle as a tool to enhance learning among students in a medical school. \u003cem\u003eNational Journal of Physiology, Pharmacy and Pharmacology. \u003c/em\u003e2019;9(8):793-797.\u003c/li\u003e\n\u003cli\u003eNazeer MS, Razia; Ahmed, Mohammad Muzammil; Asad, Mohammad Rehan; Sami, Waqas; Hattiwale, Haroon Rasheed; Sreekanth, T. Crossword puzzles as an active learning mode for student directed learning in anatomy teaching: Medical undergraduate perceptions. \u003cem\u003eInternational Journal of Medical Research \u0026amp; Health Sciences. \u003c/em\u003e2018;7(10):12-19.\u003c/li\u003e\n\u003cli\u003eSaxena AN, Raenelle; Pahwa, Punam; Mills, Sheryl. Crossword puzzles: active learning in undergraduate pathology and medical education. \u003cem\u003eArchives of pathology \u0026amp; laboratory medicine. \u003c/em\u003e2009;133(9):1457-1462.\u003c/li\u003e\n\u003cli\u003eCrossman EK, Crossman SM. The crossword puzzle as a teaching tool. \u003cem\u003eTeaching of Psychology. \u003c/em\u003e1983;10(2):98-99.\u003c/li\u003e\n\u003cli\u003eMueller ST, Veinott ES. Testing the effectiveness of crossword games on immediate and delayed memory for scientific vocabulary and concepts. Paper presented at: CogSci2018.\u003c/li\u003e\n\u003cli\u003eRaines DA. An innovation to facilitate student engagement and learning: Crossword puzzles in the classroom. \u003cem\u003eTeaching and Learning in Nursing. \u003c/em\u003e2010;5(2):85-90.\u003c/li\u003e\n\u003cli\u003eRajyaguru KA, MN Mohd; Nadiawati, AR; Reddy, SC. An Innovative Crossword Puzzle Tool to Evaluate the Undergraduate Medical Student\u0026rsquo;s Knowledge in Forensic Medicine. \u003cem\u003eJournal of Advances in Medicine and Medical Research. \u003c/em\u003e2016:1-7.\u003c/li\u003e\n\u003cli\u003eSaran R, Kumar S. Use of crossword puzzle as a teaching aid to facilitate active learning in dental materials. \u003cem\u003eIndian Journal of Applied Research. \u003c/em\u003e2015;5(4):456-457.\u003c/li\u003e\n\u003cli\u003eJohn EMN, Chin Fen; Ming, Long Chiau; Hong, Yet Hoi; Hassan, Yahaya. 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Experience applying the Pharmacist Learning Styles Inventory (PILS) to experiential clerkships as a preceptor: A reflection. \u003cem\u003eCurrents in Pharmacy Teaching and Learning. \u003c/em\u003e2013;5(1):62-67.\u003c/li\u003e\n\u003cli\u003eAbuelo A, Castillo C, May SA. Usefulness of crossword puzzles in helping first-year BVSc students learn veterinary terminology. \u003cem\u003eJournal of veterinary medical education. \u003c/em\u003e2016;43(3):255-262.\u003c/li\u003e\n\u003cli\u003eKumar L, Bangera S, Thalenjeri P. Introducing innovative crossword puzzles in undergraduate physiology teaching- learning process. \u003cem\u003eArchives of Medicine and Health Sciences. \u003c/em\u003e2015;3(1):127-130.\u003c/li\u003e\n\u003cli\u003eOyler DRR, F.; Piascik, P.; Cain, J. Practical Insights for the Pharmacist Educator on Student Engagement. \u003cem\u003eAm J Pharm Educ. \u003c/em\u003e2016;80(8):143.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"crossword game, pharmacy, anticoagulation, therapeutics, learning style, active learning.","lastPublishedDoi":"10.21203/rs.3.rs-1078884/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1078884/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\u003cp\u003eEducational games make the learning process more enjoyable, fun, and create a competitive classroom environment that can positively affect learning. This study sought to implement and evaluate pharmacy students’ perceptions towards using crossword puzzles (CWPs) as a learning tool in the pharmacotherapy cardiovascular module focusing on the therapeutics of anticoagulants.\u003c/p\u003e\u003cp\u003eMethods\u003c/p\u003e\u003cp\u003eClues for the puzzle were developed, validated, and piloted by course faculty. A free internet puzzle generator was used to create puzzles with 10 to 20 clues. Students were given 30 minutes to solve the puzzle following the completion of the didactic topic. An 8-item survey instrument and Pharmacists’ Inventory of Learning Styles (PILS) questionnaire were administered to examine students’ perceptions of the game and their learning style preference, respectively.\u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003eOver three consecutive course offerings, 267 students participated in the activity from both undergraduate programs (Bachelor of Pharmacy (BPharm) and Doctor of Pharmacy (PharmD). Most students expressed favorable perceptions of the puzzle. Female and BPharm students had significantly more favorable perceptions than male students and PharmD students on several perception items. There was no association between student perceptions and their learning styles.\u003c/p\u003e\u003cp\u003eConclusion\u003c/p\u003e\u003cp\u003eCWP presented an innovative, creative, and easy active learning tool to enhance students’ learning and engagement.\u003c/p\u003e","manuscriptTitle":"Crossword Puzzle as a Learning Tool to Enhance Learning about Anticoagulant Therapeutics","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-11-30 16:58:55","doi":"10.21203/rs.3.rs-1078884/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-02-28T05:25:06+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"3e238bce-e29b-42eb-bb02-eac2629cecaa","date":"2021-12-07T09:17:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-11-26T03:57:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f8e3339a-de1d-453f-8342-1a6662373c20","date":"2021-11-25T13:56:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-11-25T09:51:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-11-25T09:46:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-11-25T06:16:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-11-25T06:14:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2021-11-14T11:16:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af03d227-9946-4d56-a22f-d4126c18ff5a","owner":[],"postedDate":"November 30th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":8837747,"name":"Internal Medicine"}],"tags":[],"updatedAt":"2022-04-11T09:49:48+00:00","versionOfRecord":{"articleIdentity":"rs-1078884","link":"https://doi.org/10.1186/s12909-022-03348-0","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2022-04-11 09:49:48","publishedOnDateReadable":"April 11th, 2022"},"versionCreatedAt":"2021-11-30 16:58:55","video":"","vorDoi":"10.1186/s12909-022-03348-0","vorDoiUrl":"https://doi.org/10.1186/s12909-022-03348-0","workflowStages":[]},"version":"v1","identity":"rs-1078884","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1078884","identity":"rs-1078884","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}