The Role of Game-Based Learning in Experiential Education: Tool Validation, Motivation Assessment, and Outcomes Evaluation among a Sample of Pharmacy Students

: (1) Background: There is a scarcity of data regarding game-based learning (GBL) in experiential pharmacy education; in addition, the impact of educational games on the attainment of intended learning outcomes and students’ motivation to actively learn and practice through non-traditional pedagogical tools are yet to be explored. (2) Methods: This was a prospective quasi-experimental study that introduced GBL into the Pharmacy Practice Experience course of the Bachelor of Pharmacy (BPharm) program at the Lebanese International University in Lebanon. Data collection took place between July and September 2021. The study objectives were to assess the impact of GBL on attaining intended learning outcomes, determine students’ motivation to engage in GBL, and assess the impact of this motivation on the attainment of learning outcomes. (3) Results: GBL was associated with a signiﬁcantly higher exam average (mean difference = 7.152, p < 0.001). Moreover, an active learning motivation assessment scale (ALMAS) was constructed and validated; it was found to have good reliability as well as high sensitivity and speciﬁcity, and it determined a good level of motivation to engage in GBL. Game-based learners with higher motivation scores had signiﬁcantly higher exam averages compared to those with lower scores (Beta = 0.296, 95% CI 0.110–0.545, p = 0.004). (4) Conclusion: GBL was associated with better attainment of intended learning outcomes. Students appear to be motivated to learn by this style of active learning, and motivation is prognostic of the attainment of learning outcomes.


Introduction
Game-based learning (GBL) is the addition of certain game principles and elements to conventional pedagogies in order to engage learners in a joyful and dynamic way [1]. GBL is not just creating games for students to play; it is designing learning activities that incrementally introduce concepts and guide learners towards an end goal [2]. Game mechanics are the building blocks of games that invoke a meaningful response from the learner [3]. They are utilized to improve interactivity, rewards, and motivation through a distinctive combination of strategies and game features [4,5]. Game mechanics can be subclassified into game attributes and game elements. Game attributes, such as rules, goals, and competition, are features inherent in the game structure that initiate interest in gaming activities [6]. On the other hand, game elements, such as badges, levels, and rewards, are tools shared by games but not necessarily critical conditions of games [1].
GBL provides a fun, interactive, personalized, and challenging learning environment while enabling learners to experience and apply knowledge [7][8][9]. Despite the popularity of educational games, there is little consensus about whether they improve academic performance [10]. Several studies suggested that GBL enhances learning performance and outcomes through affective (e.g., enjoyment), cognitive (e.g., cognitive load), and behavioral (e.g., intention to participate in learning) mechanisms [11][12][13][14]. However, other studies reported no effect [15] or even negative effects of educational games on students' exam scores [16]. Lack of integration between gaming and teaching, as well as a poor balance between enjoyment and education, are important drawbacks of educational games. Games can be too attractive but fail to reflect intended learning outcomes, or they can be too educational but unable to trigger interest among learners [17].
GBL improves students' self-efficacy in that educational games can provide more diverse learning methods that are effective in increasing students' interest and learning efficiency [18,19]. In addition, such games deepen the students' understanding of the educational content so they can solve more complex problems and develop creative and critical thinking [20,21]. Several studies have highlighted the positive impact of GBL on learners' motivation and attitude [22,23]. Motivation is crucial to learning, and educational games can help motivate learners [24]. Utilizing game mechanics and aesthetics, such as levels, points, leaderboards, and a competitive environment, can enhance the students' external and internal motivations to engage in these games [25]. Appropriate use of competition, challenge, scoring, and ranking can motivate learners to win, help learners gain a sense of accomplishment and satisfaction, and make learners highly motivated to learn [26]. GBL aims to improve motivation and, consequently, the teaching-learning process [27]. Encouraging interaction between the teacher and the student through educational games increases motivation, leading to an improvement in the capacity to assimilate knowledge and acquire skills [28].
The limited use of innovative teaching techniques in pharmacy education, with the widespread use of teacher-centered strategies, led to the decreased retention of knowledge, lower student engagement, decreased motivation, and an increased classroom absence rate [29]. This highlights the need for the refinement of teaching methods and the implementation of new pedagogical methods in the pharmacy curriculum to enhance learner motivation, engagement, and knowledge retention. GBL is a current teaching and learning trend spanning a range of academic studies [2]. Many universities have begun to employ a variety of game-based technologies in an effort to add an extra level of motivation and incentive to many higher education activities. The Accreditation Council for Pharmacy Education (ACPE) has included active learning as a required component of the pharmacy curriculum [30]. Pharmacy educators are trying to meet ACPE standards through the utilization of GBL activities. Escape rooms, software and real-life simulations, and quizbased review games are examples of GBL activities applied in pharmacy education [2]. GBL was utilized in pharmaceutical and non-pharmaceutical modules, including immunology, opioid safety, community pharmacy, and pharmacy management [31]. Examples of educational games for pharmacy students include an advanced software program that allows players to manage a city that produces multiple herbal products [32], a 3D simulation of working at a community pharmacy [33,34], an innovative escape room utilizing pre-set locks, clues, and boxes to teach clinical concepts of toxicology [35], and groupbased quizzing followed by a Kahoot! ® competition to prepare students for immunology assessments [36]. Several advantages of GBL experienced by pharmacy students were demonstrated, such as practicing their clinical skills without the risk of endangering the patients' health, implementing collaborative learning, receiving immediate feedback, and inducing behavioral and attitude changes [37].
Gaming activities can be an especially effective method to teach students when content is application-based; this allows students to practice with a more hands-on approach or review previous content covered by other traditional teaching methods. Experiential education is an essential cornerstone of pharmacy education and training, according to several international organizations [38]. It is a practice-based experience that provides pharmacy students with real-life training opportunities to apply taught knowledge and develop personal attributes and professional skills [39,40]. Community pharmacy practice experience courses offer pharmacy students rich learning opportunities to become competent pharmacists and worthwhile members of healthcare teams [41]. Although GBL was introduced to higher education in Lebanon by an English teacher in 2015 [42], limited literature exists with respect to pharmacy education. Moreover, there is a scarcity of data regarding GBL in pharmacy practice experience (PPE) courses; in addition, the impact of educational games on the attainment of intended learning outcomes and students' motivation to actively learn and practice through non-traditional pedagogical tools are yet to be explored. This study aimed to assess the impact of GBL on attaining the intended learning outcomes of a PPE course. It also aimed to determine students' motivation to engage in these active learning activities and assess the role of this motivation on the attainment of learning outcomes.

Study Design and Setting
This was a prospective quasi-experimental study that introduced GBL into the PPE II course of the Bachelor of Pharmacy (BPharm) program at the Lebanese International University (LIU) in Lebanon. Data collection took place between July and September 2021. PPE II is a twelve-week supervised experiential education course in a community pharmacy setting that takes place at the end of the second professional year of the program. PPE II explores advanced non-communicable and communicable diseases topics related to patient care. This practice experience provides students with adequate advanced community knowledge and communication skills to engage in patient care and interact with healthcare professionals. A manual with several modules tackling the required topics has to be reviewed and discussed by students. The manual aims to guide students to acquire and develop the necessary knowledge, skills, and values in order to be effective and competent community pharmacists. The learning outcomes of the course are to equip students with competencies related to 4 domains, including (1) foundational knowledge, (2) pharmaceutical care, (3) essentials for practice and care, and (4) approach to practice and care.
With the suspension of community pharmacy onsite trainings due to COVID-19 restrictions, the PPE II delivery method was switched to a virtual training rotation. Various activities were performed to acquire the needed competencies and to compensate for the impact of the loss of the onsite community training. Thus, students met their preceptor, who was the faculty member supervising their experiential education, on a weekly basis via Google Meet. The meetings of students with their preceptors included open discussions on the different module topics included in the course manual. The discussions also included simulated patient cases, simulated patient prescriptions, and online topic presentations.

Educational Setting and Procedures
The study protocol was approved by the Research and Ethics Committee of the School of Pharmacy at the Lebanese International University (2020RC-055-LIUSOP). Students were invited to voluntarily participate in GBL activities by an email invitation that was sent to all students registered in the PPE II course. The PPE II students were then divided into two groups. The first group contained students who engaged in GBL, while the second group contained students who only took part in the traditional learning activities of the course. All students were examined at the beginning of the course in order to determine the baseline characteristics and comparability of the research groups. Students in both groups were then evaluated at the end of the course by a standardized common exam that is routinely used to evaluate the course outcomes. This final examination was used to assess the overall attainment of the intended learning outcomes and the subsequent competencybased domains relating to foundational knowledge, pharmaceutical care, essentials for practice and care, and approach to practice and care. In addition, the GBL group responded to a questionnaire after 12 weeks of engagement in educational gamification to assess students' motivation to engage in GBL.

Game-Based Learning Activities
The PPE II course coordinator prepared several games using different gaming platforms, such as Gamilab, Wisc-Online, and Quizizz, and encouraged students to utilize these gaming tools at their own pace in order to memorize medications' brand names and advance their counseling skills in a fun way. In addition, the course coordinator created a Google Classroom and met with the students every other week over a 12-week course period. Students were divided into teams and challenged to answer different open-ended and multiple-choice questions related to different case scenarios. The scenarios aimed to improve students' skills, and all questions were mapped to the intended learning outcomes of the course distributed over the four previously described competency-based domains. Teams who answered first earned points, and each time the winner was the team with the highest score.

Variables and Outcomes
The sociodemographic and academic characteristics relating to age, gender, grade point average (GPA), area of residence, and examination scores were collected for all students through the university management system. Students' variables were linked at the beginning and at the end of the study by their student university identification numbers, which were changed at the end of the study into sequential numbering to de-identify students prior to analysis. The final exam scores were used to evaluate the learning outcomes. The exam total average and the subsequent averages of the four competency-based domains were used to assess the attainment of the intended learning outcomes. Motivation to engage in GBL was assessed for the participating group through a questionnaire that was inspired by another study [43]. Permission was granted to utilize the questionnaire from the corresponding author. The questionnaire in the current study included 14 items that were positively phrased to evaluate motivation by a 5-point Likert scale ranging from "strongly disagree" to "strongly agree". An active learning motivation assessment scale (ALMAS) was constructed from the 14 items on the questionnaire to assess the impact of motivation to engage in GBL on the attainment of learning outcomes. The objectives of this study were to (1) assess the impact of GBL on attaining the intended learning outcomes, (2) determine students' motivation to engage in GBL, and (3) assess the impact of this motivation on the attainment of learning outcomes.

Statistical Analysis
Data were analyzed using the IBM Statistical Package for Social Sciences (IBM SPSS) version 26.0. The baseline characteristics of the students were evaluated by descriptive statistics and compared by bivariate analysis. Continuous variables were reported by their means (±standard deviation) or medians (interquartile range, IQR), and categorical variables were reported by their frequencies and percentages. The normal distribution of variables was assessed by histogram and the Shapiro-Wilk test. Bivariate analyses utilized the independent sample t-test and the Pearson correlation (r) for continuous variables and the chi-square for categorical variables. Factor analysis with principal component analysis was conducted to validate the ALMAS for GBL with a rotated matrix. Factors retained in the final scale had Eigen values greater than one. Adequate values for the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett's test of sphericity were ensured. The correlation of each scale component with the whole scale was determined by the Pearson correlation (r). Cronbach's alpha was used to measure the internal consistency and reliabil-ity of the total scale and the subscales. The scale sensitivity and specificity were determined by receiver operating characteristic (ROC) curve analysis, with an optimal cutoff point determined by the Youden index, defined as J = maximum (sensitivity + specificity − 1). A multivariable linear regression was conducted to determine the impact of GBL motivation on the attainment of learning outcomes, using the ALMAS as the independent variable and using the end-of-class total average of the GBL group as the dependent variable, while adjusting for the pre-game-based-learning average as well as students' age, gender, and GPA as potential confounders. Results were reported as an unadjusted beta with a 95% confidence interval (CI). p values < 0.05 were considered statistically significant with an acceptable margin of error = 5%.

Baseline Characteristics of Students
A total of 233 students were included in the study, with 69 students (29.6%) in the GBL group and 164 students (70.4%) in the traditional learning group. The baseline characteristics of the study groups were comparable, except for the average score in essentials for practice and care, which was higher in the GBL group. The total sample included 70% female students and 36.1% students from the capital city of Beirut, and the mean age of the students was 23.16 ± 1.82. The pre-game-based-learning total average was 65.59 ± 18.86, and the averages of the competency-specific domains were 13.68 ± 4.15 for foundational knowledge, 13.79 ± 4.15 for pharmaceutical care, 17.53 ± 7.07 for essentials for practice and care, and 20.59 ± 6.62 for approach to practice and care. The complete baseline characteristics of the students are shown in Table 1.

Learning Outcomes
The impact of GBL on the attainment of the course's intended learning outcomes was determined by comparing the class averages for game-based learners to those of traditional learners at the completion of the course. The total average was significantly higher among the game-based learners (mean difference = 7.152, p < 0.001). The game-based learners also had significantly higher averages for foundational knowledge (mean difference = 1.369, p < 0.001), pharmaceutical care (mean difference = 1.431, p = 0.002), essentials for practice and care (mean difference = 1.850, p = 0.03), and approach to practice and care (mean difference = 2.502, p < 0.001). The comparison of class averages between game-based learners and traditional learners is shown in Table 2. The ALMAS was used to determine students' motivation to engage in GBL, a form of experiential education. Factor analysis was run to validate the ALMAS among the game-based learners' group. All 14 items of the initial scale were extracted and, thus, constituted the final ALMAS for GBL. No variables over-correlated with each other (r > 0.9), had low communality (<0.3), or low factor loading (<0.3). The KMO measure of sampling adequacy was 0.889, with a significant Bartlett's test of sphericity (p < 0.001). The scale items converged over two factors with Eigen values greater than 1, explaining 68.81% of the total variance. Table 3 shows the Promax rotated matrix of the ALMAS components.

Reliability and Validity Measures
The ALMAS had a high Cronbach's alpha of 0.968, and the subscales loading over factor 1 and factor 2 also had high Cronbach's alphas (0.965 and 0.904, respectively). All items of the scale significantly correlated with the total scale. The correlation coefficients ranged between 0.653 and 0.914. Table 4 reports the correlation of each item of the ALMAS with the whole scale. The ALMAS had a median of 40 (IQR 32-45), with higher values indicating higher motivation. The ROC curve analysis revealed an optimal cutoff point for better motivation at 33.50, with 91.3% sensitivity and 76.9% specificity. The area under the curve was 0.878 (95% CI 0.801-0.956, p < 0.001). Figure 1 presents the ROC curve of the ALMAS comparing game-based learners to traditional learners.
Educ. Sci. 2022, 12, x FOR PEER REVIEW 7 of 13 ranged between 0.653 and 0.914. Table 4 reports the correlation of each item of the ALMAS with the whole scale. The ALMAS had a median of 40 (IQR 32-45), with higher values indicating higher motivation. The ROC curve analysis revealed an optimal cutoff point for better motivation at 33.50, with 91.3% sensitivity and 76.9% specificity. The area under the curve was 0.878 (95% CI 0.801-0.956, p < 0.001). Figure 1 presents the ROC curve of the ALMAS comparing game-based learners to traditional learners.

Motivation and Learning Outcomes
The bivariate analysis of the ALMAS and the total class average determined a significant correlation between the two (r = 0.350, p = 0.001) among game-based learners. To preclude potential confounders, a multivariable linear regression was conducted, taking the end-of-class total average as the dependent variable and the ALMAS as the independent variable, while adjusting for the pre-game-based-learning total average, GPA, age, and gender. A significant positive association between motivation and post-game-based attainment of learning outcomes was found. Students with higher ALMAS scores had significantly higher total averages compared to those with lower scores (Beta = 0.296, 95% CI 0.110-0.545, p = 0.004). Table 5 reports the multivariable linear regression of the post-game-based-learning total average.

Discussion
The current study evaluated the impact of GBL on the attainment of intended learning outcomes of experiential education in a professional BPharm program. It also constructed and validated the ALMAS and determined the impact of motivation to learn actively utilizing GBL on the attainment of course learning outcomes. GBL was associated with better acquisition of all intended learning outcomes in terms of foundational knowledge, pharmaceutical care, essentials for practice and care, and approach to practice and care. The ALMAS was validated as a reliable tool to assess students' motivation to engage in GBL and to determine the impact of this motivation on the attainment of learning outcomes. Attainment of the intended learning outcomes was predicted by motivation to participate in GBL, with higher ALMAS scores being associated with better achievement with respect to learning outcomes as determined by the higher average of the game-based learners.
We found a significant association between GBL and attaining the intended learning outcomes. Students who participated in educational games had significantly higher average scores on the PPE course assessment exam compared to students who were in the traditional learning group. Therefore, GBL appears to play an important role in active learning, information retention, and attainment of competencies in pharmacy experiential education. Our findings are comparable with those of other research that found that students who used educational gamification as an additional pedagogical tool in an introductory PPE course obtained higher scores on quizzes [44]. Nonetheless, that study only looked at low-order thinking since it contained material and gamification elements requiring routine memorization. The current study, on the other hand, also assessed higher-order thinking by incorporating challenging questions that simulated real clinical case scenarios on the platforms of the games. The higher-level thinking related to dealing with real patient case scenarios that required students to analyze patient data, evaluate and select available pharmacotherapeutic options, and create an individualized care plan for the patient. The required levels of thinking, ranging from lower-to higher-order, are mapped to the four competency-based domains of the PPE course. GBL apparently triggers active learning that boosts information retention and overall performance [45]. Our findings add to the literature evidence that GBL is not only important for knowledge retention but also has a significant role in the acquisition of skills via practical experiences of pharmacy education.
The intended learning outcomes of introductory experiential education in a pharmacy curriculum are to equip students with four competency-specific domains relating to foundational knowledge, pharmaceutical care, essentials for practice and care, and approach to practice and care [46]. Foundational knowledge is the first basic domain that allows students to make a clinical decision by applying knowledge learned in didactic courses. Pharmaceutical care is the second domain, and it empowers students to select correct drug dosage forms, compound and dispense medications, and provide patient counseling. In the third domain, students acquire essentials for practice and care to offer and optimize patient-centered care and promote health. The fourth domain is approach to practice and care, which provide competencies that enable students to collaborate, advocate, and become problem solvers by developing the necessary behaviors and skills [30,47,48].
Educational gamification can improve learner performance in several cognitive areas, including memory, comprehension, and the application of concepts [49]. To further understand the role of educational games as an active learning activity and determine their outcomes in depth, this study assessed the impact of GBL on the competency-specific domains of the intended learning outcomes. We found that GBL had an important positive impact on all of the four competency-specific domains by significantly improving the outcomes for foundational knowledge, pharmaceutical care, essentials for practice and care, and approach to practice and care. The GBL educational activities supported students in obtaining foundational knowledge and memorizing the brand names of medications. Furthermore, students practiced pharmaceutical mathematics to calculate the proper dosages of medications. Students also practiced presenting effective health and drug information to patients or caregivers through case scenarios that focused on vital counseling, side effects, and drug interactions. Students worked together in a team collaboration environment to offer patient counseling services. To the best of our knowledge, no studies have looked at the effect of GBL on competency-specific domains of courses. However, our findings are coherent with previous research that revealed that GBL could enhance knowledge, build long-term memory, encourage teamwork, and improve communication skills [50][51][52].
Motivation to learn using various active learning activities can substantially influence students' engagement in educational activities and, therefore, can have an important impact on the attainment of learning outcomes [28]. Higher motivation may be associated with active engagement in game-based learning; thus, it is suggested that motivation enhances the attainment of intended learning outcomes [27]. To assess motivation and determine its impact on achieving learning outcomes, the present study constructed and validated the ALMAS as a reliable tool to assess motivation to engage in GBL and determine the prognostic role of motivation on the outcomes of active learning activities. Our findings provide evidence that the ALMAS is valid and reliable in determining motivation to engage in GBL. The two factors of the scale have a very good internal consistency [53], and the results suggest excellent reproducibility because all components correlated highly significantly with the total scale. To the best of our knowledge, no valid tools are available for determining students' motivation to engage in game-based or other forms of active learning. The present study provides an important tool for motivation assessment in this context. The construct validity was confirmed by computing the sensitivity and specificity of the scale. The ALMAS had high sensitivity and specificity, supporting its use for GBL.
We found that gamification is motivational for students and encourages them to engage in GBL activities, as the ALMAS median score among our sample was higher than the ROC curve cutoff point for higher motivation. We also found a significant positive association between motivation to engage in GBL and the attainment of learning outcomes. Students who were more motivated to engage in GBL had better results with respect to learning outcomes, as determined by a higher mean of the course final exam scores. Consequently, this study verifies that educational gamification is motivational for students, encouraging them to engage and obtain the required knowledge and skills through active learning involving game-based activities. Students are motivated to engage in these activities, which may be more motivational for learning compared to traditional class activities. Moreover, higher motivation to engage in GBL may be associated with higher rates of class attendance, more active participation, better focus, and greater interest in learning the subject; all of these factors, in turn, can improve the attainment of intended learning outcomes and the students' grades in the course. Although no other studies have measured the prognostic role of motivation to engage in active learning activities on the attainment of learning outcomes, our findings are consistent with previous literature that reported engagement and satisfaction of students who participated in GBL activities, in addition to confidence in the acquired information and skills [54][55][56]. Educational games improve student participation in the educational journey and offer learning in a joyful and interactive environment [57]. Game mechanics incorporating immediate feedback, scores, and leader boards are principal features of educational games, and it is suggested that they have a vital role in encouraging engagement and motivation [58][59][60]. These features were incorporated into each of the gaming activities in this research study in order to promote competition between students by rewarding winning teams with points, which could be an additional reason for the observed better attainment of the intended learning outcomes.

Strengths and Limitations
The quasi-experimental design of the study endorses the impact of GBL on the attainment of intended learning outcomes and supports the internal validity of our results. Our findings are valid and reliable because the assessment tool used in this research was validated and had excellent internal consistency. Moreover, the assessment of learning outcomes employed valid measurements by utilizing the standard assessment examination of the studied course. This valid and objective assessment minimized any possible risk of selection or information bias. On the other hand, several limitations cannot be avoided. Traditional examination may not be the best technique to assess success with respect to the outcomes of all areas of the competency-based domains. Moreover, the sizes of the study groups were not equal; this was because of student self-selection into each group. This may indicate a possible risk of selection bias; however, this bias was minimized because the two groups were academically and demographically comparable, and there was no significant difference in the baseline characteristics of the students. Our findings also do not have a high external validity because this research involved only students from a practice course in the second professional year of the professional BPharm program. Additional research is recommended in this area to assess the impact of GBL during different years of professional pharmacy programs on the attainment of intended learning outcomes for both experiential and didactic courses to confirm the generalizability of the results.

Conclusions
GBL was associated with better attainment of the intended learning outcomes and resulted in better acquisition of foundational knowledge, pharmaceutical care, essentials for practice and care, and approach to practice and care. Students appear to be motivated to learn by this style of active learning, and this motivation is prognostic of the attainment of learning outcomes. GBL offers an added pedagogical method for faculty members to encourage the greater retention of knowledge and development of skills, and it is recommended for implementation in PPE courses and for future research in didactic pharmacy courses in Lebanon and all over the world. The ALMAS is a novel, valid, and reliable tool for assessing students' motivation to engage in GBL. It can also be suggested as a generic tool for assessing motivation to engage in different non-traditional learning activities. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data presented in this study are available from the corresponding author on reasonable request.