Connecting the pieces: Exploring the use of jigsaw puzzles in medical education to teach psychiatric disorders

Abstract

BACKGROUND:

Puzzle-solving has been recognized as an effective game-based educational strategy for active learning and can be used to learn complex topics such as psychiatric disorders. This research was designed to investigate the benefits of this technique on the learning, memorization, and satisfaction of general medical students in the clinical rotation of the psychiatry department and the role of related demographic factors.

MATERIALS AND METHODS:

Sixty-three medical students participated in this quasi-experimental study from January 2022 to February 2023. After completing a pre-test, the students engaged in three puzzle sets related to panic attacks, generalized anxiety, and social anxiety disorders based on the DSM-5 criteria. Following the completion of the puzzles, the students took a post-test and filled out a satisfaction questionnaire. Twenty days later, a follow-up test was conducted to assess knowledge retention. The data were then analyzed using SPSS-19 at a significance level of 0.05.

RESULTS:

The post-test and follow-up test average scores were significantly higher than the pre-test (P < 0.05), with a non-significant decrease in the follow-up (P = 0.13). Additionally, the participants reported a high level of satisfaction.

CONCLUSIONS:

The puzzle-solving technique as an active strategy can have a very important role in the efficacy of the teaching-learning process, especially in complex subjects like psychiatry. The present study provides evidence that puzzle-solving training significantly improves the learning and memorization of psychiatric DSM criteria in medical students. The results of this study can be used to design a more active learning environment to improve learning outcomes in medical education.

Introduction

Teaching and learning in the vast field of medical sciences have posed challenges for students and instructors globally. While efforts have been made to improve the quality of education, the conventional approach of teacher-centered instruction remains dominant. The traditional teaching techniques centered around lectures and memorization may fail to address students’ diverse learning preferences and skills, as well as the changing demands of the job market. This traditional method may not adequately foster critical thinking, problem-solving, or creativity in medical students.[1] On the other hand, it is possible to enhance students’ deep learning using active learning approaches; active learning emphasizes the importance of student engagement in the learning process, requiring them to do more than passively listen.[2] Such a result has been observed for other soft skills as well; Sharifzadeh et al.[3] (2021) identified that Problem-Based Learning (PBL), as an active learning strategy, could improve internal motivation and the relationship between tutors and medical students. Game-Based Learning (GBL) has emerged as a novel and promising teaching method that encourages learner participation and has gradually become a popular addition to medical education.[4] These educational games are strategically designed to improve students’ information processing, problem-solving, and critical thinking skills.[5] In most conditions, the emergence of serious games and gamification in teaching approaches is well-received by learners and can create an immersive experience for students considered effective, engaging, easy to understand, enjoyable, and educational in comparison with traditional teaching activities.[4] In this regard, the study conducted by Mosalanejad et al.[6] (2020) highlighted the beneficial impact of incorporating gamification into blended learning on student learning outcomes and satisfaction levels.

Like other games, puzzles can enhance problem-solving and logical thinking skills. In addition, as a tool for active and interactive teaching-learning processes, they can increase students’ interest and participation in learning activities.[7,8] The effectiveness of the puzzle-solving technique in enhancing students’ problem-solving skills goes beyond the structured explanations provided in textbooks. It encourages students to think critically when approaching problem-solving scenarios.[9] By using the puzzle-solving technique, students learn how to effectively approach problem-solving by breaking it down into smaller components. By solving these parts, students can finally tackle the problem as a whole. This approach promotes the understanding that achieving larger goals is possible through the achievement of smaller, interconnected goals.[8]

There are documents about other beneficial effects of puzzles in teaching and learning, especially in medical education. A scoping review by Koelewijn et al.[10] (2024) shows that puzzle games are used to support clinical reasoning in health professions education. Moreover, educational games, particularly puzzles, enhance students’ visualization and mental imagery abilities and improve their spatial-visual learning skills.[11] Another notable advantage of this technique is its ability to strengthen students’ critical thinking skills.[12] The two skills of spatial-visual learning and critical thinking are the primary goals of active education and serve as the foundation for fostering a scientific mindset.[8] In addition, apart from increasing students’ motivation, the puzzle-solving technique can also improve their self-confidence after completing a puzzle.[8,12] Teamwork is crucial for medical students to develop collaboration and communication skills while solving educational puzzles.[13] Healthcare professionals need teamwork skills to work effectively and provide optimal patient care. Group puzzle-solving activities can help enhance collaboration, communication, and active listening, fostering the development of these crucial skills.

As one of the most popular puzzle forms, the jigsaw puzzle consists of several pieces in a well-combined unit without gaps between adjacent pieces.[14] Jigsaw puzzles require careful attention to detail and can be a creative and engaging way to learn the details of a subject, such as anatomical structures; they are also used to teach anatomy to first-year MBBS students.[7]

There is some evidence of using the puzzle technique in teaching psychiatry. Yalcinturk et al.[15] (2023, preprint) reported using the puzzle technique to teach 4^th-year nursing students psychiatric semiology. This study indicates the effectiveness of integrating the puzzle method in teaching psychiatric semiology compared to the traditional teaching method. Another study is that of Mosalanejad and Abdollahifar[16] (2019), which showed that using a two-dimensional puzzle to teach mental illnesses to health profession students (Health, Laboratory Sciences, and Medicine) can have a positive impact on students’ learning.

It is worth highlighting that previous studies have extensively examined the impact of the puzzle technique on learning in subjects like anatomy. However, there needs to be more research when it comes to its application in teaching psychiatric disorders. The inherently subjective nature of psychiatric subjects can be a reason for the limitations of such studies. Based on extensive research, few studies have explored the teaching of complex and abstract psychiatric concepts for diagnosing related disorders using puzzle-solving methods. These studies targeted different groups and employed various puzzle types (such as crossword puzzles and electronic crossword puzzles) compared to the jigsaw puzzles used in our current study. Therefore, our study aimed to assess the effectiveness of the jigsaw puzzle-solving technique on medical students’ learning in psychiatry, retention of learned concepts, student satisfaction with this teaching technique, and also compared certain demographic factors in this context.

Materials and Methods

Study design and setting

The primary goal of this descriptive-analytical study was to analyze the effects of teaching the subjective aspects of psychiatry using the puzzle technique. Instead of comparing this technique with other strategies, we used a quasi-experimental approach without a control group, performing a pre-test, post-test, and follow-up test to assess the effectiveness of the puzzle on learning and retention [Figure 1].

Figure 1.

Conceptual framework of the study

The puzzle was created based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for three common anxiety disorders: panic disorder, generalized anxiety disorder, and social anxiety disorder. The criteria were transcribed into Word files and uploaded to “im-a-puzzle.com.” Puzzles of different difficulty levels, with 25, 50, and 100 pieces, were created. A pilot study involved providing these puzzles to several medical students to assess their difficulty and the time needed to solve them. Ultimately, puzzles with 50 pieces were chosen for the study.

The image quality of the puzzles improved, and ultimately, 15 puzzles were printed on A3-size paper. Soft foam with a thickness of 5 millimeters was used as a thick backing for attaching puzzle paper pieces to it, which proved to be an effective tool for this purpose. Puzzle paper pieces were glued onto the soft foam using adhesive glue and cut with a sharp twenty-blade knife with maximum precision.

Finally, we created five similar puzzle sets for each of the mentioned diagnostic criteria for the three anxiety disorders (15 puzzle sets in total).

The participants were divided into groups of three. First, the students took a pre-test. Then, they were given 15 min to look up each of the three puzzle sets related to the criteria for panic attack, generalized anxiety, and social anxiety disorders (5 min per puzzle). Subsequently, the pieces of each puzzle set were intentionally mixed up under the supervision of the project coordinator. Finally, the students collaboratively completed each puzzle set in groups.

To evaluate the study’s outcomes based on the first two levels of the Kirkpatrick Model, we conducted three academic achievement tests (which included multiple-choice questions) and administered a satisfaction questionnaire. Immediately after completing all three sets of puzzles, the participants took the post-test and completed the satisfaction questionnaire. Then, 20 days later, another knowledge exam was conducted to assess the students’ knowledge retention as a follow-up.

Study participants and sampling

Sixty-three medical students from Birjand University of Medical Sciences, Iran, participated in the study after providing informed consent. The participants were in the fifth to seventh year of the MD program and were selected using the convenience sampling method from January 2022 to February 2023. The study included participants who had not received any relevant courses on the three anxiety disorders (panic attack, generalized anxiety, and social anxiety) within the past year. Of the participants, 30 were in the clerkship (fifth year of medical course training), and 33 were in the internship level (sixth and seventh years). It is important to note that the medical education curriculum in Iran consists of a seven-year training program.

Data collection tool and technique

The three academic achievement tests were designed, including a pre-test, a post-test, and a follow-up test 20 days after the intervention (to assess long-term memory). Each exam consisted of 15 questions, with five questions addressing each of the diagnostic criteria of the mentioned disorders (generalized anxiety disorder, social anxiety disorder, panic disorder). A satisfaction questionnaire with reliability and validity has been approved to measure the students’ satisfaction with the puzzle-solving technique.[17] The questionnaire, developed by the Development Center of Medical Education of the Ministry of Health, Treatment, and Medical Education, Iran, consists of 22 items and uses a Likert scale ranging from 1 (poor) to 3 (good). The total score varies from 22 to 66, and the higher the score, the higher the level of satisfaction.

Ethical consideration

The Research Ethics Committees of the National Agency for Strategic Research in Medical Education have approved this study, which has the code IR.NASRME.REC.1400.445.

The objectives and study process were carefully explained to the participants, who were free to withdraw at any time.

Statistical analysis method

The data were analyzed using SPSS version 19 software. Descriptive statistics, including frequency, central tendency, and dispersion measures, were used to analyze the descriptive data. For the inferential data, the paired t-test was employed due to the normality of the distribution. A significance level of 0.05 was considered for determining statistical significance.

Results

The present study had 63 participants, 26 men and 37 women, with an average age of 25.37 ± 2.42.

The maximum score in the knowledge exam was 15, with one mark assigned to each question. The average score in the pre-test was 7.26 ± 2.23; the post-test was 9.65 ± 2.52; and the follow-up test (conducted 20 days after the intervention) was 8.98 ± 2.34.

Table 1 demonstrates the results of the two-by-two comparison of the average test scores. The post-test and follow-up test scores were significantly higher than the pre-test (P < 0.05). However, although the follow-up test score was lower than the post-test, this difference was not statistically significant (P = 0.13).

Table 1.

Comparison of the average test scores

Scientific test		Mean±Standard deviation		Median (interquartile range)		Test statistic		P		Post-Hoc
Pre-test (1)		7.26±2.23		7 (3)		38.32		<0.001		1–2<0.001
Post-test (2)		9.65±2.52		10 (4)						1–3<0.001
Follow-up test (3)		8.98±2.34		9 (4)						2–3=0.13

The findings from the marginal longitudinal model using the Generalized Estimating Equations (GEE) approach to examine the combined impact of age, gender, and educational level on students’ performance over time revealed that the knowledge test scores of male participants exhibited a significant change throughout the study period (P < 0.001). However, educational level and age did not significantly influence the variations in grades [Table 2].

Table 2.

The results of the marginal longitudinal model with the GEE approach

Variable		Coefficient		Standard Error		Test Statistic
Gender (Male)		−1.547		0.3394		20.778
Education Level		−0.439		0.3374		1.692
Age		−0.012		0.0634		0.0370
Time		0.857		0.2048		17.502

The satisfaction test, with a scoring range of 22 to 66, revealed that participants achieved a wide range of scores. The highest score recorded was 66, while the lowest score was 44. On average, participants reported a satisfaction score of 61 ± 5.89, indicating a generally high level of satisfaction.

Discussion

Learning the rigid criteria of psychiatric disorders can be challenging for students in the field of medical sciences. However, the interactive and objective nature of puzzles can allow students to actively engage with the material and foster a deep understanding of the diagnostic criteria of psychiatric disorders. Therefore, in this study, we investigated the impact of the puzzle-solving technique on the learning of the DSM criteria of psychiatry.

Our study indicates that solving puzzles positively impacts the learning process associated with psychiatric disorders, significantly improving post-test and follow-up test scores with a non-significant decrease in the follow-up, which means good knowledge retention. These findings align with previous studies by various researchers, which also found increased knowledge and performance among students who engaged in puzzle-solving activities.[9,18] Another study in this regard was published by Shakerian and Abadi[19] (2020) that showed the participation of health workers in the teaching and learning process (jigsaw technique) has improved their motivation and performance compared to the control group (lecture method). This positive impact on learning can be attributed to several factors: First, when students engage in puzzle-solving activities, they actively process information and connect concepts with a hands-on approach. This process can enhance their self-learning,[20] analytical skills, and problem-solving abilities using the information they have acquired about psychiatric disorders and their related diagnostic criteria. Second, puzzle-solving in learning groups provides a pleasurable, competitive learning environment, which can facilitate students’ understanding of complex psychiatric concepts, leaving a positive impact on learning and retaining information for the longer term.[21]

In addition, information retention is an important aspect of medical education. The results of the follow-up test indicate that solving puzzles helps students retain the acquired knowledge for a long period (at least 20 days), and this is more evident in boys, which may be due to their greater interest and involvement in solving the puzzle as a game. There are some differences in preferred learning styles between girls and boys. In their 2022 study, Bawazeer and colleagues utilized crosswords as a learning tool and carried out a perception survey. The results revealed that female students tend to prefer assimilator and convergent learning styles, while male students showed a preference for adaptive and divergent learning styles.[21]

This is an essential finding as it demonstrates the potential for puzzle-solving to impact students’ understanding of psychiatric disorders. Puzzles often require the memorization of key patterns, rules, or sequences. By solving puzzles, medical students can create mental connections[22] and visuospatial association[23] that aid in the recall of information. According to Mirzaei et al.[24] (2022), when dental students actively participate in the teaching-learning process by creating a concept map, they achieve higher grades in both the post-test and the follow-up test. Therefore, solving puzzles focusing on psychiatric criteria, like other active teaching-learning techniques, can help medical students reinforce their knowledge of related psychiatric disorders and their associated features.

Our study also aligns with the findings of some related studies[7,11,21] which found that a substantial percentage of students enjoyed solving puzzles and expressed interest in similar activities in the future. Furthermore, the satisfaction and acceptability of the puzzle-solving method among students indicate its positive influence on the learning experience. The high levels of satisfaction with the puzzle-solving approach reported by students indicate that it is an enjoyable and engaging educational method, potentially promoting a positive learning environment and contributing to increased motivation and enthusiasm for learning psychiatric DSM criteria. However, as medical school can be demanding and stressful, engaging in activities like puzzle solving can be a form of relaxation and leisure. Additionally, puzzles provide a sense of accomplishment when solved, which can boost self-esteem and motivation.[25]

Furthermore, puzzles can be enjoyed in social settings, allowing medical students to engage in collaborative problem-solving and foster a sense of camaraderie with their peers.[26,27] This social interaction can contribute to a supportive learning environment, essential for individuals pursuing a medical career.

However, solving puzzles and employing various cognitive skills, such as reasoning, problem-solving, and critical thinking[28,29], can act as a supportive reinforcement for other cognitive aspects of individuals, such as memory and learning.

To summarize, puzzle-solving offers several benefits for medical students in the psychiatric domain. It enhances learning and memorization by promoting critical thinking, reasoning, problem-solving, and active engagement with the subject matter. Lastly, it contributes to satisfaction by providing opportunities for relaxation, a sense of accomplishment, and social interaction.

Conclusion

The evidence obtained from this study, like previous studies, emphasizes the important role of students’ participation in the teaching-learning process and retention after teaching. Students’ activeness in this process, while improving the results of learning and long-term memory (20 days after intervention), has also increased their satisfaction. These findings support the idea that incorporating puzzle-solving as an educational tool can effectively teach the diagnostic criteria of psychiatric disorders and enhance student satisfaction. The efforts of educational departments (such as psychiatry) should focus on providing suitable contexts for students’ participation in active learning with different approaches, including solving puzzles. However, further research is warranted to explore the specific mechanisms by which puzzle-solving improves learning outcomes in psychiatry and to evaluate its long-term impact on students’ clinical skills and patient care.

Limitations and recommendations

Our research has some limitations; We did not have a control group, and our research was limited to medical students in the rotation of Psychiatry. However, this study contributes to a growing body of evidence supporting puzzle-solving use in medical education. It offers an effective approach to teaching the complex diagnostic criteria of psychiatric disorders. However, further investigations are encouraged to explore its implementation and effectiveness, especially in other subjects or disciplines like pharmacy or dentistry students.

Declaration

While preparing this work, the authors used Sage, a language model developed by Open AI, to improve readability. After using this tool, the authors reviewed and edited the content as needed and took full responsibility for the publication’s content.

Availability of data and material

The dataset presented in the study is available on request from the corresponding author during submission or after publication. However, due to confidentiality, the data are not publicly available.

Authors’ contribution

Conceptualization: MM, FG, EYKh, and BE; Formal analysis: MM, FG, and EYKh; Project administration and data gathering: MM, FG, EYKh, and BE; Writing-original draft: all authors contributed to the writing-original draft; Writing-review and editing: all authors contributed in the editing the final proof.

Abbreviations

DSM: Diagnostic and Statistical Manual of Mental Disorders

PBL: Problem-Based Learning

GBL: Game-Based Learning

MBBS: Bachelor of Medicine, Bachelor of Surgery

GEE: Generalized Estimating Equations.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This project was funded by the National Agency for Strategic Research in Medical Education. Tehran. Iran. Grant No. 400393.