American Journal of Pharmaceutical Education

Flipping the Pharmacy Classroom: Assessing the Impact of Active Learning--Manuscript Draft--

Manuscript Number:

Full Title: Flipping the Pharmacy Classroom: Assessing the Impact of Active Learning

Article Type: Instructional Design and Assessment

Keywords: Active learning, Process-oriented Guided inquiry learning, instructional design, Actionresearch, Pharmacotherapy

Corresponding Author: Richard Pierce, Ed.DShenandoah UniversityWinchester, VA UNITED STATES

Corresponding Author SecondaryInformation:

Corresponding Author's Institution: Shenandoah University

Corresponding Author's SecondaryInstitution:

First Author: Richard Pierce, Ed.D

First Author Secondary Information:

Order of Authors: Richard Pierce, Ed.D

Jeremy Fox

Order of Authors Secondary Information:

Manuscript Region of Origin: UNITED STATES

Abstract: Objective. To develop, implement, and evaluate active learning strategies to improvestudent performance.

Design. The flipped classroom model was adopted in which a process oriented guidedinquiry learning (POGIL) activity was developed and conducted in class to complementpreviously recorded didactic lectures. The activity was constructed to focus on criticalthinking and application of core principles of medication management of end-stagerenal disease (ESRD) patients receiving renal replacement therapy

Assessment. Student learning was evaluated using performance on threeassessments. Students' final exam performance was compared to the prior yearstudent performance in which no flipped classroom oriented learning activitiesoccurred. The mean student grades for the students in the flipped classroom modelincreased 6.2% over the previous years.

Conclusion. The addition of active-learning activities implemented in the flippedclassroom model accompanied improved student performance in this study. Studentevaluations of the activity suggested the flipped classroom varied from the majority ofthe other pharmacy classes and was universally endorsed by students as an engagingand effective instructional model.

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Running head: Flipping the Pharmacy Classroom

Flipping the Pharmacy Classroom: Assessing the Impact of Active Learning

Richard J. Pierce Ed.D.

Assistant Professor

Shenandoah University

Winchester Virginia US

Bernard J. Dunn School of Pharmacy

(rpierce@su.edu)

Phone 540-678-4377 Fax 540-665-1283

Jeremy Fox PharmD, Assistant Professor

Assistant Professor

Shenandoah University

Winchester Virginia US

Bernard J. Dunn School of Pharmacy

(jfo2@su.edu)

Phone 888-420-7877 Fax 540-665-1283

Cover Letter

Flipping the Pharmacy Classroom

1

INTRODUCTON

The challenge for educators in every discipline is to transition from dispensers of facts to

architects of learning activities. Critical in this process is designing experiences that facilitate

students’ development into active learners rather than passive receptacles of information.

While large group lecture continues to be a staple of medical education, advances in video and

lecture capture technology, the exponential growth of available quality online content, such as

Coursera and The Kahn Academy, and the developments in cognitive science combine to

challenge traditional notions of teaching and learning. The flipped classroom instructional model

was developed by Jonathan Bergmann and Aaron Sams in 2007 to provide instruction to

secondary students who were missing class and therefore missing instruction.1

In the flipped

classroom what used to be class work, namely the instructor led lecture and student note taking,

is done prior to class while what used to be homework, typically assigned problems, is now done

in the scheduled class. The model has transformed teaching practice, by changing traditional

roles, and increasing the instructor and student interaction during class. In the flipped classroom,

the responsibility and ownership of learning is transferred from the teacher to the students

through interactive activities.

DESIGN

The empirical support for active learning, generally defined as any instructional method

that engages students in the learning process is extensive.2 Graduate health professions continue

to grapple with the form and the extent to which they should include active learning, despite a

growing body of evidence for its efficacy. The Accreditation Council for Pharmacy Education’s

(ACPE) requires the inclusion of active learning strategies.3 Gleason, Peeters, Resman-Targoff

et. al provided a comprehensive overview of active learning strategies in pharmacy education as

*Manuscript

Flipping the Pharmacy Classroom

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well as a well-articulated rationale for adopting these strategies.4

While many programs use

lecture capture to extend learning opportunities, there is little empirical evidence concerning the

use of flipped classroom as to improve student performance in Pharmacy education. In this

project, faculty at the Shenandoah University’s Bernard J. Dunn School of Pharmacy address the

ACPE’s requirement for including active learning practices by integrating instructional

approaches that are typically associated with the flipped classroom.

A design experiment was selected as the guiding methodology of this study. The term

"design experiment" was introduced in 1992, in articles by Ann Brown and Allan Collins as a

method to conduct formative research and refine educational designs based on principles derived

from prior research.5 Design experiments are set in complex natural situations in order to avoid

the distortions of laboratory experiments and therefore constitute a means of addressing the

nuances that are hallmarks of educational settings.6 This investigation examined the impact of

active learning strategies in a Renal module within the Integrated Pharmaceutical Care and

Science (ICARE) series on student final exam performance and student perceptions of the

flipped classroom model. The Institutional Review Board of Shenandoah University approved

the project in April 2012.

Renal ICARE PHAR 608, one of nine required Integrated Pharmaceutical Care and

Science (ICARE) courses within the pharmacy curriculum, was taught in block format in spring

of 2011 and 2012. The course presented pharmacy students with the pathophysiology of common

renal diseases, renal replacement strategies, associated complications, and electrolyte and acid-

base disorders. Therapeutic management of patients with renal disease, with a specific attention

Flipping the Pharmacy Classroom

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placed on the effects of pharmacodynamic and pharmacokinetic properties of medications, was

the focus of the course.

The instructional intervention for this project was grounded in the flipped classroom

instructional model. Students were assessed initially on a pre-test, then directed to view pre-

recorded lectures on iTunes U prior to the next scheduled class. A process oriented guided

inquiry (POGIL) learning activity was conducted during the following scheduled class. The

activity, a clinically situated case, extended the application of information from the pre-recorded

lectures. The class activity was conducted at the application level of Bloom’s Taxonomy of

Learning Domains as students were required to combine patient specific data and drug

information in order to design a treatment regimen for the patient.7 The design of the activity was

structured from simple dosing calculations, to more complex pharmacokinetic calculations based

upon progressively more complex patient characteristics. The instructor-led activity guided

students from one scenario to the next, interjecting relevant contextual information that

connected lecture content and lesson objectives to the clinical settings. Attendance is mandatory

and was 100% for all scheduled classes in 2011 and 2012. During the POGIL activity, students

were randomly called upon to confirm their answers to the series of clinical questions and

calculations during the activity over a two-hour period. Each student was required to complete

five calculations in the activity. The structure of the activity mirrored the knowledge and skills

that are required on the formative assessments, the course examination, and national board

examination.

Student learning was measured across time for spring 2012 students by considering a

series of assessments including a pre-test, a post-test, and performance on the final exam

questions that related to the Renal module in ICARE PHAR 608. Comparisons were conducted

Flipping the Pharmacy Classroom

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between the final exam performance of the 2011 and 2012 classes. The same instructor

conducted all the lectures in 2011 and 2012. In spring 2011, course lectures were preformed

live, and were also recorded using Camtasia Relay in a voice over slideshow format, and made

available for viewing on iTunes U after class. In spring 2012, the lectures originally recorded in

the spring 2011 were assigned by the instructor to be viewed by students outside of class prior to

the POGIL class activity. In addition to the identical instructor and identical lecture content,

identical final exam assessment questions were used for both spring 2011 and spring 2012. It was

hypothesized that the flipped classroom would improve student test performance and student

perceptions of the Renal module. The research questions included: Did the flipped classroom

impact student performance?, and Did the flipped classroom impact student perceptions of the

Renal module?

EVALUATION AND ASSESSMENT

In the spring of 2012 teaching strategies consistent with the flipped or inverted class

model were employed to disrupt the faculty dominated lecture and replace it with active, student-

centered learning activities. The class contained 75 graduate pharmacy students. Student

performance was assessed in part by a pre-test post-test design. Assessments were administered

electronically using a secure browser in a proctored setting. Questionmark Perception was

selected for the creation, delivery, and analysis of assessments. Data was further analyzed using

the IBM SPSS/PC software version 19. Summed scores computed using yielded descriptive

statistics for the pre-test (mean=33.5, s.d. = 11.6) and post-test (mean =79.2, s.d. = 10.6)

assessments. A paired two sample for means t-test yielded significant differences between pre-

test and post-test student performance t(74) = -27.7, p = 0.000. Summed scores were computed

and yielded descriptive statistics for the 2011 (mean=78.5, s.d. = 13.7) and 2012 (mean =83.3,

Flipping the Pharmacy Classroom

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s.d. = 11.3) assessments. A t-test assuming equal variance was conducted to analyze student

performance on the Renal ICARE final exam questions for the 2011 and 2012 assessments and

yielded significant differences t(143) = -2.3, p = 0.024. Table 1 (see Appendix A) summarizes

the students’ assessment performance.

Student Evaluations

A secondary outcome concerned students’ perceptions of the flipped classroom

experience. A 10-question survey was administered to ascertain the students’ perceptions using a

five point Likert scale (Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree). The

survey instrument used investigated two domains of student perceptions: 1) attitudes about the

POGIL activity; 2) perceptions about the flipped classroom model. (Appendix A). The survey

was administered electronically using Survey Monkey and was available for a 13 day period

between the post-test and the final exam. The survey responses rate was 65.8% (N=52). Survey

items for agreement (Strongly Agree and Agree) and disagreement (Strongly Disagree and

Disagree) were combined for reporting. Responses to five items addressing student perceptions

of the process oriented guided interactive lecture POGIL yielded a Cronbach’s Alpha measure of

reliability equal to 0.82. Responses to five items addressing perceptions about the flipped

classroom model yielded a slightly larger reliability (Alpha = 0.83).

Student perceptions about the process oriented guided interactive lecture

Students’ perceptions about the POGIL activity (Table 2) were uniformly favorable.

Responses were most favorable regarding the importance of viewing the pre-recorded lectures

prior to class (n=50, 96.0%), participation in viewing the pre-recorded lectures (n=50, 96.0%),

and the extent to which the instructor required student participation in the POGIL activity (n=50,

Flipping the Pharmacy Classroom

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96.0%). Most students felt the instructor made meaningful connections between the topics in the

pre-recorded lecture and the class activities (n=47, 90.0%). To a lesser extent (n=40, 77.0%),

students perceived viewing pre-recorded lectures was essential to successfully participating in

the POGIL activity.

Student perceptions about the flipped classroom

Students’ perceptions about the flipped classroom (Table 3) were also uniformly

favorable. Responses were most favorable regarding the students’ self-efficacy to address the

topics on the final exam (n=42, 81.0%). Students’ responses regarding the favorability of being

able to view the lectures prior to class (n=40, 77.0%) was equal to responses indicating a desire

for increased faculty student interaction (n=40, 77.0%). The flipped classroom was regarded as

being dissimilar to other classes in pharmacy school (n=39, 75.0%), and a majority of

respondents (n=32, 39.0%) expressed a desire for more instructors to use the flipped classroom

model (n=40, 77.0%).

DISCUSSION

The flipped classroom replaced instructor dominated didactic lectures, where the students

would traditionally take notes. Scheduled class time was devoted exclusively to assessing, and

developing student content knowledge through activities while pre-recorded lectures were

viewed outside class. Promoting active learning through efforts, such as the POGIL, increased

student exposure to the application of knowledge to clinical case scenarios. Fostering critical

thinking and problem solving acted also as a low fidelity simulation for the final exam format

and content. The design of this project also included repeated exposure to the content in an active

setting including multiple formative assessments. Student performance on final exam questions

Flipping the Pharmacy Classroom

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improved from 2011 to 2012. Further research is needed to delineate the extent to which repeated

exposure to the concepts through the pre-test, the POGIL activity, the post-test, contributed to

improved student performance.

The results of this survey suggested that graduate pharmacy students recognized the

convenience and pedagogical benefits of the flipped classroom. Students expressed a preference

for the flipped classroom approach in which students engaged with content online prior to

interactive, face-to-face contact with their professor. In summary, these results indicated that

graduate students found the flipped classroom preferable to traditional instructor led didactic

lectures. As we redesign instructional activities in the graduate health sciences, it is important to

consider the increasing demands of millennial learners for activity and interactions.8 Students

expressed a consistently high preference for the flipped classroom relative to the traditional

instructor-led didactic lecture.

CONCLUSIONS

Graduate health professions continue to grapple with the format, implementation, and the

extent to which they include active learning, despite admonitions from accrediting bodies. The

flipped classroom model uses technology to extend content delivery beyond the scheduled class,

and thus transforms the interaction among faculty and students when they meet. The interactive

application of health science concepts in this project reframed the learners’ behaviors as well as

the instructor’s approach to pedagogy and assessment. Given these findings, the investigators of

this study offer the following recommendations for subsequent research in this area. Additional

iterations of the project in subsequent years may further identify the impact of the instructional

intervention on student performance. Administer the survey instrument used in this study to a

Flipping the Pharmacy Classroom

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larger sample for two reasons: (a) to allow for an exploratory factor analysis of the sets of items

included in the survey, and (b) to better generalize to a larger population this type of study.

Future research may wish to investigate more fully the factors impacting students’ perceptions.

Alternative research projects might focus on questions such as, “What factors make the flipped

classroom more effective?

REFERENCES

1. Bergmann, J. Sam, A. 2012. Flip Your Classroom. Reach Every Student in Every Class

Every Day. ISTE 9781564843159. 2012.

2. Bonwell CC, Eison AJ. Active Learning: Creating Excitement in the Classroom. ASHE-

ERIC Higher Education Report No. 1. Washington, DC: George Washington University

Press; 1991.

3. Accreditation Council for Pharmacy Education. Accreditation Standards and Guidelines

for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy

Degree. http://www.acpe-

accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adopted_Jan152006.pdf.

Accessed September 10, 2011.

4. An Active-Learning Strategies Primer for Achieving Ability-Based Educational

Outcomes Brenda L. Gleason, Michael J. Peeters, Beth H. Resman-Targoff, Samantha Karr,

Sarah McBane, Kristi Kelley, Tyan Thomas, Tina H. Denetclaw, American Journal of

Pharmaceutical Education. 2011;75(9):186.

5. Collins A, Joseph D, Bielaczyc K. Design Research: Theoretical and Methodological

Issue, Journal of Learning Sciences, 2004;13(1):15-42.

6. Cobb, P., Confrey J., diSessa, A., Lehrer R., Schauble, L. 2003. Design experiments in

educational research. Educational Researcher, 32(1): 9–13.

7. Bloom BS, ed. Taxonomy of Educational Objectives, Handbook I: The Cognitive

Domain. New York, NY: McKay, 1956.

8. Stephanie F. Gardner Preparing for the Nexters. American Journal of Pharmaceutical

Education 2006;70(4):1.

Figures and Tables

Table 1 Student performance on assessments in a Renal module

Pre-

test

Post

test

Renal module

final exam

questions

2011 (n= 68)

N/A N/A

77.4

(18.9)

2012 (n=75)

33.5

(11.6)

79.2

(10.6)

81.6

(17.6)

p=0.024

Table 2 Student perceptions about process oriented guided interactive lecture.

Strongly Agree /

Agree

Disagree / Strongly

Disagree

Viewing the lecture before scheduled class

prepared me for the class activity.

50 (96.0%) 1 (2.0%)

I did not view the lecture before class,

although I was supposed to.

2 (4.0%) 50 (96.0%)

The instructor required student participation

in the in-class activity.

50 (96.0%) 1 (2.0%)

Viewing the pre-recorded lecture was

essential to successfully participating in the

class activity.

40 (77.0%) 6 (12.0%)

The instructor made meaningful connections

between the topics in the pre-recorded lecture

and the class activity.

47 (90.0%) 1 (2.0%)

Table

Table 3 Student perceptions about the flipped classroom instructional model.

Agree / Strongly

Agree

Disagree /

Strongly Disagree

The flipped classroom model was similar to

other classes in the BJDSOP?

3 (6.0%) 39 (75.0%)

I enjoyed being able to view the lecture prior

to schedule class as opposed to live class

lecture.

41 (79.0%) 6 (12.0%)

I wish more instructors used the “flipped or

inverted classroom” model.

32 (62.0%) 7 (13 .0%)

I am confident about my ability to address

these topics on the final exam.

42 (81.0%) 5 (10.0%)

I want more interaction between students and

faculty in class.

41 (79.0%) 3 (6.0%)