Introducing a flipped classroom in a pharmacology course

Nursing students consider pharmacology a challenging subject and they find it difficult to implement learnt concepts in clinical practice (Alton, 2016; El-Banna et al, 2017; Njie-Carr et al, 2017).

Their major struggle with pharmacology is to understand the link between theoretical knowledge and clinical practice and how they integrate (Manias and Bullock, 2002; Hanson, 2016). Often, students consider the scientific principles of pharmacology (pharmacokinetics and pharmacodynamics) and the application of knowledge in nursing practice (patient assessment and medication preparation) as separate (Manias and Bullock, 2002). This might reduce their ability to apply theoretical concepts to patient care.

To provide safe, competent patient care regarding medications management, a thorough understanding of pharmacology knowledge is required (Sulosaari et al, 2015).

In an effort to bridge the pharmacology knowledge–practice gap among nursing students, several dynamic teaching strategies have been tested. An emerging strategy is the flipped classroom, which is considered to be an effective teaching–learning pedagogy to suit the diverse needs of millennial learners who have grown up in a technological world (Hanson, 2016). This generation is known to have shorter attention spans and to multitask, and is comfortable using several electronic gadgets for communication, entertainment and learning (Towle and Breda, 2014). With such attributes, these students will benefit most if they are given an opportunity to learn at their own convenience at home and integrate their learnt knowledge through interactive activities in the classroom (Towle and Breda, 2014; Lucardie et al, 2017).

Literature review

The flipped classroom concept was derived by high-school chemistry teachers Jonathan Bergmann and Aaron Sams in 2007 (Phillips and Trainor, 2014). The idea is to flip the traditional mode of instruction and learning.

Traditionally, teachers deliver content through lectures and students passively listen to them for most of the class time (Towle and Breda, 2014). In the flipped classroom approach, students access the class's resources at home beforehand and, once in class, they integrate learnt concepts while actively engaging in collaborative learning (Pickering and Roberts, 2018). The flipped classroom works on the principles of active learning and self-directed learning, with students and educators sharing the responsibility for learning (El-Banna et al, 2017).

The pre-class component can include any of the following activities: reading, watching interactive and standard videos, viewing pre-recorded lectures, completing puzzles and quizzes, listening to podcasts, or completing an assignment (Cukurbasi and Kiyici, 2018; Han and Klein, 2019). Computer-aided instruction has augmented this.

While in class, students participate in interactive activities in the form of quizzes, games, case studies, puzzles, experiments and small group discussions (El-Banna et al, 2017). Such activities empower students to apply learnt content, generate discussions and to exchange ideas in group sessions (Cukurbasi and Kiyici, 2018). Throughout the process, a learner-centred approach is ensured (Roehl et al, 2013).

There are several advantages of flipping a class. For example, teachers spend less time and effort on module preparation (Roehl et al, 2013). The time can be spent on in-class interactive activities to enhance conceptual understanding and promote knowledge retention (Roehl, et al, 2013; Milman, 2012). Furthermore, students prepare for the class at their own pace at a time convenient for them. A pre-class recorded lecture can serve as a learning resource for students (Phillips and Trainor, 2014). During the entire process, students' awareness of both their learning style and their knowledge improves, and reflection helps them to connect strongly with the content (Roehl et al, 2013).

The flipped classroom model has been tested in several disciplines with positive outcomes (Njie-Carr et al, 2017). Many nursing courses have used flipped approaches, such as those in mental health nursing (Burden et al, 2015), paediatric nursing (Critz and Knight, 2013), pharmacology (Geist et al, 2015; Munson and Pierce, 2015), and medical-surgical nursing (Harrington et al, 2015). Results from these studies have indicated that a flipped classroom strategy helps students to develop an in-depth understanding of concepts and to improve their application of learnt concepts to clinical practice; students were also more satisfied with the approach. In addition, providing materials before classes and classroom activities were useful and students' performance on knowledge assessments improved.

Although the literature shows that flipped classroom pedagogy is effective, there is limited evidence to support that such pedagogy has potential to improve students' performance on pharmacology knowledge tests in Pakistan.

The authors' university believes in fostering a learning environment that enhances students' active learning and promotes their critical thinking abilities and academic performance. As per the university's strategic planning for teaching and learning, nursing course delivery is shifting from traditional to flipped-style teaching.

Purpose

To determine the effect of flipped classroom on students' pharmacology assessment scores.

Methods

Research setting and sample

The research was conducted at a private university school of nursing and midwifery. The details of the programme, course, and teaching strategies are described below. Ethical approval for the study was obtained from institution's ethical review committee (number: 2018-0495-398].

The 4-year bachelor's nursing programme (BScN) at the study setting offers pharmacology courses to nursing students in their second year. It is a theory-based course. The theoretical knowledge is assessed via paper-and-pen multiple choice and subjective assessment questions. Clinical integration of the concepts is encouraged in the adult health nursing clinical course, which is offered parallel to this course in the second year, with pass/fail clinical assessment criteria.

The purpose of the pharmacology course is to familiarise nursing students with basic pharmacology and its integration to clinical practice. The course covers a broad spectrum of body systems and diseases and their medical management with drug therapy. One of the modules is ‘drugs used for the management of common cardiovascular disorders’.

Until 2017, the module was offered through a conventional teaching style of student-teacher discussion related to the topic. From January to June 2018, the module was offered in a flipped classroom style and the pedagogy was pilot tested.

The following topics were taught using the flipped approach:

• Anti-hypertensive drugs
• Drugs used for the treatment of heart failure
• Anti-anginal drugs
• Anti-arrhythmic drugs
• Anticoagulants.

Teaching strategies for the 2020 graduation cohort (second year: 2018)

Reading material was sent to students on Google Classroom before class. Voiceover PowerPoint presentations (VOPPs), videos, articles to read and discussion questions were shared with the students 10 days before the classroom sessions. Students were given these materials as ‘tasks’ to be completed before coming to the class. These resources allowed students to learn the primary concepts at their own convenience before attending. Learning objectives were clearly stated.

Two face-to-face (F2F) class sessions were held, each lasting 2.5–3 hours, for two large classes of 59 students each (a total of 118 students). There was a gap of 15 days between the two F2F sessions. Class attendance was mandatory.

During class time, active-learning activities were given to students. At the beginning of the class, students were each given a small quiz and a puzzle; this helped them to assess their own learning from the pre-class material. Answers were discussed and misconceptions clarified by the teacher. This helped the teacher to gauge students' learning from the pre-class material and also indicated how this could be used as a bridge to in-class activities. A few case studies pertinent to cardiac conditions were presented to students, with 4-5 questions per case. Students worked in pairs to analyse the case and identify drug therapy and its effects, side-effects and nursing management. Afterwards, the questions with their answers were discussed with the class.

Drug dose calculations for cardiac drugs was covered in two F2F sessions lasting 1–1.5 hours each, in three groups of 39–40 students. Practice sheets with questions related to cardiac drugs were given to individual and pairs of students. Answers were discussed with students and queries were resolved. More practice sheets were given to students for further work at home.

Knowledge of course content was assessed in a continuous assessment test (CAT), which was scheduled for 2 weeks after the sessions.

Teaching strategies for the graduation cohort of 2019 (second year: 2017)

The 2019 cohort, with 70 students per class, was offered the above modules in two F2F sessions. No pre-class material was provided; however, session objectives and recommended reading were clearly stated in the course grids that had been provided at the beginning of the semester.

During class, the teacher used PowerPoint presentations to guide discussion. Most of the classes took a lecture-based approach, with most teacher-student interaction being one way. All essential concepts and their application to clinical scenarios were taught by the teacher in an interactive class lecture. The tutor used examples from literature and real life to emphasise important points and answered students' questions with the whole class. Each class took 3 hours. At the end of the class, the teacher provided a few case scenarios for students to review at home.

For the cohort of 2019, cardiac drug dose calculations were covered in two F2F sessions of 1-1.5 hours each, in small groups with 48 students each. Practice sheets were given to students, answers were discussed with them, and queries were resolved. Additional practice sheets were given to students so they could practise more at home.

The same tutors taught both cohorts to control for individual approaches to teaching.

Data collection and analysis

A retrospective chart review was performed. Mark sheets with pharmacology CAT scores of the BScN cohorts of 2020 and 2019 were reviewed and the scores were compared.

Students' demographic data were obtained from the office of the registrar, which included the variables age, sex and pre-BScN qualifications. Continuous variables that followed a non-normal distribution were compared using a Mann-Whitney U test and variables following a normal distribution were compared using the Student's t-test. Proportions were calculated for categorical variables. All the numerical data were analysed using STATA/SE 13.0. In addition, students' summative evaluations of the course and their verbal feedback, obtained after each class, were analysed.

Results

The mean age of all study participants was 21.01 (±1.22) years (Table 1); across both cohorts 10.1% were male and 89.9% were female. Students in the 2020 cohort were slightly younger than those in the 2019 cohort and the difference was statistically significant (P<0.001). The median pharmacology CAT score of the cohort of 2019 was 35 (IQR 32-38), while that of the 2020 cohort was 38 (IQR 35-41); the difference in scores was statistically significant (P<0.001).

The summative evaluations given by the 2020 cohort at the end of the semester revealed that students appreciated the flipped classroom approach. They acknowledged that this pedagogy has the potential to enhance their critical thinking and problem-solving skills and that they were able to relate their knowledge of pharmacology to the clinical setting. However, a few students reported that, despite getting good scores in the assessment, they did not like this pedagogic approach and wished to study in the traditional way.

Regarding pre-class materials, students appreciated receiving them 10 days before the F2F session. They found them easy to understand, in particular the VOPPs, which they could review after a class too. Some students also acknowledged that they did not come prepared for the F2F class despite having received the materials beforehand.

Students' specific, detailed feedback about the course and pedagogies were obtained from the evaluation forms given to them at the end of the semester. However, at the end of each flipped class, only verbal feedback was obtained.

Verbal feedback that was obtained from the 2020 cohort after each session indicated that some students were satisfied with the flipped classroom approach but others desired to be taught using a conventional teaching style.

For some students, the blended online and F2F approach was useful; for others, pre-class tasks were time consuming and difficult to understand on their own. A few students found pharmacology content complex and difficult to understand without a teacher's facilitation, because both conceptual understanding and memorising drug names were difficult.

Moreover, many students said that, since the pharmacology course was the first time they had learnt through a flipped class style, they were not accustomed to this format and had expected the teacher to deliver the content in a lecture style. Therefore, they had not come prepared for the class, which may have compromised learning. Many students went through the pre-class materials before their assessments.

A few students said that, since they were studying many courses at the same time, they found the pharmacology pre-class material inundating and difficult to learn alongside the other courses.

Discussion

Although the concept of the flipped classroom is not novel, it is new to nursing courses in the authors' university. This study indicated that flipped classroom pedagogy significantly improved students' knowledge scores in pharmacology CATs. These findings strengthened the existing body of evidence that shows flipped teaching pedagogy can improve nursing students' academic performance.

Earlier studies have shown that this emerging pedagogy has improved academic outcomes in nursing courses (Betihavas et al, 2016; Njie-Carr et al, 2017; Tan et al, 2017; Hu et al, 2018). This could be because a flipped classroom is more engaging, uses higher-order thinking and focuses on student-centred learning, which encourages interaction between a student and a teacher and boosts student motivation (Hu et al, 2018).

Moreover, when students come to class prepared with a basic understanding of the concept to be covered, they actively participate in the class and their integration of knowledge and skills during the class improves (Hu et al, 2018). Students in the authors' study came prepared with questions to ask during class time, as evident from the teachers' observations. They had been able to focus on given objectives beforehand and thought-provoking questions might have encouraged them to reflect. The pre-class exercise, in turn, might have helped them to bridge the gap between their learning and interactive activities. In addition, case studies based on clinical case scenarios might have helped students in learning critical thinking and problem-solving skills (Hanson, 2016; Tan et al, 2017).

Another reason for improved scores in a flipped classroom could be that pre-class preparation materials were comprehensive and useful. Specifically, students appreciated VOPPs, which were helpful in reinforcing the class content even after the class and before taking an exam. Being able to view VOPPs repeatedly is liked by students because they help them to clarify and revise their concepts (Hanson, 2016; Post et al, 2015).

Despite improved scores in flipped teaching pedagogy, students' responses in evaluation forms and verbal feedback varied regarding their preference or not for flipped pedagogy. While some students liked the flipped approach, others desired to learn through conventional pedagogy. Other studies have reported similar findings (Hanson, 2016; El-Banna et al, 2017).

Students shared their concern that since pharmacology involves technical language and has many dry and dense concepts (Alton, 2016), it is difficult to understand these on their own and they are unable to retain the information (Thomas and Schuessler, 2016). Similar views have been reported elsewhere (Hanson, 2016).

The results also indicate that students liked the timely sharing of the pre-class material but did not use it to prepare for the class. They were also afraid of studying pharmacology via an unconventional pedagogy. This fear is perhaps a common feeling because they are asked to learn new concepts in an entirely new style. Students can find it overwhelming and burdensome (El-Banna et al, 2017). Earlier studies have indicated that students appreciate the flipped style more in areas where they already have some basic knowledge (El-Banna et al, 2017). Since pharmacology was an entirely new subject for the students, they found it difficult to learn in a non-conventional way.

This study has several implications. First, students should be introduced to flipped teaching pedagogy in their earlier academic years so that, by the time they learn pharmacology in the second year, they are accustomed to it.

Moreover, tutors teaching parallel courses in the same year that also use flipped pedagogy, such as pathophysiology and adult health nursing, should coordinate with each other frequently so that the nursing content is well integrated and students do not feel overloaded with an abundance of pre-class material.

Finally, a prospective longitudinal design could be used to evaluate the temporal effect of the flipped classroom approach on the test scores of nursing students.

This study was novel with regard to this teaching style and its evaluation in a pharmacology course. Large class sizes fulfilled the adequacy of sample size; however, the retrospective nature of the study suggest that the results should be interpreted cautiously.

Conclusion

This study offers an insight into the effect of a relatively novel flipped classroom pedagogy, and shows that it improves pharmacology knowledge test scores among nursing students.

However, appreciation and use of the pedagogy varied between students. Therefore, it would be valuable to perform an in-depth exploration of students' perceptions and level of satisfaction with this teaching pedagogy in future research.

KEY POINTS

• The flipped classroom is an emerging teaching strategy to meet the diverse learning needs of millennial nursing students
• The approach helps to promote critical thinking among nursing students so they can better integrate pharmacology knowledge into clinical practice
• The flipped classroom is an effective pedagogy that promotes critical thinking, self-directed learning and flexibility in learning difficult and dense concepts
• Pre-class and In-class activities should be carefully designed to promote maximum learning

CPD reflective questions

• Think about your experience of learning via online or blended (face-to-face and online combined) approaches. Consider an example where they improved your critical-thinking or problem-solving skills
• How can flipped classroom pedagogy be used most effectively for nursing students? What challenges in their learning do you anticipate?
• Think about nursing students in a developing country with limited resources. How could e-learning pedagogy benefit these students and their tutors?