Blended Teaching Strategy in a Pharmacy Course

The Tri-layer Approach of Teaching Physiology, Pathophysiology, and Pharmacology concepts in a first year pharmacy course: The TLAT Model

Running Head: Blended teaching strategy in a pharmacy course

Abstract

This paper describes the development, implementation, and students’ perceptions of a new tri-layer approach of teaching (TLAT). The TLAT model involved blending lecture, in-class group activities, and out-of-class assignments on selected content areas and was implemented initially in a first-year integrated pharmacy course. Course contents were either delivered by traditional lectures or by the TLAT.  A survey instrument was distributed by SurveyMonkey to determine students’ perceptions of the TLAT model. Descriptive statistics were used for data analysis. Students’ performance in a total 225 examination and quiz questions were analyzed to evaluate whether the TLAT model improved students’ learning. Students’ (n=98) performance scores for TLAT-based and lecture-based questions were 83.3±10.2 and 79.5±14.0, respectively (p<0.05). Ninety three percent of students believed that in-class group activities enhanced conceptual understanding of course materials, helped them take responsibility of their own learning, and enhanced their overall learning experiences. More than 80% of respondents felt that solving cases and developing concept maps helped them sharpen creative and critical thinking skills.  In addition, 90% of the respondents indicated that the homework throughout the semester helped them stay up-to-date and focused with the progress of the course. The use of the TLAT model led to an improvement in student learning of complex concepts. Moreover, the results suggest that this model improves students’ self-reliance and attitudes toward learning. Our findings should serve as an impetus for inclusion of diverse active learning strategies in pharmacy education.

KEYWORDS:  Blended teaching strategies; active learning; physiology; pathophysiology; pharmacy; case studies, concept mapping, homework

INTRODUCTION

With the rapid influx of new biomedical knowledge, its contextual understanding and application to clinical reasoning is becoming increasingly crucial for the current generation of learners in health profession education. This requires a paradigm shift from the traditional lecture-based passive mode of teaching to a learner-centered approach of teaching (33, 56). Consequently, active learning strategies are being increasingly utilized by faculty in healthcare education (24, 49) because they are thought to promote higher-order learning  (41), foster problem-solving abilities (18), and improve the application of learned knowledge to solve complex concepts (21).

There are several reports of improved student performance and satisfaction with pharmacy and medical curricula taught by means of an “engaged lecture” format (21, 29). Pharmacy education literature reports the use of in-class active learning strategies by pharmacy educators to various extents in US colleges and schools of pharmacy (16, 25, 40, 48, 58). In a recent article, we reported that US pharmacy programs employ diverse teaching and learning strategies in the delivery of physiology contents to PharmD students. Commonly employed active learning methods include in-class discussion/recitation, assignment, audio response systems, games, workshop, projects, journal club, problem-based learning, and team-based learning (TBL) (17). Active learning methodologies such as flipping the classroom (32), TBL (19, 20, 22, 28), and simulation-based education (1, 13) have been reported to improve medical students’ learning outcomes compared with lecture. The integration of various active learning activities including puzzle, board game, video, and debate with lectures had positive effects on medical students’ ability to comprehend physiological concepts in neurology and cardiology (30). The use of short presentation breaks during didactic lectures improves students’ ability to learn physiology (11).

Out-of-class learning activities such as homework, individual or group assignments, projects have been utilized in medical (15, 51), nursing (39), and pharmacy education (43). Studies have shown that assigning homework related to classroom topics positively affects students’ academic performance(6). However, there is limited information on the impact that utilizing blended teaching and learning strategies that integrate lecture, in-class activities, and out-of-class assignments might have on student learning of a complex topic. This article describes the development and implementation of an innovative tri-layer approach of teaching (TLAT) to deliver physiology, pathophysiology and pharmacology topics in an integrated pharmacy course. The TLAT involves instructor-led lecture, engagement of students in in-class activities and out-of-class homework assignments. The article also describes the impact of the TLAT model on students’ performance on examinations and quizzes. We also present the findings of a student survey about their attitudes toward this TLAT model and their learning experiences. 

METHODS

At the West Coast University School of Pharmacy, there are nine integrated courses in which the concepts of physiology/pathophysiology, medicinal chemistry, pharmacology, and pharmacotherapy are taught in an integrated manner. A three-credit foundational course, PHAR 611-Principles of Drug Action, is implemented in the spring semester of the first professional year of PharmD program prior to students’ exposure to the integrated courses. The goals of the course are to focus on the physiological, pathophysiological, and physicochemical basis of drug actions. In addition, the course expands on discussion of cellular excitability and electrochemical transmission; physiology of autonomic nervous system; and adrenergic and cholinergic pharmacology (Table 1).

The TLAT model was developed and implemented in the Principles of Drug Action course during the spring 2015 and 2016 semesters. The numbers of students in the 2015 and 2016 springs was 44 and 54, respectively. The class met twice weekly, once for a two-hour and once for a one-hour session. The course contents were delivered either by lecture or by TLAT. Table 2 shows the selected contents of the course that were taught by TLAT. In addition to PowerPoint lectures, the TLAT model involved student participation in group activities and in both in and out-of-class learning exercises. This approach involves three layers in teaching selected topics: 1) delivery of materials by the instructor using PowerPoint lecture, 2) engagement of students in the classroom in active learning, and 3) out-of-class individual/group assignments in the same content areas (Figure 1). The linkages between in-class activities and the out-of-class individual/group assignments are shown in Figure 2. The 5-15 min in-class active learning activities that were integrated during didactic lecture involved instructor-led class discussion (questions and answer session), Think-Pair-Share, and peer teaching on selected topics. The contents covered in these short sessions were incorporated in individual homework assignments which involved problem-solving and self-study questions. A total of six 30-60 min sessions were designed for group discussions on three patient cases and three concept map assignments. To further reinforce learning, students completed the cases and concept maps as homework assignments individually or in group. All homework was due one week after it was assigned.

Both formative and summative assessment strategies were used to evaluate student learning outcomes. Qualitative and quantitative data were collected from students enrolled in the course over 2 years (2015-2016) to measure learning outcomes. Students’ knowledge of course contents was evaluated by examinations, quizzes, and out-of-class home works/assignments. Grading rubrics were used to assess individual or group case studies and concept maps. A rubric-based peer evaluation was also utilized as an assessment strategy for group case studies. As a part of formative assessment, the instructor provided students with comments and feedback on their in-class activities, homework, case studies, and assignments. Students’ performance in examination or quiz questions from contents which were delivered either by lecture only or by TLAT was analyzed to evaluate whether TLAT model improved students’ learning.

A survey instrument was developed to determine perceptions of the students of the TLAT model and their learning experiences. An electronic invitation including the hyperlink to the survey questionnaires was emailed to the students. The questionnaire contained 13 statements focused on the perceptions of students regarding the teaching strategies employed in the course. The survey instrument was initially sent on at the end of the 2015 and 2016 spring semesters followed by two subsequent reminders four weeks apart. A cover letter accompanied the survey which explained the purpose of the survey along with the assurance that participation will be voluntary and identity will remain confidential. SurveyMonkey (SurveyMonkey, Inc., Portland, OR) was employed to collect responses. The respondents indicated their degree of agreement or disagreement with individual statements using a 5-point Likert scale (range: 1=strongly disagree to 5=strongly agree). Survey responses were downloaded into Microsoft Excel. One-way ANOVA followed by Mann-Whitney U test was performed using SPSS Statistics software (version 22.0; IBM, Armonk, NY) to determine any differences among responses from two cohorts of students. Text-based comments were collated and thematic analysis of the content was performed by using constant comparison method (2). Initial coding and theme generation were performed manually by two investigators independently. An iterative review process which involved another investigator was utilized to further clarify themes and reach a consensus amongst investigators. This study was given exempt status by the Institutional Review Board of the West Coast University. 

RESULTS

Qualitative and quantitative data were collected to measure student learning outcomes and assess their attitudes on learning experiences. Students’ knowledge of course content was evaluated by 3 standardized examinations and four quizzes, and out-of-class assignments/home work. The two midterm examinations and 4 quizzes counted 40% and 16% of the course grade, respectively. The final examination was comprehensive and cumulative, and counted 30% of the course grade. All examinations included multiple-choice questions, true/false statements, and short-answer questions. Students completed six short answer problem sets, three patient cases, and three concept maps which counted 16% of the course grade. Class average grades for the course were 84.5±9.6 in 2015 and 81.3±7.4 in 2016.

Student performance on a total of 225 examination and quiz questions was analyzed to evaluate whether the TLAT model improved student learning.  Questions were categorized on the basis of contents which were delivered by only lecture or by TLAT. The percentage of correct answers for each question was analyzed by Microsoft Excel. Student performance scores for 75 TLAT-based and 150 lecture-based questions were 83.3±10.2 and 79.5±14.0, respectively (p<0.05, unpaired two-tailed Student’s t-test).

Students highly rated the development, teaching strategies, and implementation of the TLAT model (Table 3). The response rate for this survey was 73%. On the question “I am clear on how I will use the information presented in this course as a pharmacist,” the response was overwhelmingly positive (98% of the students agreed or strongly agreed). Ninety-five percent of the students agreed or strongly agreed that the course learning objectives and goals were clear. More than 90% of students also agreed/strongly agreed that the course contents were highly challenging, but were also vital for pharmacy practice. A majority of students perceived that the diverse learning strategies in the TLAT model made learning fun and interactive [median response rate (IQR), 5(5-4)] and helped them accommodate their learning style [median response rate (IQR), 5(5-4)]. Moreover, different teaching and learning strategies made learning fun and interactive and stimulated their active participation in the learning process (Table 3 and Figure 3).

Survey questions specifically asked students about the impact of in-class activities, solving cases, developing concept maps, and homework/assignments (Table 3 and Figure 4 and 5).  The majority of the students (93%) believed that the in-class group discussion/activities enhanced conceptual understanding of course materials, helped them take responsibility of their own learning, and enhanced their overall learning experiences (Figure 4). Over 90% of students agreed/strongly agreed that case studies focused on clinically significant learning issues and concepts. Over 80% of respondents felt that solving cases and developing concept maps helped them sharpen creative and critical thinking skills and synthesize complex clinical information. In addition, 90% of the respondents felt that the numerous amount of homework throughout the semester helped them stay up-to-date and focused with the progress of the course (Figure 5).

Forty-one open-ended comments from 72 respondents were recorded and subjected to thematic analysis (Table 4). Students’ comments on their learning experiences in the course were overwhelmingly positive. Two major themes emerged from these comments: enriched learning experiences and effective teaching strategies for improved student learning outcomes. The strategy of utilizing diverse teaching and learning activities was well-received by students. Students indicated that the in-class active learning sessions and homework assignments were very conducive to learning and achieving course outcomes. Students also commented that the teaching strategies enriched their learning experiences, helped them learn materials and apply in practice Three students indicated that individual assignments were more effective than group assignments. One student found the active learning strategies useless for his/her learning. 

DISCUSSION

The overarching goal of the development and implementation of the TLAT model was to foster conceptual learning of physiology, pathophysiology, and pharmacology contents in a student centric interactive learning environment. The TLAT model integrated lecture, in-class active learning activities, and out-of-class assignments to help students see the relevance and meaningfulness of contents in real-life situations. The current study demonstrates that the TLAT method improves students’ performance in the examination as well as improves their satisfaction and learning experiences. The results of this study suggest that the TLAT model improved students’ learning.

Students taking the course in the 2015 and 2016 spring semesters performed better in the quiz and exam questions from contents which were taught by the TLAT method compared with questions from contents taught by lecture only.  However, when the comparison was made in either cohort of students (2015 or 2016), the differences were not statistically significant. Miller et al. reported an 8.6% higher score with engaging lecture compared to traditional lecture (29). It is noteworthy that the authors compared engaged lecture by one faculty versus traditional lecture by four different faculty members. It is likely that different teaching styles may have impacted the students’ performances, specifically in traditional lectures. In our study, although three instructors contributed in teaching the course, the principal investigator (PI) taught over 70% of the contents utilizing TLAT as well as traditional lectures. Therefore, examination and quiz questions from the PI were included in this study. The smaller difference compared to the findings of Miller et al. may also be due to the teaching style of the instructor.

Despite its passive nature, traditional lecture still remains a key teaching method in professional educational settings (5, 44).  A well-organized lecture allows instructors to present information from multiple sources to clarify complex concepts (26, 37).  Lectures help students better understand the contents and develop comprehension and skills for outside of class activity (29). Indeed, a well-designed lecture may serve as a guiding tool for incorporating active learning activities in the classrooms (7). In the delivery of Principles of Drug Action course, lecture materials and PowerPoint slides were posted on Blackboard ahead of time for students to review prior to lecture. The lecture contents in the areas of physiology, pathophysiology, and pharmacology were tailored not to overwhelm students with vast information and unnecessary details. Complex concepts were made simpler for students to comprehend so that they did not have to rely on memorization of facts.

Active learning is an instructional approach which encourages students to accomplish higher-order objectives such as critical analysis, synthesis, and evaluation (6). Some recent studies have documented improved student learning when different active learning methods were integrated in traditional lectures (8, 26). The active learning activities are designed to help reinforce the material presented by lecture. In the present study, we have adopted a number of active learning activities including class discussions, group discussions, think-pair share, and peer tutoring.  For example, in a lecture of pathophysiology of asthma and COPD, the physiology of respiratory muscles, the mechanism of muscle contraction and relaxation, and the pathophysiology were presented. Then, students were engaged in think-pair share to identify possible drug targets for the treatment of asthma or COPD. Similarly, after a lecture on autonomic nervous system, students were engaged in 5—15 minute sessions of class discussion on the physiological roles of sympathetic and parasympathetic nervous systems. During the same session, student volunteers were asked to share their answers or ideas to the whole class. In addition, 30—60 minute sessions of case discussion, problem solving, and construction of concept maps were incorporated following respective didactic lecturers for diverse content areas as outlined in Table 2.  Three cases were developed involving contents acetaminophen toxicity, cholinergic physiology and pharmacology (mushroom poisoning), and tyramine toxicity and hypertensive crisis. Each case included a number of questions/problems which reflected content knowledge from physiology, pathophysiology, pharmacology and their application in solving the clinical problems. Similarly, students were engaged in the development of concept maps on: 1) physiology and pharmacology of catecholamine synthesis, storage, and release; 2) pharmacology of epinephrine and norepinephrine; and 3) adrenergic receptor subtypes and their pharmacology. Students were provided with written instructions and assessment rubrics. The classroom sessions for cases and concept mapping were designed to stimulate group discussions with the instructor being served as a facilitator. In several instances, students were provided open-ended questions to discuss among peers in the classroom settings.

The student survey responses reflected their appreciation of how the TLAT model encouraged learning. An overwhelming majority of students perceived that diverse learning strategies made the learning environment encouraging and interactive, and helped them accommodate their learning style. Moreover, the students also indicated that active learning strategies stimulated active participation in the learning process and helped them take responsibility for their own learning. These findings are consistent with previous studies in professional schools. Miller et al. (29) has shown that active learning strategies enhance contextual understanding of complex concepts, facilitate student engagement, and promote student comprehension, and application of knowledge. A multitude of studies have indicated that active processing of information can improve students’ comprehension of physiology, problem-solving abilities, and critical thinking skills (3, 4). The use of such strategies was shown to develop a deeper understanding of physiology concepts (23). One of the key benefits of active learning methods is the ability to conduct formative assessment of student progress (38). Gleason et. al. have shown that multiple 2-minute breaks during lecture allowed students to work in pairs and  compare their lecture notes which improved  retention of lecture materials (12). Lectures with peer-instruction pauses increase student recall and comprehension compared with traditional lectures (57). Peer instruction in a medical course enhanced student learning, increased ability to solve novel problems, and improved performance on examinations (34). Case-based learning in medical physiology has been reported to foster self-directed learning and develop soft skills (10). In a pharmaceutics course, implementation of “quick thinks” activity into lectures every 15 minutes and case-based learning enhanced student outcomes, improved problem solving ability, and fostered critical-thinking ability (35). Similarly, a learner-led, discussion-based active-learning strategy significantly enhanced students’ interest and overall performance in an elective course on  emerging infectious diseases (27). Classroom sessions of student generated test questions following a lecture improved students’ learning experiences in a PharmD elective course (16). In-class case discussions in a Clinical Pharmacokinetics course increased students’ satisfaction as well as performance in the course (7).

One important aspect of our study was to incorporate out-of-class individual or group assignments in the form of case studies, concept mapping, and problem-solving study questions on contents covered during in-class lectures. Following a classroom discussion and exploration of the concepts, students were asked to continue working on the problems outside of class. For the case studies, students were required to provide background information on the cases, identify the clinical problem, and provide a reasonable solution to the problem. Similarly, to complete the concept map students linked concepts of biochemistry, physiology, medicinal chemistry, and pharmacology to solve clinical problems. Out-of-class assignments were carefully designed to enhance deeper learning through linking new knowledge with existing knowledge and integrating basic science concepts to clinical problems.  Literature on the efficacy of homework assignments and academic performance is mixed. In a rigorous and comprehensive meta-analysis, Copper et al. found homework as being beneficial for student achievement in upper grades more than elementary grades in K-12 education (6).  There is limited literature on the influence of homework in professional education. A computer-guided homework and assigned reading were utilized in teaching pathology to undergraduate and graduate allied health professional students (9). An integrated homework assignment on pharmaceutics and pharmacotherapeutics has been found as an effective means of demonstrating the connection between specific pharmaceutics concepts and practice applications to pharmacy students (47).  However, Rehfeldt et al. found that the effects of homework assignments and quiz performance was relatively unaffected (36). In our current study, we found that over 90% of the respondents felt that homework assignments were helpful to keep them focused with the course materials. In addition, overwhelming majority of the students felt that solving cases and developing concept maps out-side-of class helped them sharpen creative and critical thinking skills and synthesize complex clinical information. The use of case studies promotes application of basic science knowledge to clinical practice and deeper understanding of content (46). Research in medical education suggests that case discussions with appropriate feedback facilitate the development of reflective thinking, deeper conceptual understanding, and clinical reasoning (50).   Researchers have recognized concept maps as being an important educational tool in healthcare education. Concept maps have been widely utilized for helping students organize their knowledge structures for conceptual understanding (45, 53-55). The use of concept maps has been shown to increase student performance and satisfaction in learning physiology concepts among first-year medical students (52).  Similar observations were made among pharmacy students when concept map was used as a learning tool (14, 31).

Studies have shown a multitude of challenges and barriers in the implementation of active learning strategies that include faculty buy-in, lack of faculty interest, significant time commitment for preparation of active learning activities, and finally, balancing the time and depth of content to be covered (42). 

CONCLUSION

In conclusion, it was found that the use of the TLAT model led to a significant improvement in student performance on quizzes and examinations. Moreover, the results of this study suggest that class lectures with embedded in-class active learning activities and out-of-class homework assignments, when combined, may improve student learning, self-responsibility, and attitudes toward learning in professional schools. This indicates a need for an increased emphasis on in-class active learning activities and out-of-class assignments in the curricular delivery in pharmacy schools. We believe that the TLAT model can be adopted by instructors in similar courses in other professional programs.

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Figure Legends

Fig. 1. Tri-layer approach of teaching (TLAT). The TLAT model involves instructor-led lecture, engagement of students in in-class activities, and out-of-class homework assignments.

Fig. 2. Integration of lecture, in-class active learning activities, and out-of-class assignments. The top panel (A) represents the integration of mini-sessions (5-15 minutes) and bottom panel (B) represents the integration of 30-60 minute active learning sessions with respective out-of-class assignments.

Fig. 3. Student perceptions of the overall course. Student perceptions were self-reported on a five-point Likert scale with 1-strongly disagree, 2-disagree, 3-neutral, 4-agree, and 5-strongly agree.  For data analysis, respondents’ scores were combined for 1) strongly agree and agree; and 2) strongly disagree and disagree.

Fig. 4. Student perceptions of in-class active learning strategies used in the TLAT model. Student perceptions were self-reported on a five-point Likert scale with 1-strongly disagree, 2-disagree, 3-neutral, 4-agree, and 5-strongly agree.  For data analysis, respondents’ scores were combined for 1) strongly agree and agree; and 2) strongly disagree and disagree.

Fig. 5. Student perceptions of out-of-class homework, case studies, and concept mapping used in the TLAT model. Student perceptions were self-reported on a five-point Likert scale with 1-strongly disagree, 2-disagree, 3-neutral, 4-agree, and 5-strongly agree.  For data analysis, respondents’ scores were combined for 1) strongly agree and agree; and 2) strongly disagree and disagree.