Out With the Old, in With the New: Transitioning to a Flipped Classroom in Pharmacy Schools

by Ciera Patzke, PGY-1 Pharmacy Practice Resident, University of Maryland Medical Center

In 2015, the American Association of Colleges of Pharmacy reported that 47.7% of the pharmacy school applicants had a baccalaureate degree or higher (Taylor et al. 2016). This is markedly increased from the 40.7% reported in 2008 (Taylor et al. 2009). As the classrooms of our pharmacy schools consist of more mature students, the student body becomes more self-directed in their learning. This additionally occurs as students progress through the pharmacy curriculum. It is therefore important that instructional strategies transition toward andragogic approaches to meet the learning needs of this maturing student body (Peeters 2011). One such approach is the “flipped classroom,” one that transitions toward a learner-centered, learner-responsible approach to education.

What is the “flipped classroom”?

The “flipped classroom” model flips the learning activities that occur during class with those that occur outside of class (University of Texas 2016). It encourages a more active approach to learning, rather than the passive approach that is typical in lecture settings. It also transitions much of the learning responsibility onto the learner. Traditionally, learners are expected to review materials prior to class, listen to a lecture during class, and then apply concepts learned through homework after class. Conversely, the flipped classroom moves a majority of the didactic teaching to outside (prior to) the classroom and utilizes class time for application of concepts. Learners review interactive lectures and materials prior to class and utilize in class time to work through higher cognitive processes with the direct guidance of the instructor (Armstrong 2017).

Does the “flipped classroom” work?

In a study that compared before and after results of the implementation of a flipped classroom in a second-year pharmacotherapy course, final grades of an A or B were much higher after the implementation as compared to before (88% vs. 67%, p=0.005) (Koo et al. 2016). Similar results were seen by Prescott and colleagues after implementing the flipped classroom in their first-year, 2-semester patient assessment sequence (2016). Higher course grades were seen with the flipped classroom model as compared to the traditional classroom setting in both semesters (Fall: 92.2% vs. 90.0%, Spring: 90.3% vs. 85.8%, p<0.001).

Conversely, negative results were seen by Bossaer and colleagues after flipping their third-year oncology pharmacotherapy course, with numerically lower examination scores after implementation of the flipped classroom (2016). These negative results were attributed to the lack of student accountability for completing pre-class assignments. These results are therefore not surprising: not only are the students evading the higher levels of learning during class from inadequate preparation, but they are also eliminating the lower levels of learning that they minimally would have achieved in the traditional classroom setting.

What are some of the drawbacks of a “flipped classroom”?

Time allocation, from both the learner’s and the teacher’s perspective, seems to be the biggest barrier to implementing the flipped classroom model (Rotellar et al. 2016). From the student’s perspective, should in-class time be removed to account for (some of) the increased time spent outside the classroom learning? Or should the number of credit hours received for a course be increased to account for this added time? Koo and colleagues opted to decrease in-class time by 30-60% (and keep earned credit hours the same), yet students still perceived the amount of workload to be much greater than prior to the flipped classroom setting (2016). From a teacher’s perspective, the time (and subsequent cost) allocation is large both upfront (during course development) and throughout (as evidence and guidelines change, and as feedback is received year to year) (Spangler 2014). This time and cost problem can additionally be exacerbated if more than one course (or all courses) in a program is/are flipped.

How do I implement the “flipped classroom”?

There are 9 major principles for design acknowledged by Rotellar and colleagues (2016):

1.    Provide student exposure to content before class

Pre-course activities should comprise of multiple short activities (ex. 6 5-minute videos, each focusing on a different topic) that cover primary learning points and are not excessive in detail. This makes pre-class work more manageable for the learner, and allows for modification of the activities more manageable for the teacher.

2.    Provide an incentive for students to complete the pre-class work

This often is incorporated into a quiz, which a successful grade can only be achieved by completing the required pre-class work.

3.    Provide a mechanism by which to assess students’ understanding of pre-class work

This often includes a quiz at the beginning of class, that also helps increase accountability of students to complete the pre-class work.

4.    During in-class activities, link material back to pre-class material learned

Various activities can be used for the in-class time, and should be tailored to both the material learned, as well as the level of learning the instructor would like the students to achieve. Examples of activities that can be used include (but are not limited to): simulated patients, case discussions, and group learning activities.

5.    Clearly define expectations and provide well-structured guidance

This becomes important particularly for students unfamiliar with the flipped classroom setting. For the past 15+ years, students have been accustomed to (and successful with) learning in the traditional classroom setting, a setting that is much more regimented.  Conversely, the in-class portion of the flipped classroom can be viewed as chaotic and unorganized if well-structured guidance is not provided.

6.    Ensure students have enough time to complete required activities

Timing of when materials will be available or due must be flexible and allow adequate time for the students to complete. Providing materials far enough in advance is crucial for achievability.

7.    Facilitate the construction of a learning community

In-class activities often thrive on group learning, so fostering an environment of collaboration is necessary.

8.    Feedback should be prompt and adaptive

This should occur both within the classroom (during active learning) and after.

9.    Technologies used should be familiar to the learners, and easy to use

This is crucial for the success of pre-class work, which is a prerequisite for success during the in-class work.

References:

Bossaer JB, Panus P, Stewart DW, Hagemeier NE, George J. Student Performance in a Pharmacotherapy Oncology Module Before and After Flipping the Classroom. Am J Pharm Educ. 2016 Mar 25; 80(2): 31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827582

Armstrong P. Bloom’s Taxonomy [Internet]. Nashville (TN): Vanderbilt University – The Center for Teaching; 2017 [cited 2017 Mar 17]. Available from: https://cft.vanderbilt.edu/guides-sub-pages/blooms-taxonomy/

“Flipping” a class [Internet]. Austin (TX): University of Texas at Austin Faculty Innovation Center; 2016 [cited 2017 Mar 16]. Available from: https://facultyinnovate.utexas.edu/teaching/strategies/flipping

Koo CL, Demps EL, Farris C, Bowman JD, Panahi L, Boyle P. Impact of Flipped Classroom Design on Student Performance and Perceptions in a Pharmacotherapy Course. Am J Pharm Educ. 2016 Mar 25; 80(2): 33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827584

Peeters MJ. Cognitive development of learners in pharmacy education. Curr Pharm Teach Learn 2011;3(3):224-9. www.sciencedirect.com/science/article/pii/S1877129711000396

Prescott WA, Woodruff A, Prescott GM, Albanese N, Bernhardi C, Doloresco F. Introduction and Assessment of a Blended-Learning Model to Teach Patient Assessment in a Doctor of Pharmacy Program. Am J Pharm Educ. 2016 Dec 25;80(10):176. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5289732

Rotellar C, Cain J. Research, Perspectives, and Recommendations on Implementing the Flipped Classroom. Am J Pharm Educ 2016; 80(2): 34. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827585

Spangler J. Costs related to a flipped classroom. Acad Med. 2014 Nov; 89(11): 1429. https://www.ncbi.nlm.nih.gov/pubmed/25350324

Taylor DA, Patton JM. The Pharmacy Student Population: Applications Received 2007-08, Degrees Conferred 2007-08, Fall 2008 Enrollments. Am J Pharm Educ. 2009 Dec 17; 73(Suppl): S2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058400

Taylor JN, Taylor DA, Nguyen NT. The Pharmacy Student Population: Applications Received 2014-15, Degrees Conferred 2014-15, Fall 2015 Enrollments. Am J Pharm Educ. 2016 Aug 25; 80(6): S3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5023992