Student Performance in a Flipped Class Module

Student Performance in a Flipped Class Module

Richard Pierce
Shenandoah Univesity
United States
rpierce2@su.edu

Introduction
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 (Bergman & Sams, 2012) to provide instruction to secondary students who were
missing class and therefore missing instruction. 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.
The empirical support (Bonwell & Eison, 1991) for active learning, generally defined, as
any instructional method that engages students in the learning process is extensive. Graduate

Student Performance in a Flipped Class Module

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 Educations (ACPE, 2006) requires the inclusion of active learning strategies.
Gleason, Peeters, Resman-Targoff, et. al, 2001) provided a comprehensive overview of active
learning strategies in pharmacy education as well as a well-articulated rationale for adopting
these strategies. 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 Universitys
Bernard J. Dunn School of Pharmacy address the ACPEs 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. In design
experiments, researchers study interventions in practice, with the dual goal of progressively
refining the design of the intervention itself and the theories of learning and teaching that inform
the design (e.g., Barab, 2004; Brown, 1992; Collins, 1992; Kelly, 2003; Sandoval & Bell, 2004,
Collins & Bielaczyc, 2004). This investigation examined the impact of a flipped class
intervention 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
intervention. 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

Student Performance in a Flipped Class Module

renal diseases, renal replacement strategies, associated complications, and electrolyte and acidbase disorders. Therapeutic management of patients with renal disease, with a specific attention
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 prerecorded 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 Blooms Taxonomy of
Learning Domains (Bloom, 1956) as students were required to combine patient specific data and
drug information in order to design a treatment regimen for the patient. 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 Performance in a Flipped Class Module

Student learning was measured across time for spring 2012 students by considering a
series of assessments including a pre-test, a post-test, subscale performance on the final exam
questions that related to the Renal module in ICARE PHAR 608, and final exam performance.
Comparisons were conducted between the final exam performance of the 2011 and 2012 classes
for the questions that related to the Renal module and final exam performance. 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 University 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 intervention 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?
Method
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, studentcentered 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. Descriptive statistics included pre-test (mean=33.5,

Student Performance in a Flipped Class Module

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. Descriptive statistics for the 75 question final exam were computed for
2011 (mean =76.8, s.d. = 10.97) and 2012 (mean =77.3, s.d. = 8.7). A t-test assuming equal
variance was conducted to compare student performance on the 75 question final exam between
2011 and 2012. No significant differences were found between the 2011 and 2011 final exam
scores t(143) = -2.9, p = 0.76. To further identify the impact of the flipped class intervention, a
t-test assuming equal variance was conducted to analyze student performance on the 16 Renal
ICARE final exam questions for 2011 and 2012. The test yielded significant differences t(143) =
-2.3, p = 0.024. Table 1 summarizes all student assessment performance data.
Student Evaluations
A secondary outcome concerned students perceptions of the flipped classroom
experience. Table 2 details the 10-question survey questions and responses. The 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. 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 Cronbachs Alpha measure of reliability equal to 0.82. Responses to five items

Student Performance in a Flipped Class Module

addressing perceptions about the flipped classroom model yielded a slightly larger reliability
(Alpha = 0.83).
Student perceptions about the process oriented guided interactive lecture and flipped classroom
Students perceptions about the POGIL activity 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, 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.
Students perceptions about the flipped classroom 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 intervention replaced instructor dominated didactic lectures and
required students to engage beyond note taking. Scheduled class time was devoted exclusively to

Student Performance in a Flipped Class Module

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. Overall final exam
performance improved 0.6 % while performance on the material addressed during the flipped
class intervention improved 5.9 % between 2011 and 2012. The researchers expected to see a
corresponding 1.2 % improvement in final exam scores between 2011 and 2012 based upon the
gains 5.9% from the intervention, which represented 21% (16/75) of the final exam. The 0.6 %
improvement between 2011 and 2012 final exams scores indicate 1) the performance gains from
the intervention are responsible for all of gains in student performance and, 2) student
performance declined on the remaining 79% (59/75) of questions not addressed by the
intervention. These findings support the efficacy of the flipped class instructional model. Further
research is needed to reproduce the outcomes and further delineate the extent to which aspects of
the intervention 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. Students

Student Performance in a Flipped Class Module

expressed a consistently high preference for the flipped classroom relative to the traditional
instructor-led didactic lecture. Science courses, especially at the graduate level 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 instructors 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. Future research may wish to investigate more fully the factors impacting students
perceptions. Additionally future research projects might focus on isolating the impact of the
individual components of the intervention such as the formative assessments, the POGIL
activity, and the vodcasts.

Student Performance in a Flipped Class Module

References
Accreditation Council for Pharmacy Education. Accreditation Standards and Guidelines for the
Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree.
http://www.acpeaccredit.org/pdf/ACPE_Revised_PharmD_Standards_Adopted_Jan15
2006.pdf. Accessed June 2012
Barab, S. A. (2004). (Ed.) Special issue: Design-based research: Clarifying the terms. Journal of
the Learning Sciences, 13(1), 1-128.
Bergmann, J. Sams, A. (2012). Flip Your Classroom. Reach Every Student in Every Class Every
Day. ISTE 9781564843159.
Bloom B. (1956). Taxonomy of Educational Objectives, Handbook I: The Cognitive
Domain. New York, NY: McKay, 1956.
Bonwell C., Eison A. (1991). Active Learning: Creating Excitement in the Classroom. ASHEERIC Higher Education Report No. 1. Washington, DC: George Washington University
Press.
Brown, A. L. (1992). Design experiments: Theoretical and methodological challenges in creating
complex interventions. Journal of the Learning Sciences, 2 (2), 141-178.

Student Performance in a Flipped Class Module

10

Cobb, P., Confrey J., diSessa, A., Lehrer R., Schauble, L. (2003). Design experiments in
educational research. Educational Researcher, 32(1): 913.
Collins, A. (1992) Toward a design science of education. In E. Scanlon & T. O'Shea (Eds.) New
directions in educational technology. Berlin: Springer-Verlag, 1992.
Collins A, Joseph D, Bielaczyc K. (2004) Design Research: Theoretical and Methodological
Issue, Journal of Learning Sciences, 13(1): 15-42.
Gardner S. (2006). Preparing for the Nexters. American Journal of Pharmaceutical Education,
70(4):1.
Gleason, B. Peeters, T., Resman-Targoff, B., Karr, S., McBane, S., Kelley, K., Thomas, T., H.
Denetclaw, T. (2011) An Active-Learning Strategies Primer for Achieving Ability-Based
Educational Outcomes American Journal of Pharmaceutical Education.75(9):186.
Kelly, A. (2004). Design research in education: yes, but is it methodological? Journal of the
Learning Sciences, 13(1), 115-128.

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Student Performance in a Flipped Class Module

Table 1
Student performance on assessments in an infectious disease course
Control Group
2011
M

SD

Experimental Group
2012
M

SD

Pre-test

33.5*

11.6

Post-test

79.2*

10.6

*<.001

Final exam

76.8

10.97

77.3

8.7

.76

Flipped
module

77.4

18.9

81.6

17.6

<.05

12

Student Performance in a Flipped Class Module

Table 2

Strongly Agree/

Disagree /

Agree

Strongly Disagree

13

Student Performance in a Flipped Class Module

Viewing the lecture before scheduled class
prepared me for the class activity.

50 (96.0%)

1 (2.0%)

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%)

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%)

I did not view the lecture before class, although I

was supposed to.

The flipped classroom model was similar to

other classes in the BJDSOP?

Student perceptions about flipped instructional model and POGIL activity.