Abstract
Objective. Blended learning combines traditional face-to-face education with online instruction. This learner-centered approach has been shown to improve student engagement, critical thinking, and performance outcomes. The objective of this study was to assess and trend student pharmacist perceptions of blended and online learning used to teach pharmacy management, leadership, and economics within a Doctor of Pharmacy (PharmD) curriculum.
Methods. Qualitative methods were employed using in-depth, semistructured interviews. Second- and third-year student pharmacists were recruited by purposeful and snowball sampling and interviewed to a point of saturation. The interview guide was based on social cognitive theory. Themes identified through initial deductive thematic analysis were categorized by the three domains of social cognitive theory: cognitive, behavioral, and environmental factors. The coding team additionally analyzed the transcripts using inductive thematic analysis to ensure no themes outside of social cognitive theory were missed.
Results. Twenty students were interviewed. Themes reveal perceptions that blended learning facilitated greater understanding of course material, increased motivation among learners, provided more flexibility in workload completion, and was a more enjoyable way to learn compared to traditional didactic instruction. Furthermore, blended learning offered additional distinct advantages over traditional and online-only pedagogies.
Conclusion. Student pharmacists perceived blended and online learning positively and acceptable for the delivery of a pharmacy course on management, leadership, and economics over traditional didactic instruction. Blended learning may enhance innovation, leadership, management, and economics content delivery and the student learning experience.
INTRODUCTION
Teaching pharmacy-related social, administrative, and behavioral sciences within Doctor of Pharmacy (PharmD) curricula can be challenging given that students are generally less engaged in the content, prioritize this coursework lower than more clinically based courses, and perceive a lack of applicability to entry-level pharmacy practice.1 However, few solutions to this issue have been suggested over the past several decades, and even fewer have been explored and reported in the published literature.1-7 At the same time, the Accreditation Council for Pharmacy Education (ACPE) has only increased its calls for colleges of pharmacy to strengthen the focus on these areas (ACPE Standard 4).8
Despite advancements in higher education instructional strategies and technology, the majority of content in higher education is still delivered via the traditional lecture method.9 While the traditional model of didactic, instructor-focused, classroom-based education remains dominant, this model may lead to student disengagement and low retention of material, especially when intrinsic motivation to learn is low.10 As the educational landscape and population of adult learners evolve, so does the need for innovative and relevant instructional methods. For instance, technology has been incorporated into many innovative instructional methods across multiple levels of education to enrich student engagement and customize the learning experience; such methods have included using web-based discussion boards, online reading materials, asynchronous modules, videos, interactive vignettes, virtual patients, social media, and smartphones.11-13
As teaching and learning practices continue to evolve, online learning has increasingly been incorporated throughout higher education due to advancements in technology and to meet learner preferences and expectations.14,15 However, due to low course completion rates and the importance of student engagement with instructors and peers, online instruction alone is not expected to be the most effective educational strategy.15-19 According to a 2015 study, online course completion rates ranged from 0.7% to 52.1% (median 12.6%) and had a 10%-40% higher dropout rate compared to face-to-face courses.17,19 There are, however, certain elements of online learning that may complement traditional didactic instruction.16 For example, blended learning is a learner-centered approach that combines live, in-class instruction with technology-based home study.20,21 Blended learning has been shown to enhance student engagement, enjoyment, self-efficacy, critical thinking, and performance outcomes.22-29 Though there exists evidence on the use of blended learning in varying courses and levels of education, no research has been published regarding its use in postgraduate pharmacy management, leadership, or economics courses.
The objective of this study was to assess and trend student pharmacist perceptions of blended and online learning used to teach pharmacy management, leadership, and economics within a PharmD curriculum.
METHODS
The theoretical framework used for this study was Bandura’s social cognitive theory.30 Social cognitive theory emphasizes three reciprocal factors that determine human motivation, learning, and performance31: cognitive, behavioral, and environmental factors (Figure 1). An individual’s self-regulation, confidence, and practice all influence and are influenced by their personal knowledge, beliefs, and attitudes as well as their physical and social learning environment.32-34 These elements continually affect the learning process and are not independent of each other; they interact dynamically.
Social cognitive theory: cognitive, behavioral, and environmental factors.
Social cognitive theory has been studied across a variety of disciplines including psychology, education, business, and health.31 This theory was selected as the underlying theoretical basis for the study because it posits that knowledge acquisition is directly related to observing others, which informs the learner’s perception of self-efficacy or personal belief in their ability to complete the learned behavior correctly, a core component of social cognitive theory.30,32 This observation may take many forms beyond the instructor at the podium, including via direct observation, media (eg, videos, podcasts, articles), or stories.30
The traditional classroom lecture format in US colleges of pharmacy is didactic direct instruction about patients.9 Self-efficacy in therapeutics-based courses may be more readily achieved by student pharmacists through those observations made within the classroom and their direct comparisons to a plethora of patient-related experiences, including introductory pharmacy practice experiences, internships, other classes, media, and social interactions with other students, preceptors, and faculty about patient care. In contrast, topics related to leadership and management may presumably be less tangible to students, as these topics are observed less often, and, therefore, traditional forms of teaching may be less effective. Core to social cognitive theory is the triadic reciprocal causation system that connects person (ie, cognition), behavior, and environment through their direct influence on one another. Online and blended learning paradigms manipulate the environment, thereby providing additional “virtual” space to improve self-efficacy through additional means to observe behaviors.20,21 Accordingly, blended and online learning models would thereby influence both cognition and behaviors of student pharmacists in ways different from more traditional classroom delivery of content.
In-depth, semi-structured phone interviews were used to collect data. Students enrolled in the pharmacy management, leadership, and economics course in fall 2019 or spring 2020 qualified for inclusion in the study. Students not enrolled in this course in fall 2019 or spring 2020 were excluded from participating. Second-year (P2) and third-year (P3) student pharmacists within the study institution were recruited by purposive expert sampling and subsequent snowball sampling so as to elicit rich and representative data from the group.35 Invited participants were identified using expert judgment of the researchers according to factors (eg, academic performance, professionalism) believed to generate the greatest depth of information regarding the interview questions, and after the interview, participants were invited to refer other classmates for recruitment who they believed would also provide helpful insight via interview. Participants were invited via email to share their perspectives of and experiences with online (P3 class) and blended (P2 class) learning formats of a required PharmD-level course in leadership, management, and economics. Due to a curricular change, P3 students (n=163) were enrolled in a course with the same content as P2 students (n=202). For the P3 students, the course used online-only instruction in fall 2019, while the P2 students experienced the course using a blended learning format in spring 2020. Both courses were directed by the same instructor. For the purposes of this study, students were instructed that “traditional” learning styles were those that were lecture based, non–active-learning classroom sessions with online platforms used primarily to post lecture content and send communication from instructors to students. In both blended and online courses, lecture recordings were made available to students each week on the course’s web-based learning management system, Blackboard (Blackboard Inc), and supplemented with related videos, articles, and other materials to further support learning. Students could choose any time during the week to complete these home study materials. Each module ended with a brief quiz and worksheet assignment, due at the end of each week, assessing student understanding of key concepts and application toward their longitudinal (semester-long) project: developing a unique innovative pharmacy service idea. Scheduled class time in the blended learning course was reserved for active learning and group exercises to facilitate application of learned concepts to real-world scenarios.
All key study personnel were faculty or consultants within the study institution. One was course director but was not involved in data collection. Interviews were conducted after completion of the P2 and P3 courses and after final grades were assigned. Informed consent was obtained verbally from each participant prior to the interview. Participants received a copy of the informed consent document in advance of the conversation. The investigator conducting the interview explained the research and ensured the participant understood all aspects before proceeding. All sessions were conducted and audio recorded on Zoom (Zoom Video Communications Inc) by the study’s lead investigator, who had prior experience in qualitative data collection to a point of saturation, a time at which no new information or themes were gathered.36 No individuals other than the participant and researcher were present at the time of interview. After all interviews were complete, each participant received a $20 Amazon.com gift card. Interview data were maintained safely in a password-protected electronic file storage system (Microsoft OneDrive) and transcribed verbatim by a third-party service (Rev; Rev.com Inc). A two-coder team who had been trained in qualitative research methods then analyzed the transcripts using a thematic approach and licensed coding software (NVivo; QSR International LLC).37 Thematic analysis involved initial deductive thematic assessment, primarily categorized by the three domains of Bandura’s social cognitive theory that influence learning, action, and change: cognitive, behavioral, and environmental factors.31,37 The coding team also analyzed the transcripts using the inductive thematic analysis methods as defined by Braun and Clarke to ensure no themes outside of social cognitive theory were missed.37 To accurately signify themes as one coding system and avoid introducing bias, the researchers first coded the transcripts separately before determining consensus on codes and themes.37 Transcripts were not returned to participants for review. Field notes were made during and after the interviews and used in qualitative data analysis to enhance data exploration and context and extract meaning.38 Researchers consulted the consolidated criteria for reporting qualitative research (COREQ) during data collection and analysis.39 Approval of this study was granted by the study institution’s institutional review board.
RESULTS
Thirty-four students were invited to participate in an interview; of these, 20 students accepted the invitation, while 14 students declined or did not respond. A total of 20 interviews, ranging from 16 to 42 minutes, were conducted. Table 1 highlights participant demographic information. There were no participants who dropped out of the study, and no repeat interviews were conducted. Appendix 1 contains sample supporting quotes from each of the themes identified.
Demographics of Student Pharmacists in Either the Online Only or Blended Learning Cohort
In general, students in the online-only cohort shared positive opinions and preference for the variety of learning materials provided and for the increased flexibility, autonomy, and accountability that the online course facilitated. Students in the blended learning cohort also referenced and preferred these same ideas, in addition to favoring the synergistic combination of in-class and online instruction (not just one or the other), which led to a perceived increase in motivation and learning.
For Theme 1 (coined as, “student pharmacists desire self-directed learning with a focus on application”), the degree of learner control, a behavioral factor, offered in both the blended and online-only learning structures, was viewed positively by participants and provided students flexibility in terms of when and how often to practice new behaviors (eg, strengths, weaknesses, opportunities, threats [SWOT] analysis, develop innovative ideas, pitch a novel business concept). Participants felt these learner-driven, self-regulated models granted them a high level of flexibility and autonomy to choose when and where to learn at the best time for their schedule and attention rather than passively absorbing (and possibly not retaining) information in traditional lecture format.
Students reported an increased level of personal accountability with online and blended learning, as they felt responsible for exploring and understanding the course material in these learner-driven environments. Students noted the substitution of external controls (eg, set class times, faculty facilitation of direct instruction) with internal environmental or social factors, which enabled self-regulation of the learning process. Additionally, in the blended learning environment, students felt motivated to comprehend material and improve new skill proficiency because the in-class sessions required students to apply the material with activities and discussions in peer groups.
Similarly, because of the self-driven nature of both courses and the freedom to choose when, where, and what activities or materials with which to engage and participate, students noted how essential accountability was for engaging in online material. Though the perceived increase in autonomy and flexibility was often cited as positively fueling accountability and, thereby, motivation to learn in the blended and online course environments, some students reported autonomy and flexibility alone was insufficient. These students cited the need for external environmental factors, including assessments (eg, examinations, quizzes), to improve low prioritization and motivation toward these courses. Some students participated in all course materials; others chose to skip certain activities, especially if not required. Furthermore, though most students expressed positive opinions and understanding of the importance of pharmacoeconomics, leadership, and management skills taught within pharmacy curricula and the value of these topics to their professional careers, a few students noted that these topics often took a back seat to other therapeutics-based topics that were tested on a multiple-course integrated examination every other week.
For Theme 2 (“student pharmacists prefer a variety of learning mediums and settings”), both online and blended learning models provided means to observe content through various learning mediums, such as videos, podcasts, articles, and other educational modes. The narratives of both cohorts highlighted positive views of the variety and inclusion of multimedia digital content, revealing that the multiple learning modes were interesting, helped relate important concepts, and catered to various learning preferences of students. Participants noted that these cognitive factors led to greater comprehension and retention of course topics. Students appreciated the interesting variety in content delivery and the change of pace compared to the traditional instructor-driven style of lecturing.
Furthermore, students in both cohorts enjoyed and reported perceived benefit from the active-learning elements of the course, including in-class and at-home assignments. Students appreciated the opportunity to directly apply (behavioral factor) skills and knowledge through weekly assignments such as worksheets, which, in turn, increased students’ perceived self-confidence in the material, a key behavioral factor in the learning process. Participants also appreciated the real-world application observed through supplemental readings, podcasts, and videos as part of the online portion of both courses. Moreover, facilitated in-class sessions by faculty experts in the blended learning cohort provided an additional opportunity to observe experts and peers, in addition to applying the material themselves. Students noted in particular that leadership, management, and innovation topics for student pharmacists were well suited for this format.
For Theme 3 (“blended learning offers distinct advantages over traditional and online-only pedagogies”), additional benefits of the combination of in-person and online learning were described for the blended learning cohort over traditional and online-only models. A key and highly referenced characteristic of the blended learning narratives was that the students felt more driven to learn the course material since it was up to them to receive, understand, and apply it. The self-directed nature of the course and weekly assignments enabled learners to do the work and formulate their own ideas when working through topics. Furthermore, participants reported enjoying the blended learning process more than traditional didactic instruction. Some students noted they were more engaged in the material, viewing more than just the required readings and videos provided each week.
Students referenced the novelty of this course design, which combined online, self-paced learning with in-class application of concepts. Importantly, students appreciated being empowered to determine their own time, space, and pace to learn the material as part of the self-directed home study portion of the course. Students also reported that they believed live application and active-learning activities were a better, more optimal use of class time compared to traditional didactic lecturing. Participants liked the balance between both in-class and online components, and these cognitive attitudes directly influenced student learning behavior. The majority of interviewees in the blended learning cohort recommended future applications of blended learning in other PharmD courses.
Specific to the blended learning cohort, because the main lecture content was presented via online platforms, in-class time was reserved for interaction and application of learned concepts through case scenarios, discussion, worksheets, and group work. According to interviewees, this in-class application piece helped solidify learned concepts and facilitated deeper understanding of topics and mastery of competencies. Students reported that blended learning empowered them to experience learning, comprehension, and retention on a deeper level, increasing self-efficacy and the behavior of learning.
Overall, students enjoyed and benefitted from group work that involved in-class discussions and problem-solving. Students liked being able to first explore and digest the material on their own time and at their own pace before discussing and applying it in an in-class group setting, an environmental factor that fostered proficient use of in-class time. According to some interviewees, friendly competition between classmates fueled motivation to participate and succeed during in-class activities. However, some students called attention to unequal contributions among group members and the need for some external accountability.
DISCUSSION
The results of this study provide insights into the use of blended and online learning pedagogy through the lens of Bandura’s social cognitive theory.30 Findings indicate that student learning is influenced by three factors: the collaborative, dynamic relationship of the students’ perceptions that the course material is generally less important than clinical topics; a varied learning environment; and the students’ behaviors in interacting with the material.30 Our results suggest that altering the learning environment to leverage online or hybrid online/in-person (ie, blended learning) approaches may positively impact student learning for unique topics like leadership, management, and innovation within a PharmD curriculum.
According to our study, students favored the increased level of flexibility and autonomy that was offered in online and blended learning formats compared to traditional instructor-led teaching. Students appreciated and enjoyed taking charge of their learning by approaching content at their own pace and on their own time, enabling them to choose when they were best prepared to absorb and apply the information. This personalized level of control helped boost student-perceived self-efficacy and course workload management during the P2 (blended learning cohort) and P3 semester (online cohort). This was an important finding, as college stakeholders expressed initial concerns that the self-paced nature of the course format in addition to the level of autonomy and control provided to learners may result in less engagement and overall worse learning outcomes. Students within the study institution were not accustomed to self-directed learning. Furthermore, a substantial proportion of the class belonged to Generation Z, whose main use of technology has been for communication and entertainment, and that has shown to lead to challenges with incorporating technology into education for developing knowledge and skills.40-42 With proper support and orientation to course and technology expectations, students can learn to use these resources and the flexibility and autonomy that comes with blended and online learning to facilitate engagement and learning.40
Self-efficacy is a core construct of social cognitive theory that refers to the extent to which an individual believes in their own ability to achieve or perform, and it may be a key driver of the positive perceptions held by students.30,32 According to Bandura,32 self-efficacy is directly related to human behavior, including the behavior of learning.33 Self-efficacy has been previously established as a factor directly related to student success and motivation to learn.30,43-46 This was supported in the present study through student narratives discussing increased motivation to learn and self-efficacy gained through flexibility, autonomy, and accountability compared to the traditional learning style. These self-regulation learning strategies have been shown to enhance personalized learning for students.22,24,25,27-29 The self-directed nature and learner control of online and blended learning was perceived to boost self-efficacy and course workload management, while offering appealing autonomy and flexibility to busy postgraduate pharmacy students, allowing them control over the time, pace, space, and path of the learning process.
According to Bandura, people strive to represent their own sense of agency or autonomy and possess control over their actions and behaviors.30,31 This is an important motivating factor in the learning process. Motivation itself is another key element in the learning process.47,48 Participants in both blended learning and online groups highlighted their increased motivation levels when compared to traditional didactic instruction. Furthermore, students of the blended learning cohort indicated even higher levels of motivation than their online-only peers. Student motivation is vital to learning, as negative emotions toward learning, such as boredom and frustration, diminish student motivation, self-efficacy, and academic success.49 Such findings and findings from the present study emphasize the importance of student self-regulation in an online and blended learning course.49 That being said, students interviewed suggested that autonomy and intrinsic motivation were sometimes insufficient to compel students to engage closely with all course materials, with some students suggesting external accountability measures, such as examinations and quizzes. These findings suggest that the ideal learning modality privileges self-efficacy by providing autonomy and encouraging internal motivation while leveraging external accountability mechanisms like quizzes, examinations, and relevant in-class activities. The inclusion of quizzing and examinations aligns with Wood and Bandura’s assertion that the “most effective way individuals develop a strong sense of efficacy is through mastery experiences.”50 Ultimately, student experiences in the blended learning and online courses indicate that there is a need to couple autonomy and internal motivation (self-guided learning) with mastery experiences (quizzes, examinations, and in-class exercises) in order to inculcate and reinforce self-efficacy beliefs.
Social cognitive theory posits that self-efficacy in learning is gained through experience, observation, and practice.30 Each student is equipped with a set of learned personal experiences, knowledge, expectations, attitudes, and other cognitive factors that are affected by the learning environment and influence behavior and learning.30 Students of both the online and blended learning groups shared positive perceptions of the variety of learning materials and real-world examples incorporated into the courses, including articles, videos, podcasts, and lectures, which increased perceived engagement. According to students, the variety in content delivery was preferred over the traditional instructor-driven lecture style. Students posited that these various modes of concept delivery and application led to greater comprehension and retention of course topics, thereby enhancing feelings of self-efficacy and motivation in a continuous cycle.
According to social cognitive theory, student learning behavior is influenced by physical and social characteristics of the educational environment, which in turn affect student motivation and engagement in the learning space, suggesting that humans are both simultaneously products and producers of their environment.34 In blended learning specifically, the thoughtful integration of multimedia home study and live, in-person learning motivated students to engage in the learning process more fully. These results support other pharmacy education research reporting increased student engagement due to blended learning.22,24,25,27 Students perceived that live application and active-learning activities optimized class time in comparison to traditional didactic lectures. Students in the blended learning cohort reported preference for the combination of in-class active learning and self-regulated home study, asserting that engaging with supplemental materials and activities before class and then discussing and applying course content during class helped them learn the material better than online-only or traditional in-class didactic instruction. Based on our findings, future research should specifically assess blended learning’s impact on student engagement, motivation, self-efficacy, satisfaction, and overall academic success.
This study has limitations. It was conducted at one institution using qualitative methods. Different questions and probes could have resulted in different responses. Furthermore, the number of interview participants accounted for a small percentage (5.5%) of the overall population of students enrolled in the course. As with all qualitative studies, results are not meant to be generalized alone. The results of this study represent perceptions of a sample group of students at the present study’s institution. Future research should couple the findings of this study with quantitative data, such as student surveys and academic performance (eg, grades, other performance assessments), and implementation across multiple courses and/or institutions.
CONCLUSION
This study applied Bandura’s social cognitive theory to understand and compare student pharmacists’ perspectives and experiences with online and blended learning approaches used to teach pharmacy management, leadership, and economics in a PharmD curriculum. In both blended and online learning environments, students enjoyed the flexibility, autonomy, and the variety of learning materials that were offered. Students in the blended learning cohort specifically noted that they preferred the synergistic combination of online home study and live, application-based class time. This blended design was perceived to enhance student learning, engagement, motivation, self-efficacy, and satisfaction compared to online-only and traditional instructor-led teaching. According to this study, blended learning seems to align best with student pharmacists’ learning needs and preferences. To fully engage students in the learning process and better meet their learning needs and preferences, educators may consider the findings of this study when designing and developing instructional activities moving forward. Further research should be conducted on blended learning’s impact on student performance.
Appendix
Sample Quotes From Interviews With 20 Student Pharmacists Regarding Their Perceptions of Either an Online or Blended Learning Course in Pharmacoeconomics, Management, and Leadership
- Received December 16, 2021.
- Accepted July 28, 2022.
- © 2023 American Association of Colleges of Pharmacy
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