The primary pre-clinical pharmacology course included the following modules: basic principles, fundamentals of pharmacokinetics, pharmacodynamics and pharmacotherapeutics, autonomic drugs, cardiovascular-Renal drugs, drugs with significant effects on smooth muscle, drugs used for blood disease treatment, drugs influencing glucose balance, anti-inflammatory drugs, and pulmonary pharmacology.

Subsequent topics were addressed either within smaller specialized pharmacology courses or integrated within other pre-clinical modules.

The lecture-based learning (LBL) format spanned a 14-week semester, totaling 56 h. Each week, four academic hours were dedicated exclusively to in-person lectures. Starting in 2016, this LBL approach, catering to approximately 170 students per cohort, was complemented by a problem-based learning (PBL) workshop that focused on cardiovascular-renal system pharmacology. This workshop featured small group discussions, with 10–12 students per group, delving into pharmacological treatments through case studies, all facilitated by a teaching assistant. Workshop preparations entailed attending in-person lectures and studying pertinent course book chapters, along with drug information condensed into a workshop booklet. The workshop grade, which contributed to the final course score, included an initial test to measure students’ basic understanding and a concluding test to assess their ability to apply this knowledge to clinical case scenarios. These tests comprised of multiple-choice and open-ended questions.

The course’s final exam encompassed all topics presented during the term, assessing the pharmacological skills and knowledge necessary for students’ upcoming clinical training in hospitals in the following semester. This exam comprised 40 multiple-choice questions, in a randomized order, with five options each. Students were required to correctly answer at least 24 of these questions (minimum grade 60).

In 2022, a renewed course model was launched and has since been adopted by two student cohorts with 216 and 210 students in 2022 and 2023, respectively. The course, curated primarily by the coordinator, maintained the original LBL timeline but integrated a blended learning approach, melding the flipped classroom paradigm with question-based learning (QBL). The content was structured hierarchically, breaking the syllabus down into distinct units, each with different pharmacological dimensions (Table 1).

Progression began when the learners accessed advanced pre-recorded videos and live synchronous sessions. Subsequently, they participated in online quizzes. Asynchronous online participation was facilitated via a dedicated Moodle™ platform, which served as the primary Learning Management System (LMS). This platform displayed an array of tools: video sessions concluded with quizzes and supported by specialized Q&A and news forums. Employing PowerPoint^® (Microsoft Corporation, Redmond, Washington) and Panopto™ (Panopto: Seattle, Washington), lectures were constructed and uploaded as concise videos to the course site using Panopto™ technology. The online quizzes created within the LMS incorporated immediate post-completion feedback to further the learning curve.

Following to 4–6 h of asynchronous online activity, students participated in 2-h synchronous, in-person discussions with the course faculty. These sessions, held in a hall room, mandated full attendance as specified in the course guidelines. During these meetings, students engaged in peer learning, interacting with questions projected on the screen, which were subsequently discussed under the faculty’s guidance.

Notably, the cardiovascular system pharmacology workshops remained unchanged from the LBL format. Likewise, the structure of the concluding examination was held in class and remained consistent with the previous versions.

The study utilized a self-administered electronic questionnaire developed according to practice guidelines for surveys (Artino et al., 2014). Data were collected anonymously at the end of the course and before the final examination. Although the native language of the nursing student population varied (i.e., Hebrew, Arabic, Russian, etc.), all the students were proficient in Hebrew, including reading and writing. Participants were provided with information about the voluntary nature of their participation and assurances of anonymity and confidentiality with no impact on their assessment. The questionnaires, focusing on overall course satisfaction via a graded scale, collected responses from five LBL cohorts (n = 328) and two blended course cohorts (n = 133), using the same format for consistency. Additionally, they featured open-ended sections for students to elaborate on the positive and negative aspects of the course. This study was approved by the Ethics Committee of Hebrew University (number 05122023).

Data collected from the two cohorts of the new blended course structure (n = 426 students) were compared with data from 5 years of cohorts from the previous LBL course (n = 849 students). The LBL cohort sizes for 2016–2020 were 160, 170, 184, 169, and 166 students, respectively. Data from 2021 were omitted because of the disruptions caused by the COVID-19 pandemic.

Data were analyzed using GraphPad Prism (Boston, MA, United States) statistical software and are presented as mean ± SD. Frequency distributions, with numbers and percentages for all variables, were produced. t-test and One-way ANOVA statistical tests were used for comparison between categorical variables; p-value < 0.05 was considered to be significant.

For more than 25 years, our pharmacology course for nursing students in pre-clinical training was structured around in-class lecture-based learning (LBL). In the past decade, problem-based learning (PBL) workshops have complemented LBL. A review of the course’s academic outcomes identified a recurring challenge: A substantial percentage of students did not meet the required standards on their final exams (Figure 1A). On average, across five cohorts, 37.8% ± 7.9% of students did not pass the course. An in-depth analysis of the grade distribution revealed a troubling trend: the average final exam score across these cohorts was 64.6 ± 16.0, alarmingly close to the minimum passing score of 60. This suggests that a large segment of students was not just underperforming, but barely reaching the threshold of competence.

To better comprehend the gaps in student learning, we applied Bloom’s taxonomy (Giffin, 2002) and methods from Kim et al. (2012) to analyze pharmacology exam questions. Each question was categorized into the taxonomy’s six cognitive levels:

1) Remember : Recognizing basic drug knowledge; e.g., Identifying drug names.

An example of the graduated questions is presented in Supplementary Table S1.

The final exam questions from the five LBL cohorts were then classified (Figure 1B) and the success rate in each category was calculated (Figure 1C). Questions at the “Remember” level recorded the highest success, with 75.7% ± 14.0% of students answering correctly. By contrast, the success rate for questions at all other cognitive levels was significantly lower. The “Understand” and “Apply” categories presented challenges, with correct response rates of 64.1% ± 11.9% and 64.1% ± 9.4%, respectively. For the “Analyze” category, roughly 56.3% ± 13.2% of students could successfully break down complex pharmacological scenarios. The “Evaluate” category shows only 51.7% ± 13.0% of students able to integrate and act on multiple factors in patient-based cases. Finally, the demanding “Create” level presented the most significant challenges, with just 47.1% ± 22.1% of students being able to construct solutions from various case details.

Student feedback from end-of-course surveys offers insights into the course’s strengths and areas for improvement. Comments were grouped into themes for analysis. The positive aspects (104 comments) included the course’s relevance (39%), its organization (12%), and the quality of teaching (23%), with the workshop being particularly appreciated as beneficial for learning (26%). However, improvement suggestions (121 comments) pointed to the course’s difficulty (32%), teaching style concerns (14%), and organizational issues (12%). Notably, 41% of the students recommended a more practice-oriented approach to enhance content retention and understanding.

In response to the identified academic deficits, the pharmacology course was substantially restructured into a new blended structure. The central aim was to immerse students in critical thinking exercises across all cognitive tiers of Bloom’s taxonomy. This comprehensive approach was designed to equip students with rigorous analytical skills that are imperative for safe and adept administration of drugs in clinical scenarios.

The course was redesigned with a hierarchical structure segmented into learning divisions, each tailored to cover specific pharmacological aspects (Table 1). This ensured the focused learning of one set of concepts before transitioning to the next. Within these divisions, the content was meticulously segmented into concise learning units, each containing a scaffolded learning experience that progressively elevated students from foundational knowledge retention to sophisticated problem-solving abilities. The learning journey unfolds with increasing intricacy, starting with knowledge acquisition using synchronically in-person or asynchronically recorded videos. Thereafter, students took online quizzes, reinforcing their understanding and tapping into all levels of critical thinking skills, proportionally divided in similarity to Figure 1B. Altogether, 130 online quizzes were distributed in each learning unit as follows: remember 27% ± 2.9%, understand 22% ± 2.4%, apply 18% ± 2.1%, analyze 16% ± 1.4%, evaluate 10% ± 1.1%, and create 7% ± 2.3%. Following the practice of online questions in each learning unit, students were gathered for synchronous face-to-face discussions. The objective of these sessions was to deepen the understanding of and pinpoint challenging areas informed by student performance on online quizzes. These discussions further explore how slight shifts in the pharmacological situation can dramatically alter the scenario, resulting in significant clinical consequences. This pedagogical method encourages students to elevate to higher levels of applying, analyzing, evaluating, and creating critical thinking.

In the cardiovascular renal drug division, students encounter the same complex problem-solving exercises integral to the LBL course structure. Addressed in small groups, these exercises were designed to promote in-depth discussions, propelling students toward the analysis, evaluation, and creation of the stages of Bloom’s taxonomy (Shawahna, 2021).

Finally, the course culminates in an online mock examination that allows students to practice across a spectrum of cognitive complexities within all learning divisions.

As the pharmacology nursing course underwent a transformational shift from the classical LBL method to the question-based blended approach, a significant improvement in academic performance was evident (Figure 2). The examination results revealed a marked contrast in the failure rates between the instructional formats. While the LBL format had a high average failure rate of 37.9% ± 7.9%, the blended method substantially lowered it to 13.6% ± 1.5%, indicating a reduction of 24% (compare Figure 2A; Figure 1A). In line with the failure rate, the blended course structure delivered an improved average grade of 76.4 ± 16.0. The observed difference in the mean score between the two methods was 11.8, indicating a statistically significant improvement in the blended course structure (Figure 2B). Furthermore, a histogram depicting exam grade distribution for both the LBL and blended course structures further illustrates this positive shift, showing a notable increase in the frequency of higher grades among students in the blended format compared with the LBL approach (Supplementary Figure S1). An improvement was also observed in small-group activity. Examining the cardiovascular-renal workshop test scores, the LBL structure yielded a mean of 82.2 ± 14.1. In contrast, the blended format surpassed this with an average of 86.6 ± 13.2, marking a significant enhancement in scores by 4.4 points (Figure 2C). These results strongly suggest that the blended format increases the learning outcomes of the course. However, a possible explanation for this data is an increase in student satisfaction with the new format. To test this, average student satisfaction data derived from anonymous surveys were examined. The analysis showed no statistically significant change with an average of 8.3 ± 0.7 vs. 7.8 ± 1.3 (out of 10.1) for blended and LBL, respectively.

Given the observed academic advantages of the blended course approach in the final exams, we sought to understand its impact on learning outcomes categorized by cognitive level. Therefore, the success rates across cognitive levels in the blended course exams were compared with those presented in Figure 1C for the LBL format. In every cognitive category, the blended course demonstrated a significant upward trend in student success rates in the blended course structure as compared to the LBL (Figure 2D). As in the LBL format, questions at the “Remember” level recorded the highest success, with 85.5% ± 7.3% of students answering correctly. In contrast to LBL, a less dramatic decrease in the success rate of questions at all other cognitive levels was observed for the blended format. A notable enhancement was observed in the higher cognitive realms of “Evaluate” and “Create,” where the blended format demonstrated a leap of 19.0% and 24.2% points, respectively. These findings underscore the blended courses’ proficiency in fostering advanced cognitive skills.

The juxtaposition of beginning- and end-cardiovascular-renal workshop test outcomes in both blended and LBL formats offered additional insights (Figure 2E). While the beginning-test was designed to evaluate lower levels of cognitive skills (Remembering, Understanding, Applying), the end-test was used to assess advanced cognitive abilities concerning drug-based patient care (Analyzing, Evaluating, Creating). A pronounced increase in end-workshop test scores of 11 was observed for the blended structure compared to the LBL. This substantiates the enhanced capacity of students in the blended course to navigate the complexity of higher-order pharmacological problem-solving.

In summary, not only does the blended course format offer superior overall academic results but it also notably enhances outcomes across all cognitive domains, especially in the intricate realms of evaluation and creation. This synergistic effect confirms the blended course’s efficacy in creating a holistic, well-rounded learning environment in pharmacology.

Finally, to test whether the blended course generated a better learning environment, the dynamics of student engagement was the next focus.

Students exhibited substantial engagement with online quizzes that encompassed the spectrum of cognitive levels defined by Bloom’s Taxonomy (Figure 3A). A consistent trend emerged across all six cognitive domains, with an average participation rate of 74.1% ± 1.9% of registered students. Such uniformity indicates that the online platform was effective in engaging students irrespective of the cognitive difficulty of the questions or the pharmacological topic they addressed.

An important metric of perseverance and determination in mastering a topic is willingness to reattempt challenging questions. The data revealed a segment of students who revisited specific questions twice or more. Such retrials were also categorized based on cognitive learning outcomes, thereby providing a lens into areas where students might have faced initial difficulties, but displayed resilience to enhance their understanding (Figure 3B). The data show that most repeated questions were related to advanced cognitive levels of analysis, evaluation, and creation, which involve decision-making considering multiple factors in a patient case (Kim et al., 2012).

Essentially, the blended course appeared to have successfully fostered a culture of active participation and iterative learning. Students not only actively engaged with the content but also displayed a commendable willingness to persevere through challenging materials.