Student-led development, delivery, and assessment of an integrated learning activity focusing on acute myocardial infarction

Article Outline

• Abstract
• Introduction
• Background
  • Description of IPA courses
  • P4 student research project on teaching and learning
• Methods
  • Development of the integrated, active learning session for P1 students by a P4 student
    • Literature review
    • Development of integrated, active learning activity
    • Development of IPA evaluation instruments
  • Study sample and data collection
• Results
  • Literature review by the P4 student
  • Description of the development of the integrated, active learning session by the P4 student
  • Description of the delivery of the integrated, active learning session by the P4 student
  • Evaluation of the integrated, active learning session by the P4 pharmacy student
    • Knowledge pre- and post-tests
    • Perception questionnaire
• Discussion
• Lessons learned
  • P4 student perspective (Dr. Campbell)
  • Faculty facilitator perspective (Dr. Monk-Tutor)
• Final thoughts
• Conclusion
• Appendix A
  • Learning activity for P1 students developed by P4 student on angina and use of nitroglycerin
    • Learning objectives
    • Patient case
  • Case guide and questions
• References
• Copyright

Abstract 

Background

Our school adopted a new curriculum in 2009 that uses integrated, active learning sessions to help students apply concepts learned in didactic lectures. Selected fourth-year pharmacy students have the opportunity to assist in these sessions. Objective: To describe the results of a fourth-year student research project that included the design, delivery, and evaluation of a new active learning session for first-year students. Material and Methods: Using criteria provided by faculty, the student developed a patient case–based activity integrating learning objectives from three first-year courses that related to myocardial infarctions. The activity was delivered to 128 students and then evaluated using a pre/post-test design to examine change in knowledge and an attitudinal survey to evaluate student perception of learning. Data were analyzed using descriptive statistics. Results: The pretest was completed by 127 students (99.2% response); the post-test and survey were completed by 124 students (96.6% response). Post-test scores reflected up to a 41.5% improvement in correct responses on individual questions; a paired t-test indicated that the average score was statistically significantly higher after the activity than that on the pretest (p < 0.01). Most students agreed that the activity contributed to their learning, was relevant to pharmacy practice, improved their confidence and ability to provide pharmaceutical care, and reinforced didactic lecture material. Conclusion: An integrated, active learning exercise developed and delivered by a fourth-year pharmacy student was successful for helping first-year students reinforce and integrate didactic content related to myocardial infarctions.

Keywords:  Active learning , Integrated learning , Student-led learning , Myocardial infarction , Pharmaceutical compounding

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Introduction 

Our school adopted a new curriculum in 2009 that uses integrated, active learning courses to help students apply concepts learned across didactic courses and meet requirements of the Accreditation Council for Pharmacy Education (ACPE) Standards 2007.¹ These courses, similar to skills laboratories and named “Integrated Pharmacy Applications” (IPAs), are designed to integrate learning objectives from didactic courses both horizontally and vertically across the curriculum. These courses focus on the application of concepts presented in traditional didactic lectures during each semester of the first three years of the professional curriculum. Although other schools may offer similar types of courses, one aspect that we feel is unique to our program is the selective use of fourth-year pharmacy (P4) students to assist in teaching IPAs. This paper describes one P4 student's design, delivery, and evaluation of a learning activity in the IPA course for first-year pharmacy (P1) students.

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Background 

Description of IPA courses 

ACPE encourages the use of active teaching and learning methods¹ and the literature reports that their use results in improved student confidence, communication skills, and feelings of preparation for practice, as well as a better understanding of a complete pharmaceutical care model.², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹ Our IPA courses were developed with these principles in mind as well as with a desire to more fully integrate content across the curriculum. To achieve a horizontally integrated component of the curriculum, each IPA course (one in each didactic semester) includes a weekly 3-hour “laboratory” session, offered four afternoons each week. During each session, 32 students complete an active assignment that combines content from all didactic courses taught within that semester. For example, patient-specific case studies or other hands-on activities, such as compounding or patient counseling, are provided during the IPA to supplement and apply background knowledge provided in didactic courses. To achieve a vertically integrated component, additional IPA case discussion sessions are scheduled periodically during each semester that combine content and students from multiple years of the curriculum. For example, a P4 student might present a patient case scenario to the P1 students to help them better understand the clinical relevance of basic science concepts and their application to practice. This integrated content allows for better reinforcement of lecture material and enables students to apply concepts to practice earlier in the curriculum. Because our IPA course sequence is interwoven into the entire didactic curriculum, sufficient time is allocated for the natural development of skills such as problem solving and clinical reasoning that require continuous exposure and reinforcement to develop competence. In addition, the use of numerous active learning methods in weekly IPA sessions supports refinement of these skills and development of clinical practitioners with a broader expertise that ultimately can promote better patient care.

P4 student research project on teaching and learning 

A capstone research course (required by our university for most majors) provided an opportunity for a P4 pharmacy student to integrate his/her own knowledge and apply it to make a significant contribution to our IPA course in its inaugural year. Currently designed as a 2-credit-hour longitudinal course that spans the entire fourth year of the curriculum, all P4 students are enrolled in the research course in addition to their Advanced Pharmacy Practice Experiences (APPEs). Research topics are chosen by the students based on their area of personal interest and may range from literature reviews to bench research. Each faculty member is assigned as a mentor to three to four P4 students annually to facilitate their research projects. For successful completion of the capstone course, P4 students are required to prepare two professional-quality written papers and two verbal presentations that are evaluated using standardized rubrics. Copies of the capstone course syllabus and rubrics are available upon request from the authors.

The P4 student involved in this project chose to complete research related to teaching and learning and desired an opportunity to gain experience teaching other pharmacy students. A summary of student and faculty responsibilities for this specific project appear in Table 1. After subsequent approval of the proposal by the faculty involved, the P4 student began to implement the study methodology.

Table 1. General Student and Faculty Responsibilities for Teaching and Learning Capstone Research Project

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Methods 

Development of the integrated, active learning session for P1 students by a P4 student 

Methods to accomplish the student research project involved a literature review on active learning in pharmacy education, development of a complete learning activity, and development of an evaluation of the learning activity. Each is discussed in more detail below.

Using the search terms “active learning,” “problem-based learning,” “integrated learning,” or “student-centered learning,” along with “pharmacy,” the P4 student conducted a literature review in International Pharmaceutical Abstracts for the last 15 years. The review focused on articles describing the use and assessment of active learning techniques in general pharmacy education rather than on a specific learning technique or on myocardial infarction (MI) content specifically. Although some faculty guidance was provided during the literature search phase regarding search terms and possible journals, the student largely identified literature on her own using drug information retrieval skills learned in school.

Using defined faculty criteria (Table 2), course descriptions,²² and information gathered in the literature review,¹⁴, ¹⁵, ¹⁶, ²³, ²⁴, ²⁵ the P4 student designed the learning activity in the fall 2009 semester. All courses taught in the spring 2010 semester of the P1 year during the spring 2010 semester served as possible resources for information to be included in the integrated, active learning session. The intent was that the activity would address the major learning objectives from at least three didactic courses. On the basis of a review of learning objectives, content topics and schedules for each course taught during the P1 spring 2010 semester, discussion with faculty, and the student's own availability to teach the IPA sessions, the general topic of acute MI was chosen as the central focus for the activity.

Table 2. Criteria Provided to Student by Faculty for Development of the Active Learning Exercise

Evaluation instruments for the study were designed by the student during the fall 2009 semester based on literature review¹⁴, ¹⁵, ¹⁶, ²³, ²⁴, ²⁵ with faculty input. On the basis of other reports of active learning in the literature, students were evaluated both directly (knowledge before and after the IPA session) and indirectly (perceptions of improved learning and self-confidence because of the session after the IPA session). An 8-item pre- and post-test were designed to determine the effectiveness of the IPA session for reinforcing knowledge of a few key learning objectives that had previously been covered in didactic lectures the same semester, including knowledge of various pharmaceutical dosage formulations, pathophysiology of an acute MI, and physiological effects of nitric oxide. A survey consisting of 10 items measured on a Likert-type scale was designed to evaluate student attitudes and opinions toward the activity itself. Both instruments were reviewed by a focus group consisting of two faculty members and two P4 students. The study was approved by the university's Institutional Review Board.

Study sample and data collection 

The study sample consisted of all students enrolled in the P1 IPA course for the spring 2010 semester (n = 129). The knowledge pretest was administered by the P4 student at the beginning of each of the four IPA sessions. The knowledge post-test and the perception questionnaire were administered by the P4 student at the end of each IPA session. Students were encouraged to complete both tests and the questionnaire and were given time during class to do so; however, none were mandatory and no incentives were offered. Respondent confidentiality was protected by asking students to use the same code word (not their name or identification number) on the pretest and post-test and no identifiers were recorded on the perception questionnaire. All responses were entered into a spreadsheet and analyzed using descriptive statistics; a two-tailed, paired t-test was performed using Excel (Microsoft Corp., Redmond, WA) to compare individual pre- and post-test knowledge scores.

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Results 

The entire P4 student project was subject to evaluation criteria previously established for the required capstone research course, including quality and accuracy of all written materials (case, questions, written paper, presentation to students, presentation to peers and faculty). Grading rubrics are available from the authors. Results related to each aspect of the development, delivery, and evaluation of the learning activity itself are discussed below.

Literature review by the P4 student 

Table 3 summarizes pharmacy and health care literature identified by the P4 student as being most helpful for the development and evaluation of an active learning module for our P1 students. Overall, the literature suggested that integrated, patient-based cases and group discussions improved students' understanding and retention of specific medication information, the processes involved in therapeutic decision-making, and the application of new knowledge and skills in an integrated fashion that better represents care of real patients.

Table 3. Summary of Active Learning Literature

SOAP = subjective, objective, assessment and plan; MSLQ = the motivated strategies for learning questionnaire; PBL = problem based learning; OTC= over-the-counter.

Description of the development of the integrated, active learning session by the P4 student 

On the basis of the topic chosen (myocardial infarction), the P4 student developed an integrated case–based activity that included a medication compounding component (Appendix A). The activity was designed to incorporate and reinforce concepts from three didactic courses: Physiologic Basis of Diseases II, Drug Delivery Systems II, and Introduction to Drug Information. The intent of the case was to engage students in a real-life patient scenario that prompted them to ask appropriate questions about information that was still needed from the patient (such as medication storage conditions and medication expiration date), recall the mechanism of action of the drug involved, and apply their knowledge of physiology, drug delivery systems, and drug information to determine appropriateness of the medication for a specific patient. Learning objectives and a broad, fairly simple patient case based on a real patient scenario were developed by the P4 student, including discussion questions, and selected literature resources. Directions for the compounding exercise, including a calculations and ingredients worksheet, were also created by the P4 student. All components of the learning activity designed by the P4 student were reviewed by a focus group consisting of three faculty members (pharmaceutics faculty member, IPA course coordinator, student's research project facilitator) and two P4 students. On the basis of the review, corrections and improvements were made to the original documents. After final faculty approval, the P4 student was scheduled to lead the exercise in the IPA course.

Description of the delivery of the integrated, active learning session by the P4 student 

For consistency, delivery of the IPA session was structured similarly to those held previously during the semester. Four different “laboratory” sections containing 32 P1 students each met during the week of March 1, 2010. Each session was 2.5 hours in length, with the first hour devoted to recitation and discussion and the remaining time spent in the pharmaceutics compounding laboratory to prepare a required prescription. P1 students were expected to arrive at class prepared, having previously read the compounding activity and having performed any needed calculations. Upon arrival to class, P1 students were seated with their designated group of five individuals ready to participate in the class activity.

After administration of the pretest, the P4 student^a provided P1 students with verbal instructions for the activity and explained that her role in developing and delivering the activity was related to completion of her capstone research project. Using a PowerPoint (Microsoft Corp.) presentation that she developed, the P4 student delivered a short (∼20 min) overview of learning objectives and case information and then led a 30- to 45-minute group discussion, including review of calculations required for the compounding portion of the activity. At least one faculty member and a laboratory manager were also present to answer questions, if needed. After the discussion, P1 students completed the knowledge post-test and then moved to the pharmaceutics compounding laboratory. There, pairs of students worked together to complete a hands-on activity practicing previously learned pharmaceutical compounding skills to formulate a nitroglycerin ointment prescription for the patient in the case. Again, to be consistent with the structure of previous IPA sessions, P1 students were required to complete a write-up of the questions from the patient case using appropriate literature sources to be turned in the next day. Although P1 student performance on this assignment was assessed by the course instructor (rather than the P4 student), the assignment itself was created by the student.

Evaluation of the integrated, active learning session by the P4 pharmacy student 

The knowledge pretest was completed by 99.2% (127/128) of students in the P1 IPA course and 96.9% (124/128) students completed the post-test (Table 4). The median and mode scores were both six out of eight on the pretest (range 3-8) and eight out of eight on the post-test (range 5-8). On the pretest, question four was answered correctly by only 48.0% (61/127) of students and question seven was answered correctly by only 54.3% (69/127) of students even though the content material had been covered previously in didactic lecture. Although the percentage of students who answered these two questions correctly increased significantly on the post-test, question four was still missed by 10.5% (111/124) of students and question seven was missed by 7.3% (115/124) of students. A perfect score (8/8) on the knowledge quiz was achieved by only 7.9% (10/127) of students on the pretest compared with 66.1% (82/124) on the posttest. The lowest score on the pretest was a 37.5% (3 of 8 questions answered correctly), which was scored by three students. The lowest score on the post-test was a 62.5% (5 of 8 questions answered correctly), which was scored by only one student. Interestingly, three (2.4%) students' scores decreased from the pretest to the post-test, all by one point each. The mean score on the knowledge posttest increased significantly compared with the pretest mean score (7.54±0.72 vs. 6.01±1.22, respectively; p < 0.01 via paired t-test; p = 6.08E – 25). Three students who completed the pretest but not the post-test were eliminated from the t-test analysis.

Table 4. Content Knowledge Pre- and Post-Test Developed by the Student for the Integrated, Active Learning Session

Item	Pretest score, n (%) correct	Post-test score,⁎ n (%) correct	% Improvement
	(n = 127)	(n = 124)
1. What is the MAIN symptom associated with an acute MI?	86(67.7)	114(91.9)	24.2
2. What dosage form of nitroglycerin is most effective in relieving ACUTE angina?	123(96.9)	121(97.5)	0.6
3. Which statement BEST explains the pathophysiology of an acute MI?	89(70.1)	115(92.7)	22.6
4. Which statement is FALSE regarding the storage of nitroglycerin?	61(48.0)	111(89.5)	41.5
5. Which statement BEST describes nitric oxide's effects within the body?	112(88.2)	111(89.5)	1.3
6. Which resource is a secondary literature resource?	102(80.3)	119(96.0)	16
7. What type of literature source is a review article?	69(54.3)	115(92.7)	38.4
8. Which dosage formulation undergoes first pass metabolism?	124(97.6)	121(97.6)	0

The perception questionnaire was completed by 123 of 127 students in the class (96.9% response; Table 5). Mean responses for nine of the ten items on the perception instrument ranged from 4.21±0.72 to 4.73±0.56, indicating that most students agreed that the integrated, active learning IPA exercise had achieved its objectives. However, student response was generally neutral regarding the ability of the activity to improve their drug literature knowledge and searching skills (question three; mean 3.48±1.15).

Table 5. First Year Pharmacy Students' Evaluation of the IPA Laboratory's Ability to Further Knowledge, Skill, and Interest^⁎ (n = 123)

Statement	Mean (SD)⁎	Mode	Median
	Score
1. My knowledge of basic physiology and pathophysiology concepts pertaining to an MI improved.	4.28(0.85)	5	4
2. My knowledge of different pharmaceutical formulations was enhanced.	4.21(0.72)	4	4
3. My drug literature knowledge and searching skills improved.	3.48(1.15)	3	3
4. I feel more confident in counseling a patient on some of the issues associated with nitroglycerin, such as storage requirements.	4.52(0.64)	5	5
5. The IPA method of instruction encouraged my interest in and learning of the discussion topic.	4.32(0.77)	5	4
6. My understanding of lecture material corresponding to today's IPA lab material was reinforced after participation.	4.47(0.68)	5	5
7. Presented material was relevant to the practice of pharmacy.	4.73(0.56)	5	5
8. Through increased knowledge and skill, my ability to deliver pharmaceutical care to a patient was improved.	4.42(0.56)	5	5
9. Integration of various course topics in a logical manner was achieved.	4.51(0.69)	5	5
10. Overall, I would rate this IPA laboratory as beneficial to student learning.	4.60(0.62)	5	5

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Discussion 

The purpose of this study was for a P4 student to meet requirements for a required capstone research course by simulating two aspects of faculty responsibility—teaching and scholarship—to successfully design, deliver, and evaluate the effectiveness of an integrated, active learning session for P1 students. As mentioned previously, the overall quality of the learning activity developed by the P4 student was evaluated by three faculty using standardized grading rubrics for the pharmacy capstone research project as well via feedback from P1 students enrolled in the IPA course. In addition to doing very well in the course itself, the P4 student was also recognized by school faculty and administrators with a “Best Research Project Award” for her graduating class. Benefits to the P4 student who created the learning activity were not specifically measured as part of the study but are reflected on in Lessons Learned (below).

Regarding the evaluation of the learning activity developed by the P4 student, there was a statistically significant increase in P1 student knowledge post-test scores after laboratory participation compared with pretest scores. In addition, there was an increased percentage of P1 students who achieved a perfect score on the postknowledge test (66.1% or 84/124 vs. 7.9% or 10/127 on the pretest); and post-test scores on individual questions also improved by up to 41.5% (Table 4). Despite significant improvement in the correct responses to most questions on the knowledge test, up to 10% of students still answered questions 4 and 5(regarding storage of nitroglycerin and nitric oxide's effects on the body, respectively) incorrectly after the session. It is not known why three P1 students scored lower on the post-test knowledge examination than on the pretest. It may simply be that without an incentive to complete the post-test, some students did not take it seriously or rushed through it without checking their answers. If some P1 students had difficulty understanding these particular concepts in the traditional, large-group didactic lecture, then the limited information provided by the P4 student during the activity (which was intended to be only a brief review) may not have been adequate. Still, we feel that the exercise provided and presented material in an understandable and effective manner for P1 students, even reaching students who had the poorest understanding of the subject before participation in the IPA activity.

On the basis of the perception survey, most students agreed that the activity contributed to their learning, was relevant to pharmacy practice, improved their confidence and ability to provide pharmaceutical care, and reinforced didactic lecture material. Most students also agreed that the use of active learning encouraged their interest in and ability to learn about the topic of MIs. However, students reported a neutral perception regarding whether or not the activity improved their drug literature knowledge and searching skill. This may have resulted from the fact that the question combined an evaluation of both knowledge and searching skills; therefore, if the perception instrument is used again in the future these two concepts should be separated. In addition, results suggest that the activity could be improved by requiring students to retrieve primary literature (and perhaps record the amount of time needed to complete this assignment) before the session.

With regard to additional study limitations, the P4 student concluded that the activity itself could have been improved by rewording learning objectives to address higher cognition levels, expanding requirements for the use of drug information searching skills and for tracking time spent on this activity by students, and providing P1 students with the compounding worksheet before (rather than during) class so the activity itself focused more on application of material. In addition, only short-term learning and memory were evaluated and it cannot be determined whether the P1 students truly retained the new knowledge. Although the rubric developed may be appropriate for class sizes larger than 128 students, its potential for use in a larger scale application was not evaluated. Finally, data are not generalizable to other populations because the sample included only P1 students at a single school of pharmacy. Still, results obtained support the effectiveness of the delivered IPA session, its continued use, and the incorporation of similar additional integrated, active learning models into the curriculum.

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Lessons learned 

P4 student perspective (Dr. Campbell) 

P4 pharmacy students are continuously learning and developing new knowledge and skills throughout their APPE. Preceptor interactions during this experiential training help students' knowledge to evolve from the world of generalized textbook learning to the practice of individualized patient learning. With this project, I was able to simulate the role and responsibility of a faculty member by mentoring students and helping them to integrate information they had learned in current didactic courses into a real-life patient case. The magnitude of this responsibility made the process of this project very challenging for me. I wanted to provide students with the same quality of learning opportunities that had been given to me, and at first I was unsure of my abilities. However, as I began developing the activity, I became more confident in my clinical and experiential knowledge base and, with the guidance and support of faculty, ultimately produced and delivered a successful learning activity. Faculty ideas and assistance in reviewing my documents helped me to complete a successful research project and make the activity a maximal learning opportunity for the P1 students as well as to anticipate and solve potential problems proactively before encountering them in class. Faculty ideas regarding the perception evaluation were particularly beneficial in helping to maximizing the strength of the results of this study.

Being able to deliver the activity myself was an amazing experience. I did not feel like I was the person in charge or even a teacher. We were all students learning together. The P1 students appeared to enjoy having a P4 student leading the activity and seemed to really enjoy interacting with me. Because of the magnitude of educational experience a research project like this offers, I would recommend that P4 students, especially those interested in a career in academia, be given the chance to participate in teaching within each year of our didactic curriculum. I would advise the pharmacy students who are interested in getting involved in such a project to simply remember what it was like to be in a P1 student's place; students care that you understand where they are in their educational journey and that you can relate to their current learning experience.

Faculty facilitator perspective (Dr. Monk-Tutor) 

Our new IPA course is well-suited for peer teaching by P4 students simply because of its structure. First, the IPA course is intended to pull content together across multiple courses and illustrate the direct relevance of this content to practice. P4 students are in the perfect position to help other students in the program understand this relevance because they are involved in experiential courses 100% of their time. Second, the IPA generally meets two to three hours at a time in four different sections per week. This allows a P4 student to, for example, prepare a relatively short activity, perhaps over the first couple of weeks of their own rotation and then have three opportunities to deliver it, and receive formative feedback from evaluations after each session. Finally, because the main topics in our IPA change every week, all students who are interested in teaching in such a class should be able to find some time during the year when their areas of interest and experience coincide with a session topic.

We have had a similar capstone course for our pharmacy students since I began teaching here in 1996; although many amazing results have been achieved, few students have taken on a project quite as ambitious as this one. I knew this student from my own didactic class before becoming her project facilitator, so I was aware that she had the creativity, interest, discipline, and ability to be successful with a topic related to the scholarship of teaching and learning—I simply provided a starting point, some guidance and refinement along the way, and review and suggestions for what she produced on her own. I attended most of the IPA sessions in which she taught, and as she did a great job on the first day, it was most exciting for me to see her skills and confidence improve even more over the course of the four days. Because she had also been one of my academic APPE students earlier in the year (unrelated to the capstone project), it was especially gratifying to see her applying what she had learned in that experience to the design and delivery of another, much more complex learning activity than she had done in the academic APPE. I knew we had moved from a student-teacher relationship to one of colleagues when she noticed that the teacher really can see everything from the front of the class that is going on (even though students think you cannot) and that time seems to stand still when you ask a question and no one responds… for five seconds. In summary, her project is a great example of what we want all of our students to achieve from their capstone experience: the ability to combine what they already know with evidence that they critically evaluate from the literature or other sources to clearly identify and solve a problem that they have not previously encountered, then communicate that experience (both verbally and in writing) to others and know that they have the ability and the confidence to follow this same process repeatedly throughout their careers. The student successfully simulated two aspects of faculty responsibilities—teaching and scholarship.

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Final thoughts 

An integrated approach has many advantages in promoting learning; however, it also presents many challenges, especially in relation to the logistics of its implementation in large classrooms. This learning method can require an extensive amount of faculty time and effort for its development and delivery and faculty may find it difficult to learn and adapt to a new teaching style that often requires more class preparation time than does standard lecture material. Another challenge of integrated and active learning is obtaining and maintaining student engagement in the planned assignments and activities. As much as one may hope that all students will take advantage of an active learning scenario, it is ultimately up to the individual student to become responsible for his or her own learning. The need for substantial faculty organization and efficiency in the delivery of active learning may pose an additional challenge. Some students may require more guidance and direction with the activities, which may slow the progression of the activity when limited time is available for the exercise. Although overcoming these limitations will necessitate faculty time and attention, the enriched educational experience of an active learning environment (for both faculty and students) makes these efforts worthwhile.

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Conclusion 

Based on literature review, and with faculty guidance, a single P4 pharmacy student successfully designed, delivered, and evaluated an active learning session for 128 P1 students that integrated concepts related to MI. This reinforcement of specific pharmacy lecture material taken from three different didactic courses effectively increased student knowledge after laboratory participation (p < 0.01) and students reported enjoying the activity and having increased confidence in their ability to provide patient care in future practice.

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Appendix A 

Learning activity for P1 students developed by P4 student on angina and use of nitroglycerin 

EC comes into your pharmacy today and asks to speak with the pharmacist. He informs you that he has a past medical history of a heart attack and was recently admitted to Huntsville Hospital ER due to symptoms of angina. EC's doctor advised him to take one SL nitroglycerin tablet immediately following angina symptoms, and if it did not work, he was to call 911. EC was concerned because his SL nitroglycerin tablet did not relieve his recent angina episode and he had to be admitted. He asks you, “What did I do wrong? Is the medicine really not that effective?” As a pharmacist, do you have any questions for the patient? What are your suggestions?

Case guide and questions 

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• a The activity was presented and led by Dr. Campbell at three IPA sessions during the week; however, because of her own APPE schedule, she was unable to be present for a fourth session. Therefore, Dr. Nelson trained another P4 student in how to give the presentation and lead the discussion for the one session that she was unable to attend.