Best practice shows that, for optimal learning, students need to be actively engaged in the learning process (Justice et al., 2007). One method to optimize active student learning is through the pedagogy of the "flipped classroom," where didactic content is provided outside of class as prerecorded videos and readings (McLaughlin et al., 2014). Class time is then utilized to engage students, solve problems, and reinforce crucial concepts. For students to have an authentic, evidence-based learning experience, they need the opportunity for deep understanding and the exploration and application of concepts that are meaningful and relevant (Donovan, Bransford, & Pellegrino, 1999).
This article describes the implementation of the flipped classroom in an introductory pediatric diagnosis course for family nurse practitioner and pediatric nurse practitioner students. Specifically, the article provides an example of this interactive teaching approach in the care of the pediatric asthma patient.
The flipped classroom was implemented in a two-credit foundational pediatric primary care nurse practitioner course that focuses on diagnosis, symptom, and illness management. Classes met for 1 hour 50 minutes weekly for 14 weeks. The course was highly rated by students in its previous lecture-style format, but changes were made in the teaching pedagogy because of concerns about poor knowledge retention; faculty in later courses found that they needed to reteach certain concepts. Some of this concern was driven by increasing numbers of students progressing directly into the nurse practitioner program from the baccalaureate program, lacking experiential memory to draw upon in advanced nursing practice.
HOW THE COURSE WAS IMPLEMENTED
Given its high prevalence in primary care and the significant burden it places on the health care system, the topic of pediatric asthma was selected for the flipped classroom. Because children with asthma often have no observable symptoms in the clinical setting and the symptoms can be similar to many other childhood conditions, faculty saw the need to reinforce the importance of a deep understanding and application of relevant history and symptoms in order to make an appropriate diagnosis and treatment plan. This type of "learning with understanding" (Donovan et al., 1999) provides a method of learning where students have an opportunity to understand and apply concepts versus memorization of facts. Only one of four classes in the course was selected to be a flipped class; the others retained the traditional lecture format. This project was approved by the university's institutional review board.
PROCEDURE
Thirty-one students participated in the course (21 family nurse practitioners and 13 pediatric nurse practitioners). The students had a mean age of 28 years (SD = 4.5 years) and 1.71 mean years of nursing experience (SD = 1.45 years). Students were surveyed at the start of the course for information related to their experience (years of RN experience, program of study, area(s) of previous nursing practice).
Faculty placed students into groups of five, providing for diversity of nursing experience within each group with the goal that students would learn from each other. Students remained in these groups throughout the semester.
Course objectives, provided to students one week prior to the course, included the following:
1. Describe the pathophysiology of asthma, including natural history and risk factors.
2. Describe the diagnostic criteria for establishing the diagnosis of asthma, including history, physical examination findings, spirometry, allergy assessment, and differential diagnoses for children of all age groups. Classify asthma severity based on National Heart, Lung, and Blood Institute (2007) guidelines.
3. Apply pharmacological management to children with asthma for acute and chronic management, including medication risks and administration techniques.
4. Describe environmental factors impacting asthma and strategies for reducing or minimizing these factors.
5. Discuss ongoing patient education and assessment of children with asthma, including the Asthma Action Plan.
6. Apply current practice guidelines for assessment and treatment to a patient scenario.
Students were expected to prepare for class by viewing five video modules (each 5 to 15 minutes in length) on pediatric asthma and reading assignments from the textbook and peer-reviewed literature. The video modules and readings covered fundamental principles of pediatric asthma including background, history, exam findings, testing, differential diagnosis, treatment, and environmental impact.
During class time, students used their laptops to take five-question pre- and postclass quizzes (identical questions) that accounted for 10 percent of their grade. Faculty had immediate access to the preclass quiz results to provide "just in time" teaching during the classroom session.
Students were presented with a pediatric clinical case that was combined with elements of simulation. The case involved a two-year-old white male child who had been "coughing for the past week." Working in groups, students collaborated to determine what relevant history of present illness and past medical history they needed to ask the parent about. Each group wrote their responses on large tablets to display to their peers. Once groups developed their questions, the questions were asked of the faculty who simulated the role of the parent in a large-group simulation. Students were expected to individually document the history as it was obtained.
Next, exam findings were presented to the students. The child was reported to have a normal physical exam, as is common in pediatric asthma. Students resumed work in their groups to develop differential diagnoses and management plans, including medication management, environmental control, additional testing, and parent education, using national asthma guidelines. Results from each group were discussed as a larger class, including the rationale behind their decisions. This provided an opportunity for faculty to give immediate feedback and clarify elements of pediatric asthma care that were unclear or confusing to students.
STUDENT EVALUATION
Students completed an evaluation seeking feedback about the value of this teaching method and its ability to improve learning. Over 80 percent of the students agreed or strongly agreed that the content helped them meet the course objectives and helped them to learn/utilize information in new ways. Students found particular benefit from interviewing the faculty member who simulated the parent. This forced them to ask questions in layman's terms in a safe environment with a focus on relevant history.
A student reported, "I really enjoyed the learning format and the opportunity to role play as nurse practitioners with a patient/parent. I think it helps me understand how to interact with a parent/child, what to prioritize and how to communicate in terms that the parent will understand and appreciate. I like how we were encouraged to refer to [our resources] and think that it's a good exercise in looking up meds and criteria on the spot. I also enjoy working with my classmates and think it sets an important foundation for collegial collaboration and teamwork." Students appreciated the mix of group work and full-class discussions versus spending the entire class in group work.
Several students commented on the amount of work required prior to class, feeling that it was too much. It is important to note that the assigned readings did not change from the previous semesters that used the traditional teaching method. Care was given to focus readings on the most relevant content and materials to use as resources (e.g., readings from the National Heart, Lung, and Blood Institute, 2007). The only additions from the previous semester were the short video modules.
The student reactions support the notion that students often come to class having not done the expected preparation, thus giving the perception of a decreased workload in a traditional classroom setting. This type of accountability regarding reading assignments was new for many of the students, highlighting the need to discuss clearly the preparation needed for the course at the onset. One student commented, "The preclass videos were organized and helpful and not overly long. I would suggest trying to minimize preclass work a little bit (it's a lot to do all the reading, watch videos, and come to class, especially for students who are working full time and in school)." Some students wanted case studies to complete at home while listening to a lecture in class. Others preferred the flipped format.
Faculty who cotaught this course noted that attendance in class was greatly improved from previous semesters. This was likely tied to the quizzes given during class, which were part of the course grade. It was determined by faculty that students had a point about too many quizzes; administering the postquiz was time-consuming and took away class time.
CONCLUSION
Educators have been called to transform the education of nurses through implementation of new pedagogies. Benner, Sutphen, Leonard, and Day (2010) recommend an integration of clinical and classroom learning to help students bridge the gap that exists between knowledge and its application to practice. The flipped classroom method used to enhance the learning and application of concepts in pediatric asthma can serve as a framework for other content areas. Further research is needed on the long-term knowledge retention of this pedagogy when compared to traditional lecture-style delivery of content through objective longitudinal measurements.
REFERENCES