The flipped classroom and active learning are common buzzwords in education today. Within the flipped classroom model, students listen to prerecorded lectures and complete activities, such as small case studies and assigned readings, prior to the regular class period (Kowalski & Horner, 2015; Long et al., 2012). Rather than sitting passively in a classroom while the teacher lectures or reviews PowerPoint presentations, students are engaged in activities that foster critical thinking, including in-depth case studies, group activities, and student presentations.
Benner, Sutphen, Leonard, and Day (2010) called for a radical transformation in the education of nurses. The flipped classroom and other strategies were recommended to provide increased opportunity for students to engage with content. In their seminal work, How People Learn, Bransford, Brown, and Cocking (1999) introduced cognitive educational theory, stating that, to develop competence, students must be exposed to material three times and have a deep understanding of foundational content, conceptual frameworks, and application to practice.
The contemporary flipped classroom experience and its methodology promote repeated exposure to content and its application, therefore providing a deeper understanding of important concepts. Everly (2013) and Hawks (2014) discussed the flipped classroom and active learning approaches specifically with regard to nursing students. They found that these pedagogies improved learning and student satisfaction when compared to more traditional teaching methods. Critz and Knight (2013) reported that graduate nursing students responded positively to the flipped classroom approach. In comparison to traditional lectures, student engagement was increased, and class time was spent on critical thinking exercises.
Much has been written on the flipped classroom experience, but a search of the literature revealed no publications that looked specifically at nursing students and both short- and long-term content retention utilizing the flipped classroom teaching pedagogy. We conducted a pilot study to implement and evaluate a flipped classroom course for students in a direct-entry, second-degree accelerated master's of science in nursing (AMSN) program. The purpose of this study was to compare the experience of a cohort of students who participated in a flipped classroom (intervention group) to a previous cohort, who were taught with more traditional methods (control group).
PROGRAM BACKGROUND AND COURSE DESIGN
Direct-entry AMSN students have nonnursing undergraduate degrees and complete a series of prerequisite courses prior to entering the two-year accelerated program of study. Their curriculum includes essential bachelor's and master's level nursing content with a clinical nurse leader role focus. At graduation, they are eligible to take the National Council of State Boards of Nursing licensure exam (NCLEX-RN(R)) and Clinical Nurse Leader (CNL) certification examinations (American Association of Colleges of Nursing, 2013).
In contrast to traditional nursing programs, where medical-surgical content is distributed among two to three courses, the AMSN program consolidates content into one six-credit-hour course. Students must master course content quickly, transfer learned concepts to the clinical setting, and retain content for five instructor-prepared course exams, future HESI exams, and NCLEX-RN success.
Course evaluations from the previous five cohorts revealed difficulty with sustaining interest and retaining the large amount of content covered during weekly four-hour lectures that spanned the entire semester. Students stated that they memorized content "for the test." The veracity of this statement was apparent when reviewing HESI standardized examination results. Students were frustrated with their low scores and noted the need to "relearn" the material in order to prepare for subsequent examinations.
Incorporating principles from Bransford et al.'s (1999) cognitive educational theory and research by Everly (2013) and Critz and Knight (2013), the class was redesigned to provide active learning experiences that enhanced the applications of content to the practice of critical thinking skills. Each class began with a series of multiple-choice questions that focused on basic content from the readings, online lectures, and online case studies. These questions utilized Kahoot(R), a free student response system that can be used online or via an application (app) on a tablet or smartphone. These interactive quizzes were presented in a game-like format and utilized music and timed responses.
The next two hours were spent on unfolding case studies done in groups, individually, and with the entire class. As the semester progressed, the case studies became more challenging.
Videos of nurses giving simulated reports on patients were used to practice taking and giving shift reports. Students viewed the videos and practiced the process of taking report and sorting through information to determine its importance. They had to prioritize the order patients should be seen and determine which interventions were needed for each patient.
The class ended each week with a group discussion of NCLEX-RN-style questions, utilizing either the online program Socrative(R) or Immediate Feedback Assessment Technique(R) scratch-off cards, individually or in groups. Critical thinking was practiced during the entire process, thus tying in the core principles described by Bransford et al. (1999) and Benner et al. (2010). A Facebook page was developed for the course, and the students were encouraged to post thoughtful discussions as well as questions prior to class. Facebook proved to be extremely popular and promoted interactive engagement with course content.
METHOD
Institutional review board approval was obtained for this study of student outcomes from the medical-surgical nursing course. Faculty created Likert-style surveys, for which there were no reliability or validity data, to measure student satisfaction following each class session and three months following the conclusion of the semester. A standardized medical-surgical HESI examination was given three months postcourse to measure short-term retention; the comprehensive HESI exit examination was administered prior to graduation to assess long-term retention and predict NCLEX-RN readiness. Students were required to take both HESI examinations, which were administered on a specified date and time in a computer lab.
The course pedagogy and student expectations were discussed preceding the first class period. The electronic survey that followed each flipped classroom experience focused on satisfaction with the classroom methods; the survey sent three months following the course assessed satisfaction with the active learning activities. One open-ended question asked if the respondent would change anything about the course design. Retention of content was also assessed in this timeframe utilizing the HESI medical-surgical standardized exam.
Although the program had graduated five previous cohorts that did not receive the flipped classroom pedagogy, only the most recent cohort was included in the control group for statistical analysis and comparison to closely match the sample size of the intervention group. The flipped cohort had 26 students (ages 23 to 42, M = 28 years); six students were male. Most students (n = 19) were Caucasian; three were African American, two were of Middle Eastern descent, and two were of Asian descent.
The demographics were similar for the control group, which had 2 men and 19 women (mean age, 29 years). Here again, most students were Caucasian (n = 18); two were African American, and one was of Asian descent.
RESULTS
Results from the survey results varied greatly from the beginning of the semester to the end. After the first class, 46 percent of students reported that they were "greatly satisfied" with the active teaching method. By the end of the course, overall class satisfaction was 85 percent. On two surveys, one student indicated being "greatly dissatisfied" with the flipped classroom but made no negative comments; as surveys were anonymous, it was unclear if this was the same student for the two surveys or two different students.
Students were invited to respond to the question: "If you could change anything about this particular class, what would it be?" Following the last class period, 11 of 26 students commented positively. Comments included "Loved Kahoot" and "There's nothing to change." At three months after the course ended, 91 percent of students (n = 23) agreed that the active learning methods helped prepare them for subsequent clinical experiences; 62 percent agreed they had retained "most" of the content.
When asked if the active learning methods presented were beneficial in the transfer of content from the classroom to the clinical setting, 71 percent strongly agreed or agreed, and 71 percent stated that they would choose to do an active learning or flipped classroom experience again. In addition, Facebook was found to be an excellent tool for online discussion groups. The number of interactions and the quality of the postings were a surprise.
All students in both the intervention group and control group completed the course with a grade of C or better. Medical-surgical HESI scores for the two groups were analyzed using independent t-tests with p < .05. Three months following the course, scores averaged 804 (SD = 121.6) for the control cohort and 832 (SD = 126) for the intervention group, a 4 percent increase. Even though these results were not statistically significant (two-tailed t-test, p = .423; one-tailed t-test, p = .211; unequal variances assumed), the results showed an increase in short-term content retention for the intervention group. Prior to graduation and 12 months after the course, the HESI exit scores averaged 807 (SD = 89.5) for the control group and 864 (SD = 109) for the intervention group, a 7 percent increase. These results showed a statistically significant difference between the two groups (two-tailed t-test, p = .046; one tailed t-test, p = .023; unequal variances assumed). Although the results are not generalizable because of the small sample size, students did demonstrate a significant increase in mastery of content as indicated by both examinations.
It is important to note that there was no difference in admission criteria, course content, or instructor for both cohorts, making them academically homogenous. Only the teaching method changed. Limitations to this study include a small sample size at one school of nursing with both groups consisting largely of Caucasian women.
DISCUSSION AND CONCLUSION
Multiple encounters with content promote learning and retention. Utilizing core principles of cognitive educational theory (Bransford et al., 1999), the flipped classroom allows for exposure to content before class as well as multiple encounters during the class period. This study adds to the nursing literature and suggests that the flipped classroom does indeed help promote both short- and long-term retention of key medical-surgical content.
The findings parallel the results shown by both Everly (2013) and Hawks (2014), that the flipped classroom pedagogy improved both student learning and satisfaction. Results exceeded faculty expectations. Three-month HESI scores in the intervention group increased 4 percent over the control group, and long-term content retention increased by 7 percent. Student satisfaction was high, and the use of Facebook was of high quality and extremely popular.
This study bears repeating with a larger sample and greater geographical and racial diversity. The authors plan additional research on active learning methods to incorporate even more creative ways to expose foundational content and its application to practice. Change is difficult, and teaching students to be accountable for their own learning can be a monumental task. However, it is our belief that if students are able to make the transition to a more self-directed pedagogy, they may find greater satisfaction and become more accountable for their learning.
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