Nurse educators are faced with the challenge of developing nursing students' critical thinking and complex reasoning skills while keeping pace with health care industry changes. Research has shown that a significant proportion of students lack skills in weighing evidence, analyzing and synthesizing data, and responding to real-world situations (Arum & Roska, 2011). The traditional teaching/learning pattern - in which faculty introduce new materials during class and students review the information outside of class - provides limited opportunities for practicing higher-level thinking in the classroom setting (Moravec, Williams, Aguilar-Roca, & O'Dowd, 2010).
Researchers are studying the ability of the flipped classroom pedagogical model to prepare nursing students for real-world situations. In this model, traditional classroom and homework activities are reversed: students review asynchronous video lectures and readings for homework and participate in active, group-based problem-solving activities in the classroom (Bishop & Verleger, 2013). Having students view video lectures before class allows them to engage in meaningful classroom discussions of course materials and develop higher-level thinking skills.
The flipped classroom method has had mixed results in nursing education, with higher examination scores and better student engagement, along with increased student frustration and decreased satisfaction (Missildine, Fountain, Summers, & Gosselin, 2013; Post, Deal, & Hermanns, 2015; Simpson & Richards, 2015). Harrington, Bosch, Schoofs, Beel-Bates, and Anderson (2015) found that, although the flipped classroom method was an effective strategy for baccalaureate nursing students, there were no statistically significant differences in these students' exam and overall semester scores compared to students in traditional classrooms.
Other researchers found that nursing students taking pharmacology in a flipped classroom scored higher on three unit tests than students in a traditional classroom, though there was no difference in final exam performance (Geist, Larimore, Rawiszer, & Al Sager, 2015). The current study's researchers implemented a flipped classroom model in an undergraduate nursing course in order to gauge students' perceptions of and satisfaction with the pedagogical change.
METHOD
Study approval was obtained from the university's institutional review board. A convenience sample of 49 BSN students enrolled in a gerontological nursing course at a central Texas university was recruited; 42 students participated in the research. The Student Perceptions of the Flipped Classroom Experience survey tool (Pierce & Fox, 2012) was used to collect survey data. This 10-item survey uses a 5-point Likert scale with responses ranging from strongly disagree to strongly agree. It has two subscales with internal consistency reliability ranging from .82 to .83. Three open-ended questions inquire about students' favorite and least favorite course aspects and solicit additional comments about the new format.
A grounded theory approach was used to interpret responses to the open-ended questions and categorize them into themes. Two researchers analyzed the data independently and then compared results. Categories were developed with consensus; thematic analysis was conducted by both investigators (Corbin & Straus, 2014).
On the first day of class, students received a description of the flipped classroom method and its potential benefits. They were instructed to view weekly video lectures and complete assigned readings before class. In-class activities included small group work followed by class discussion, role-playing, iclicker(R) (audience response) question-and-answer sessions, and group work using case studies. Students completed the survey at the end of the semester.
FINDINGS
Most of the 42 students were female (n = 36, 85.7 percent). Ages ranged from 21 to 60 years (M = 31.5, SD = 10.02). The sample was primarily African American (n = 17, 40.5 percent), followed by Hispanic (n = 12, 28.6 percent) and Caucasian (n = 10, 23.8 percent).
Most students (88.1 percent) agreed or strongly agreed (A/SA) that viewing the video lectures prepared them for in-class activities. When asked if viewing the prerecorded lectures was essential for successful in-class participation, 64.3 percent A/SA. However, 21.4 percent A/SA that they did not view the lecture before class. When asked if the instructor made meaningful connections between video lecture topics and class activities, 90.2 percent A/SA. This response may be due to the course materials being premapped to student learning objectives.
When asked if they were confident about their ability to address assigned topics on their final examination, 61.9 percent A/SA. About half of the students (52.4 percent) A/SA that they wished more instructors used the flipped classroom model. When asked if they enjoyed viewing video lectures more than live lectures, 78.1 percent A/SA. All students agreed that student participation was required for in-class activities.
Student responses to the question about their favorite aspects of the flipped classroom revealed two themes: in-class activities (including group work) were highly regarded, and the new format's benefits were understood. Students enjoyed the group case studies and presentations and felt they were good reviews for exams. Students commented, "I enjoyed the classroom presentations[horizontal ellipsis][this is the] first time I've ever enjoyed group work," "[I was] able to do activities [by] applying information," "the instructor had us do activities to promote learning," and "class time was for practical learning." Students also noted increased student engagement.
Two themes emerged from the analysis of responses to the question about the least favorite aspects of the flipped classroom: some missed traditional lectures, and some disliked group work. One student commented: "I feel this type of class format would be better for new college students. As nursing students, we are accustomed to listening to lectures and I think most of us learn best that way." Another student indicated a preference for hearing from the instructor instead of other students. Group work made some students feel anxious and frustrated. Two of the least favorite group work aspects were giving presentations and dealing with nonparticipating members.
The last open-ended item asked students to comment on the flipped classroom format. Two themes emerged: appreciating the ability to review information and questioning the format's appropriateness for other courses. Students commented: "When I wanted to review for exams or know what the teacher wanted to focus on, I would just relisten to the lecture. I really enjoyed it!" and "It was nice because you get a lecture, but you get it twice with the presentations and other class work, in a different point of view."
DISCUSSION
A degree of student buy-in is required for successful implementation of the flipped classroom, especially when students have not been exposed to it before. The initial student orientation proved successful in securing buy-in. Although students' experiences were positive overall, more studies are needed to identify ways to meet the needs of students who do not function well in a nonpassive classroom setting.
Although most students commented positively about group work, it was also the least favorite aspect for several students. Group work can be challenging due to inconsistent member participation, varied learning styles, and discomfort with the activity. Some students naturally contribute more than others do, resulting in interaction and status inequalities (Cohen & Lotan, 2014). Expecting less of certain students may cause them to interact less. Therefore, in future flipped classrooms, instructors should ensure that students are prepared for group work as it requires specific norms, rules, and skills. Instructors should provide clear group work rules and requirements and measure individual participation, as students who do not participate learn less than if they had interacted more (Cohen & Lotan, 2014). In addition, enacting strategies to ensure fair workload distribution and provide a safe learning environment could help alleviate some of the students' frustrations with group work.
Additional research is also needed to determine which undergraduate nursing courses are suited to the flipped classroom format. Student responses indicated that a course's level of difficulty should be taken into account when considering the new format, though they did not indicate whether they thought more or less difficult courses were appropriate.
The successes experienced in flipping the gerontological nursing course may be partially attributable to the nature of the course and the work required. For example, faculty observed strong student engagement in activities of administering the Mini Nutritional Assessments, pain assessments, the Geriatric Depression Scale, Hendrich II Fall Risk Assessments, communication exercises, and assessments to distinguish normal aging changes from disease processes. Although this study's sample, students enrolled in a gerontology course at a North Central Texas BSN program, limits the generalizability of the findings to other nursing courses or programs, the results add to the existing literature on the use of the flipped classroom in nursing education.
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