Flipping the class is an active learning strategy that can promote higher-level learning in nursing education (Missildine, Fountain, Summers, & Gosselin, 2013). Bergman and Sams (2012) found that assigning prerecorded video lectures for students to view at home increased time for higher-level learning in the classroom and improved learning outcomes. Consistent with this methodology, we narrated PowerPoints for students to view at home, which allowed for application of key concepts in the classroom, shifting the focus to application of learning versus memorization.
The best educational practices support actively engaging students in the teaching-learning process, and the flipped classroom supports active learning (Billings & Halstead, 2012). The collaborative construction of knowledge in a flipped classroom promotes learning at higher cognitive levels and supports the development of clinical reasoning (Missildine et al., 2013). In a flipped classroom, students perceive themselves as more prepared to participate in class (McGowan, Balmer, & Chappell, 2014). In this process, critical thinking is supported, deeper learning occurs, and students are prepared for the complexities of clinical practice in the 21st century (Benner, Sutphen, Leonard, & Day, 2010).
METHOD
A quasiexperimental design was used to answer the following research question: What is the relationship between a flipped classroom and test scores in prelicensure baccalaureate nursing students? The theoretical framework of heutagogy was used in this study. This is an emerging pedagogy that supports the development of individual capabilities in complex environments and emphasizes the importance of turning the classroom over to the students (Bhoyrub, Hurley, Neilson, Ramsay, & Smith, 2010). This conceptual framework fosters the development of independent decision-making skills that are essential to safe clinical practice.
Approval from the institutional review board on human subjects as an exempt study was obtained prior to analyzing the preexisting data. A convenience sample of junior nursing students from a private women's college was used in this study. Students were enrolled in the same nursing course (medical-surgical), offered in the same format every semester. Participants were female, ages 20 to 35. Data were collected from all routinely scheduled tests from spring 2013 to spring 2014 (N = 215). Students enrolled in spring 2013 (n = 46) received teacher-led lectures using PowerPoint. Students enrolled in fall 2013 and spring 2014 (n = 169) were in the flipped classroom and were assigned narrated PowerPoints prior to class.
In fall 2013, as part of course orientation, a brief explanation of the instructional techniques and the rationale for flipped classroom was provided to students. PowerPoints narrated with a lecture based on content from students' textbooks were available online prior to each class. Students were instructed to listen to the narration before class time. Active learning was promoted in class by facilitating student-led group work using case studies. Questions from case studies were edited to promote increasingly complex levels of thinking. Using a rotating group leader, groups presented the answers to the class.
RESULTS
Student test scores on all scheduled course tests (four per semester) were compared before and after the flipped classroom to answer the research question: What is the relationship between a flipped classroom and test scores in prelicensure baccalaureate nursing students? Students' names were omitted on test scores to preserve confidentiality. Student test scores were entered into the Statistical Package for the Social Sciences (SPSS), Version 23. An independent samples t-test was calculated and showed a statistically significant average increase of 8.04 points after the change in instruction (p < .001). An analysis of variance was performed to compare the means of the groups and further test the hypothesis that flipping the classroom would improve test scores.
Results of the analysis of variance showed the omnibus F test was statistically significant, F(15.852), p <= .001. Post hoc tests revealed that, as hypothesized, there was a statistically significant difference in the mean test scores of students in the traditional classroom (M = 69.89) and the first semester of the flipped classroom (M = 76.58) and the second semester of the flipped classroom (M = 80.86). All students took the same tests, and the instructors remained the same for all groups.
DISCUSSION
Student test scores increased in the flipped classroom, indicating a possible relationship between the flipped classroom and test scores. Satisfaction scores initially plummeted on course evaluations and students appeared to be a bit "flipped out" by the absence of a teacher-centric classroom. Berrett (2012) and Missildine and colleagues (2013) found similar correlations with student outcomes and satisfaction. These findings, coupled with the conceptual framework of heutagogy, guided our decision to continue.
Complexity theory underpins heutagogy, and complex systems (such as nursing education) often exist on the edge of chaos and need time to self-organize and stabilize when evolving (Bhoyrub et al., 2010). This may explain the initial decrease in student satisfaction. Bolstered by the conceptual basis and the increase in test scores, we continued to use the flipped classroom in subsequent semesters with similar increases in test scores. Student satisfaction gradually increased, and the initial chaos eventually evolved into a dynamic, student-led classroom. We learned many lessons from this experience.
One lesson learned was to provide a more detailed rationale for the change in instruction. In retrospect, we could have allotted more time to the explanation. Sharing the research results was beneficial, but we learned to use the term flipped classroom with caution, as some students seemed to have preconceived notions about the concept. Using a term such as student-centered classroom seemed to elicit more favorable responses.
In the spirit of a student-centered classroom, we sought student feedback mid-semester and made selected changes. For example, students requested a return to teacher-led PowerPoints. This request did not align with the tenets of the flipped classroom, but we compromised and had collaborative discussion on portions of PowerPoints. These were student led and prompted many spontaneous minilectures that in turn sparked active discussion of key concepts. Student feedback about these discussions was positive.
Feedback about the use of group work with case studies was initially lukewarm. We thought the case studies were valuable and did not want to abandon them. Instead, we alternated them with other active learning strategies, such as role-playing scenarios, and student engagement increased. Guided by the principles of heutagogy, our instructional techniques adapted as the system evolved. Students in subsequent semesters appeared significantly more satisfied with this teaching method as compared with first semester students, with comments in evaluations such as "Narrated PowerPoints were very helpful" and "I am hoping there will be case studies to practice from in future nursing classes." As expansion of the flipped classroom continues across the nursing curriculum, student engagement and satisfaction with this method is predicted to rise.
This course was the first to implement a flipped classroom in this nursing program, which probably contributed to students' initial dissatisfaction. Since this writing, more courses have adopted the approach, and students rarely complain. In retrospect, a smoother transition may have occurred if the method had been used in multiple courses.
Future Implications
Further analysis over several semesters is needed to identify trends, including a possible effect on student attrition and National Council Licensure Examination first-time pass rates. The first cohort in the flipped classroom had a 93 percent first-time pass rate, our highest rate in many years. The flipped classroom may have contributed to this increase, although there were other concurrent curricular changes. We noted that students seemed more confident when presenting to their peers after implementing a flipped classroom. A flipped classroom may better prepare students to embrace leadership roles in practice and is a direction for further research.
Study Limitations
The data for this study were from test scores at a small, private women's college located in an urban setting. The total number of subjects was 215; subjects were all female, ages 20 to 35. Therefore, results of this study may not be generalizable to all nursing student populations. Unfortunately, only data from spring 2013 could be used as comparison for the flipped classroom (n = 46), as the test blueprint was changed in spring 2013. There is a need for further research on the flipped classroom using a control group and larger sample sizes in different geographic regions.
CONCLUSION
Trends in health care today call for a radical transformation of nursing education (Benner et al., 2010). The results of this study will help guide and advance the science of nursing education by establishing a stronger correlation between student outcomes and active learning techniques. Flipping the classroom is exciting and rewarding but can be challenging to implement, as it requires ongoing adjustments to instruction and can cause initial student dissatisfaction.
Awareness of potential student unrest and use of strategies outlined in this article may alleviate some of the student dissatisfaction when a flipped classroom is implemented. Despite these challenges, nurse educators should continue to examine their individual teaching practices critically. Evidence-based methods, as outlined in this article, can help guide the selection of pedagogy that may enhance the clinical reasoning skills of the next generation of nurses.
REFERENCES