The Flipped Learning Approach in Nursing

Education: A Literature Review

Carmen Rosa Presti, DNP, ARNP, ACNP-BC

A
ABSTRACT ctive learning has been defined as “any instructional
Background: This integrative review examines the ap- method that engages students in the learning process”
plication of the pedagogical methodology—the flipped (Prince, 2004, p. 223). In an effort to increase the
classroom—in nursing education. Method: A literature number of students who receive undergraduate science, tech-
search of the CINAHL, ERIC, and the National Library of nology, engineering, and mathematics degrees, the Executive
Medicine (PubMed and MEDLINE) databases was con- Office of the President of the United States commissioned a
ducted, using the following key words: flipped classroom, report resulting in recommendations to educators to enlist class-
inverted classroom, and nursing education. Results: Results room approaches that engage students in active learning (Presi-
of a literature search yielded 94 articles, with 13 meeting dent’s Council of Advisors on Science and Technology, 2012).
the criteria of the flipped classroom approach in nursing The President’s Council (2012) found that “substantial empiri-
education. Themes identified include the theoretical un- cal literature demonstrates that alternative models of instruc-
derpinning, strategies for implementation of a flipped tion can achieve many important learning outcomes more ef-
classroom, and student satisfaction with and outcomes of fectively than current practice” (p. 83). The flipped classroom
the flipped classroom approach. Conclusion: Syntheses of approach is one such method to enhance active learning. Bishop
the findings indicate that the flipped classroom approach and Verleger (2013) validated the President’s Council’s findings
can yield positive outcomes, but further study of this meth- in their survey of flipped classroom approaches and efficacy in
odology is needed to guide future implementation. [J Nurs general education.
Educ. 2016;55(5):252-257.] Bergmann and Sams (2014), who are recognized authorities
on the flipped classroom methodology, approved of the defini-
tion of the flipped, or inverted, classroom as being:
a pedagogical approach in which direct instruction moves
from the group learning space to the individual learning space,
and the resulting group space is transformed into a dynamic,
interactive learning environment where the educator guides
students as they apply concepts and engage creatively in the
subject matter. (p. 1)
In the flipped classroom model, content that was tradition-
Received: July 15, 2015 ally presented in the classroom setting, such as face-to-face lec-
Accepted: March 1, 2016 ture, is assigned before class as homework, allowing class time
Dr. Presti is Assistant Professor of Clinical, School of Nursing and for active learning, using case studies, laboratories, games, and
Health Studies, University of Miami, Coral Gables, Florida. simulation-based learning, or experiments, under the guidance
The author thanks Dr. Joseph De Santis for his assistance in the manu- of the instructor (Herreid & Schiller, 2013).
script preparation. The Institute of Medicine’s landmark report, Crossing the
The author has disclosed no potential conflicts of interest, financial Quality Chasm (2001), also emphasized the need for new
or otherwise. health professions educational models as essential in pre-
Address correspondence to Carmen Rosa Presti, DNP, ARNP, ACNP-BC, paring the health care workforce of the future to provide
Assistant Professor of Clinical, School of Nursing and Health Studies, Uni- evidence-based care, to work collaboratively on multidis-
versity of Miami, 5030 Brunson Drive, Suite 307, Coral Gables, FL 33146- ciplinary teams, and to manage complex patient–clinician
3850; e-mail: [email protected]. relationships. The Institute of Medicine’s report The Fu-
doi:10.3928/01484834-20160414-03 ture of Nursing: Leading Change, Advancing Health (2010)

252 Copyright © SLACK Incorporated

 PRESTI

also examined the nursing workforce’s ability to meet the RESULTS

demands of a reformed health care system, examining mul-
tiple components of the profession, including nursing educa- Initial key word searches resulted in the identification of
tion. A conclusion of the study indicated “the ways in which 94 articles. Of these, 13 articles met the inclusion and exclu-
nurses were educated during the 20th century are no longer sion criteria. Two articles discussed the theoretical framework
adequate for dealing with the realities of health care in the underpinning this teaching strategy, and 11 articles described
21st century” and “nursing curricula needs to be reexamined, the implementation of the flipped classroom approach in under-
updated, and adaptive enough to change with the patients’ graduate, graduate, and postgraduate nursing education.
changing needs and improvements in science and technol-
ogy” (Institute of Medicine, 2010, p. 2). The results of a mul- Themes
tiyear study of nursing education, Educating Nurses: A Call In 1997, Harvard professor Eric Mazur developed a teaching
for Radical Transformation, echoed those findings (Benner, strategy called peer instruction, which involved having students
Sutphen, Leonard, & Day, 2010). Benner et al. (2010) called in his physics classes prepare for class by completing preclass
for shifts in nurse educators’ approaches to foster student assignments so they were able to engage with the instructor and
learning, emphasizing teaching for a sense of salience, sit- peers during class time (Crouch & Mazur, 2001). This strat-
uated cognition, and action and the importance of clinical egy is credited as the initial iteration of the flipped classroom
reasoning (students’ ability to reason as a clinical situation approach. Subsequently, educators Jon Bergmann and Aaron
changes). Those aforementioned reports heralded the need Sams gained recognition for introducing the flipped learning
for a change in the delivery of professional education from a approach in 2007 to their high school chemistry students (Sprin-
solely traditional and passive approach to teaching and learn- gen, 2013). Although this teaching strategy has been used in
ing, to dynamic and multifaceted methodologies, with the other disciplines, national initiatives indicate that it is time for
goals of engaging students to be active learners and critical nurse educators to consider exploring the topic fully. Therefore,
and creative thinkers. The flipped classroom methodology is an important component of this novel teaching strategy includes
one such approach to achieve those objectives. a discussion of its theoretical underpinnings. Table A (available
The purpose of the current literature review is to discover in the online version of this article) presents two articles that
what is known about the use of the flipped classroom approach discuss such theoretical underpinnings. Challenges in enhanc-
in undergraduate, graduate, and postgraduate nursing educa- ing both learner satisfaction and objective evaluation measures
tion. of using the flipped learning approach emerged as a main theme
of the review. An additional group of articles described the pro-
METHOD cess of introducing the new teaching model to nursing students
and faculty, coupled with practical strategies for the implemen-
Grove, Burns, and Gray (2013) described the process of tation of the flipped classroom approach (Table B; available in
writing a literature review as being similar to replicating a the online version of this article).
systems model, with the literature search reflecting the initial
input stage, processing the literature as the secondary through- Theoretical Frameworks
put stage, and writing the literature review as the final output Hawks (2014) proposed that the flipped classroom method-
stage, with the quality of the input and throughput determin- ology incorporates both behavioral and constructivist learning
ing the quality of the output. That methodology was used to theories, with the behavioral learning theory akin to traditional
structure and organize the review. Databases searched includ- classroom instruction (lectures, tutorials, and teacher-centered
ed CINAHL®, ERIC™, and the National Library of Medicine instruction). Conversely, the constructivist learning theory “is
(PubMed® and MEDLINE®). Key words used to search the based on the primary tenet that individuals use personal experi-
databases were flipped classroom, inverted classroom, and ence to construct and understand knowledge and reflection to
nursing education. create meaning” via collaboration with students and teachers
Articles published from January 2010 to September 2015 who are “actively engaged rather than passive recipients of lec-
were sought to glean the most recent literature. Criteria for in- ture content” (Hawks, 2014, p. 265).
clusion encompassed articles describing the use of the flipped Alternatively, Bhoyrub, Hurley, Neilson, Ramsay, and Smith
classroom approach in undergraduate, graduate, and postgradu- (2010) presented heutagogy, which is “a self-determined approach
ate academic nursing education. Articles that did not meet the to learning” that is surmised to strengthen undergraduate nurs-
inclusion criteria described the use of the flipped classroom ap- ing students’ practice-based learning (p. 323). Bhoryrub et al.
proach outside of the field of nursing or described the use of the described heutagogy as an evolutionary leap from andragogy—
flipped classroom approach for teaching continuing education the adult-based learning construct—because it seeks to promote
for licensed practitioners. Studies related to medical education learning through personal experience, with the “learner being
were considered to be outside the field of the nursing specialty central to the process” (p. 323). Although those authors do not
because of the known obstacle of profession-specific education discuss specific teaching strategies that would apply the theory
and socialization (Langendyk, Hegazi, Cowin, Johnson, & Wil- of heutagogy, the flipped classroom methodology engages stu-
son, 2015), with the subsequent lack of data regarding the simi- dents to be self-directed, which is the type of learning extolled
larities and differences of the disciplines and thus the legitimacy by heutagogy. Heutagogy also promotes active learning in
of applying findings from one field to another. a dynamic, nonlinear format, more realistically mirroring the

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FLIPPED CLASSROOM

challenges faced by nursing students in the health care setting. sults (p = .57), and the difference between groups was not sta-
The flipped learning approach caters to this type of nontradi- tistically significant. Mean course grades between groups were
tional approach to learning. also analyzed with the analysis of covariance technique and
comparable results were found, with no significant difference
Guides for Implementation of the Flipped Classroom in grades between groups (p = .96). Harrington et al. (2015)
Approach in Nursing Education interpreted the findings as evidence that the flipped classroom
Five of the articles reviewed described strategies for flip- approach was successful in showing student mastery of course
ping a nursing classroom. Schlairet, Green, and Benton (2014) content, as both groups averaged 86.3% as a final grade. Al-
described the process for converting a traditional face-to-face though this may be a reasonable analysis of the outcomes, it is
undergraduate nursing Fundamental Concepts of Nursing difficult to ascertain whether the difference in the two teaching
course into a flipped approach. Students were expected to re- strategies was substantial enough to cause a change in student
view voiceover PowerPoint® lectures and complete assigned behavior because the flipped teaching strategy intervention was
textbook readings independently. Classroom activities included not thoroughly described. Also, variability among the faculty
peer instruction, small-group work, quizzes with faculty de- used to implement the strategy limits the standardization of the
briefing of answers and rationales, and simulation-based learn- study and its impact.
ing scenarios. Administrative and curriculum challenges faced Burden, Carlton, Siktberg, and Pavlechko (2015) detailed
by faculty during the pilot attempt and its subsequent iteration the 2-year process of transitioning a traditional face-to-face
were described thoroughly. The article by Schlairet et al. (2014) psychiatric–mental health course to a flipped classroom, with
is a guide for faculty, and its reflections may support the creation a total of 359 students going through the course. Those authors
of future flipped courses, although a lack of student feedback, did not indicate whether the course was at an undergraduate, a
a pretest–posttest, or comparison of previous traditional course graduate, or a postgraduate level. Preclass work included work-
iterations with the flipped approach is significantly absent. sheets, assigned readings, YouTube videos, and concept map-
Hawks (2014) summarized the background of the flipped ping. In-class activities involved small-group work, role-play,
classroom approach; discussed its theoretical underpinnings; and concept map creation. A novel integration of the clinical
reviewed the flipped approach used in nursing, medical, and component and learning objectives of the course included the
pharmacy education; and provided guidelines on how to flip a use of virtual simulation and volunteer patients, which provided
classroom. Although Hawk’s stated aim was to guide the imple- students with the time and setting to practice interview tech-
mentation of the flipped classroom approach in nurse anesthesia niques and apply learned concepts in a simulated setting. In
educational programs, the recommendations are general in na- assigned reflective journal entries, students stated that they felt
ture and can be applied to any curriculum, favorably widening better prepared for class because of the preclass work activi-
the article’s scope and applicability. Subsequently, this results ties. However, due to the lack of objective measurement of the
in a deficiency of specific recommendations tailored to flipping impact of the intervention, such as comparison with previous
a specialized nursing anesthesia educational program—an iterations of the course or the anonymous survey of students’
unmet implied goal of the article. perception of the flipped approach, the significance of the stu-
Harrington, Bosch, Schoofs, Beel-Bates, and Anderson dents’ comments is impossible to validate. With the consider-
(2015) examined the use of the flipped classroom approach, able sample size and the longitudinal design of the study by
using a convenience sample of two groups of undergraduate Burden et al. (2015), it is unfortunate that data were not gath-
nursing students (n = 82) in a medical–surgical course, with ered to validate the effectiveness of the interventions. Nonethe-
each group receiving two different teaching interventions. That less, that study thoroughly described the step-by-step process
study used a randomized, experimental design, which is gener- of implementing a flipped approach and is an effective guide
ally considered the gold standard in inferring causal relation- for transitioning courses that encompass both the clinical and
ships (Polit & Beck, 2012), and was constructed meticulously. classroom components due to the detailed description of the as-
Students were randomly assigned to one of two cohorts—the signed preclass work, the in-class activities, and the inclusion of
traditional face-to-face or the flipped classroom—with identi- clinically based activities.
cal content, examinations, and assignments. Although study
designers controlled for variability by standardizing outcome Enhanced Student Satisfaction With the Flipped
measures, the faculty that was used to implement the teaching Classroom Approach in Nursing Education
varied among groups, which could have skewed the effective- Critz and Knight (2013) reported on a graduate-level nurse
ness and outcomes. The article provides scant description of practitioner program in which students in an existing pediat-
the activities used in the flipped classroom cohort, other than ric course indicated that they felt uninvolved. The course was
one mention of “experiential activities designed to guide stu- consequently converted into a flipped classroom, and they de-
dents in the recognition of salient and relevant changes in cli- scribed the faculty preparation, assignments, in-class activities,
ent situations across time” (Harrington et al., 2015, p. 179). A technological demands, and subjective student feedback. Stu-
multivariate analysis of covariance technique was applied to the dents were polled at the end of the course (n = 20) in regard to
results of examinations, quizzes, and specific knowledge and several components of the flipped classroom strategies used. An
application questions. The examinations and quizzes yielded no anonymous 10-item survey was used, with students being able
significant difference between the two cohorts (p = .92). The to rate each component on a 5-point Likert scale, ranging from
specific knowledge and application questions had similar re- extremely worthwhile to not at all worthwhile. The majority of

254 Copyright © SLACK Incorporated

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students reported that the content, assignments, activities, and to-face format to a hybrid format. The impact of this shift and
quizzes were worthwhile and many wrote positive comments the difference in students’ progression through the curriculum
regarding the course. Thus, the goal to increase student satis- (sophomores versus juniors) may or may not have affected the
faction in the course was met. The Critz and Knight article did students’ perceptions of the flipped approach and was not ad-
not include the statistical significance of the change in attitude dressed by the authors.
toward the course or the increase in mastery of course content,
compared with previous course iterations. Improved Examination Scores and Diminished
Similarly, Schwartz (2014) reformatted a statistics course for Student Satisfaction With the Flipped Classroom
nursing students (n = 12) in a postgraduate Doctor of Philosophy Approach in Nursing Education
program from a traditional model to the flipped classroom model. Team-based learning was concomitantly introduced to stu-
The article described the assignments, activities, hardware and dents (n = 80) with a flipped classroom approach in two se-
software challenges faced, and the staff that was needed to sup- quential undergraduate fundamental nursing courses (Ratta,
port the conversion of a statistics course. Students were asked 2015). Team-based activities, assignments, the use of lecture-
to complete two anonymous questionnaires rating the impact capture software, and outcome measures are described in the
that the flipped approach had on learning; one questionnaire was article. Lecture capture is a technology that allows the previ-
completed during the third week and the second was complet- ously recorded classroom audio and video to be downloaded
ed during the last month of the course. Students agreed that the digitally by students in a variety of formats (Educause Learning
flipped approach helped to increase their understanding of the Initiative, 2008). Initial subjective feedback from most students
course, and the students had favorable views of the activities and was negative, and Ratta (2015) did not detail the aspects of the
assignments, preferring the flipped format to the traditional for- course that students found undesirable, which bears the ques-
mat. An unannounced pretest was administered on the first day of tion: Were students unhappy with the flipped approach or team-
class, and an identical posttest was given on the last day of class. based learning? In contrast, students’ scores on standardized ex-
Although scores increased from 28% to 75%, statistical signifi- aminations were higher than those from previous classes (Ratta,
cance was not reported, and the study lacks comparison of course 2015). This underscores Benner’s et al. (2010) well-known ca-
proficiency between the traditional face-to-face course and the veat that “student satisfaction may not be a good indicator of
converted flipped classroom approach. learning” (Ratta, 2015, p. 3). A limitation of Ratta’s study is a
The study by Simpson and Richards (2015) described the lack of statistical data and significance of the increase in exami-
transformation of an undergraduate population health course nation scores, compared with previous classes. Also, because
from a traditional model to a flipped modality as part of a cur- two interventions were introduced (flipping the classroom and
riculum revision. Two cohorts of students were involved— team-based learning), it is impossible to distinguish which of
juniors (n = 64) and sophomores (n = 93). The juniors were the two, or a combination of the two methods, positively affected
enrolled in the traditional course, which was converted to a test scores.
flipped design. The sophomores participated in an updated Missildine, Fountain, Summers, and Gosselin (2013) used
and transformed version of the course, which was newly pre- a quasi-experimental design study of students (n = 589) in
sented in the sophomore year as a flipped format. Preclass two undergraduate adult health courses over a period of three
work, such as voiceover PowerPoint lectures, teaching vid- semesters to compare three approaches to teaching—lecture
eos, online modules, and text readings were required. In-class only, lecture plus lecture capture, and lecture capture using
activities encompassed case studies, Web quests, videos with the flipped classroom approach. Flipped classroom activities
response time, and group-developed presentations. The term included simulation case studies, games, and other exercises,
Web quests was not defined by the authors. To evaluate the ef- which were not described. A faculty-developed, 16-item ques-
fectiveness of the intervention, the authors used two surveys— tionnaire, with good internal consistency (Cronbach’s alpha
end-of-semester course evaluations, which are provided at the .98), was used to assess student satisfaction on a 4-point Lik-
university level to gauge general student comments regarding ert scale, with higher scores indicating greater satisfaction.
the effectiveness of the course and instructor, and a faculty- Data analysis revealed that students in the lecture capture
created survey targeting student appraisal of the flipped course with flipped classroom approach cohort were significantly
design. Paired t tests were used to measure the results of the less satisfied (p , .001) with the course than students in the
course evaluations, and no statistical difference was found be- lecture only and lecture plus lecture-capture groups. The sec-
tween the traditional and flipped design scores. The student ond prong of the evaluation of the teaching methods was to
survey indicated that students perceived greater flexibility to compare the differences in mean examination scores. This was
control the pace of instruction, the flipped design enhanced conducted appropriately, with a one-way analysis of variance,
active learning and student engagement, and the course design which demonstrated a significant difference in scores related
had an appropriate balance of online work and in-class ac- to teaching methods (p , .001). The flipped approach with
tivities. Although the students claimed increased satisfaction lecture-capture group had higher average examination scores,
with the flipped course, Simpson and Richards (2015) did not compared with the lecture only (p , .001) and lecture plus
state whether the flipped classroom survey was anonymous, lecture-capture groups (p , .003). The findings of Missildine
which is an important caveat when addressing survey results. et al. (2013) echo the aforementioned conclusions by Benner
Also, the courses underwent a shift not only from a traditional et al. (2010) and Ratta (2015) regarding student satisfaction—
content delivery to a flipped classroom, but also from a face- that is, it may not correlate with learning.

Journal of Nursing Education • Vol. 55, No. 5, 2016 255

FLIPPED CLASSROOM

DISCUSSION cluded in the current review do not examine the outcome

measures to validate the use of the teaching strategy. Further
The current literature review demonstrates the state of the studies are warranted to substantiate the flipped classroom
science of the flipped learning approach in nursing educa- approach in nursing education as an effective teaching meth-
tion. Although learning theories that buttress the pedagogy are odology.
evolving, further exploration of these theories are needed to
strengthen the framework of the teaching strategy. The litera- REFERENCES
ture presented shows that the flipped classroom strategy may Benner, P., Sutphen, M., Leonard, V., & Day. L. (2010). Educating nurses:
be effective in promoting active learning by increasing student A call for radical transformation. San Francisco, CA: Jossey-Bass.
engagement and self-efficacy in the academic setting. It also Bergmann, J., & Sams, A. (2014). Flipped learning: Gateway to student
engagement. Arlington, VA: International Society for Technology in
demonstrates that student satisfaction may be inversely related
Education.
to improved performance, but although student examination Bhoyrub, J., Hurley, J., Neilson, G.R., Ramsay, M., & Smith, M. (2010).
scores improved, students may not approve of the new methods Heutagogy: An alternative practice based learning approach. Nurse
of teaching and may be wary of changes to curriculum delivery. Education in Practice, 10, 322-326.
Few studies exist on the flipped classroom approach in nurs- Bishop, J., & Verleger, M.A. (2013, June). The flipped classroom: A survey
of the research. Paper presented at the 120th ASEE Annual Conference
ing education, and only one study statistically validates its value & Exposition, Atlanta, GA. Retrieved from http://www.asee.org/public/
in improving examination scores. The current literature review conferences/20/papers/6219/view
serves to make the following recommendations: Burden, M.L, Carlton, K.H., Siktberg, L., & Pavlechko. G. (2015). Flipping
l Further development of the theoretical underpinnings of the classroom: Strategies for psychiatric–mental health course. Nurse
Educator, 40, 233-236.
the flipped classroom approach in nursing education is merited.
Critz, C.M., & Knight, D. (2013). Using the flipped classroom in graduate
l One study found that the flipped classroom teaching strat-
nursing education. Nurse Educator, 38, 210-213.
egy has been shown to improve student self-efficacy, increased Crouch, C.H., & Mazur, E. (2001). Peer instruction: Ten years of experience
student engagement, and improved examination scores in non- and results. American Journal of Physics, 69, 970-977.
nursing general education and college-level courses (Herreid & Educause Learning Initiative. (2008). 7 things you should know about
lecture capture. Retrieved from http://net.educause.edu/ir/library/pdf/
Schiller, 2013). Thus, in designing and implementing a flipped ELI7044.pdf
classroom strategy for nursing education, the examination of Grove, S.K., Burns, N., & Gray, J. (2013). The practice of nursing research:
the methods used successfully by other disciplines should be Appraisal, synthesis, and generation of evidence (7th ed.). St. Louis,
considered. MO: Elsevier Saunders
l Sams and Bergmann (2013) clarified that not all con-
Hanson, J. (2016). Surveying the experiences and perceptions of under-
graduate nursing students of a flipped classroom approach to increase
tent lends itself to flipping, such as courses that convey large understanding of drug science and its application to clinical practice.
amounts of factual content. With this caveat in mind, nursing Nurse Education in Practice, 16, 79-85.
faculty should be selective in identifying content that is best Harrington, S.A., Bosch, M.V., Schoofs, N., Beel-Bates, C., & Anderson,
suited for the flipped approach. K. (2015). Quantitative outcomes for nursing students in a flipped class-
room. Nursing Education Perspectives, 36, 179-181.
l Lack of quantifiable, significant changes in nursing stu-
Hawks, S.J. (2014). The flipped classroom: Now or never? AANA Journal,
dents’ knowledge, skills, and attitudes with the flipped learning 82, 264-269.
approach is evident in this review. Consequently, the flipped Herreid, C.F., & Schiller, N.A. (2013). Case studies and the flipped class-
learning approach in nursing education needs further validation room. Journal of College Science Teaching, 42(5), 62-67.
Institute of Medicine. (2001). Crossing the quality chasm: A new health sys-
and study before it can be recommended as an effective teach-
tem for the 21st century. Washington, DC: National Academies Press.
ing strategy. Institute of Medicine. (2010). The future of nursing: Leading change, ad-
vancing health. Washington, DC: National Academies Press.
LIMITATIONS Langendyk, V., Hegazi, H., Cowin, L., Johnson, M., & Wilson, I. (2015).
Imagining alternative professional identities: Reconfiguring profession-
al boundaries between nursing students and medical students. Academic
The current literature review has several limitations. The Medicine, 90, 732-737.
articles selected in this review excluded those from medical Mattis, K.V. (2014). Flipped classroom versus traditional textbook instruc-
education, which possibly could have further elucidated this tion: Assessing accuracy and mental effort at different levels of mathe-
topic. Also excluded were studies from general K-12 education matical complexity. Technology, Knowledge and Learning, 20, 231-248.
Missildine, K., Fountain, R., Summers, L., & Gosselin, K. (2013). Flip-
and academic education outside of nursing, where a plethora of
ping the classroom to improve student performance. Journal of Nursing
flipped classroom articles have been written and examples of its Education, 52, 597-599.
efficacy have been expounded (Bishop & Verleger, 2013). Due Patterson, B.J., Geist, M.J., Larimore, D., Rawiszer, H., & Al Sager, A.W.
to the scarcity of articles that met the inclusion criteria for the (2015). Flipped versus traditional instruction and achievement in a bac-
current review, the articles selected are based on students from calaureate nursing pharmacology course. Nursing Education Perspec-
tives, 36, 114-115.
various levels of nursing education, which may hinder appro- Polit, D.F., & Beck, C.T. (2012). Nursing research: Generating and assess-
priate comparison of findings. ing evidence for nursing practice (9th ed.). Philadelphia, PA: Lippincott
Williams & Wilkins.
CONCLUSION President’s Council of Advisors on Science and Technology. (2012). Report
to the President: Engage to excel: Producing one million additional col-
lege graduates with degrees in science, technology, engineering, and
Although the literature may describe the implementation mathematics. Retrieved from https://www.whitehouse.gov/sites/default/
of the flipped classroom approach, most of the articles in- files/microsites/ostp/pcast-executive-report-final_2-13-12.pdf

256 Copyright © SLACK Incorporated

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Prince, M. (2004). Does active learning work? A review of the research. Schwartz, T. (2014). Flipping the statistics classroom in nursing education.
Journal of Engineering Education, 93, 223-231. Journal of Nursing Education, 53, 199-206.
Ratta, C.B. (2015). Flipping the classroom with team-based learning in un- Simpson, V., & Richards, E. (2015). Flipping the classroom to teach population
dergraduate nursing education. Nurse Educator, 40, 71-74. health: Increasing relevance. Nurse Education in Practice, 15, 162-167.
Sams, A., & Bergmann, J. (2013). Flip your students’ learning. Educational Springen, K. (2013). Flipping the classroom: A revolutionary approach to
Leadership, 70(6), 16-20. learning presents some pros and cons. School Library Journal, 59(4),
Schlairet, M.C., Green, R., & Benton, M.J. (2014). The flipped classroom: 23. Retrieved from http://www.slj.com/2013/04/standards/flipping-the-
Strategies for an undergraduate nursing course. Nurse Educator, 39, classroom-a-revolutionary-approach-to-learning-presents-some-pros-
321-325. and-cons/

Journal of Nursing Education • Vol. 55, No. 5, 2016 257

 

Table A
Literature Review of Theoretical Underpinning Articles Pertaining to the Flipped Classroom Approach in Nursing Education

Study, Year Purpose Type of Study Sample Measurement Treatment Results Findings

Bhoyrub, Introduced the Theoretical None None Conceptual None Heutagogy is

Hurley, educational concept underpinnings of potentially an
Neilson, framework of heutagogy and effective
Ramsay, & heutagogy for comparison with framework to
Smith, possible current incorporate
2010 application to approaches, into nursing
nurse education challenges, and education
applications
Hawks, 2014 Introduced the Literature None None Overview of t h e None Nurse
flipped review flipped classroom anesthesia
classroom model; education may
approach and constructivist and benefit from
possible behavioral the application
implementation theories; brief of the flipped
in nurse review of classroom
anesthesia evidence in approach
education nursing, medical,
and pharmacy
education;
guidelines for
implementing the
flipped classroom
approach
 
Table B
Literature Review of the Flipped Classroom Approach in Nursing Education
 
 
Study, Year Purpose Type of Study Sample Measurement Treatment Results Findings Limitations

Burden, Carlton, Strategies to flip Descriptive Convenience Journal entries, Textbook-assigned Journal entries Active No anonymous
Siktberg, & the classroom to sample of student comments readings, YouTube reflect involvement and survey of
Pavlechko, 2015 promote a variety nursing students videos, concept consistent better effectiveness of
of learning (n = 359) mapping, Web sites themes preparation for intervention,
outcomes enrolled in a as preclass work; regarding the class reported in lack of
psychiatric– classroom activities: flipped reflective statistical data
mental health concept mapping, approach, with journals and significance
course from small- group students of intervention
2012-2014; activities, role- play, feeling better
sample does not virtual simulation, prepared for
specify whether telepsychiatry class and more
undergraduate management visits involved in
or graduate class
Critz & Knight, Used the flipped Descriptive Convenience 10-item online Voiceover Majority of Students were Lacks analysis of
2013 classroom model sample of survey measuring PowerPoint® students state positive about whether flipped
to engage students graduate satisfaction with presentations, videos, case scenarios, the flipped approach affects
in new and students (n = 20) t h e flipped reading assignments, student classroom mastery of
meaningful ways enrolled in two classroom, using and online quizzes as lectures, out- approach material,
pediatric courses a Likert scale preclass work; of-class comparison of
in a family nurse classroom activities: readings, and method versus
practitioner case studies, role- content were traditional
program play, group problem worthwhile content delivery
solving, student
presentations
Patterson, Geist, Comparison of Quasi- Convenience Identical unit tests Not described All three unit Flipped No description of
Larimore, content knowledge experimental sample of two (three) in both tests showed methodology activities used
Rawiszer, & Al in a traditional quantitative cohorts of cohorts and a significantly showed during the
Sager, 2015 lecture course undergraduate standardized higher test knowledge gains flipped
versus a flipped nursing students Health Education scores in the in three of four intervention, lack
classroom course enrolled in a Services, Inc. flipped cohort examinations of report of
pharmacology (HESI™) final ( p < .00), final students’
course using a examinaiton, HESI perceptions of
control group informal examination t h e flipped
(n = 40) and questionnaire showed no classroom
treatment group statistical approach
(n = 46) difference
between
groups;
questionnaire
results not
stated
 
Table B
Literature Review of the Flipped Classroom Approach in Nursing Education
 
Study, Year Purpose Type of Study Sample Measurement Treatment Results Findings Limitations

Hanson, 2016 Evaluate the impact Descriptive Purposive Online, 10-item Voiceover lectures Students Students did not The poor response
of the flipped sample of Questionnaire, with (eLectures), lecture reported verbalize rate (13%) may
approach on undergraduate verbal response format, quizzes, peer increased significant not have yielded
the application of nursing students and open ended discussion, teacher understanding benefits in the an accurate
lecture content to recruited from a items discussion, and case (29%), wider flipped evaluation of the
clinical practice pharmacology studies and deeper classroom intervention;
course in 2013 thinking approach participant bias
(n = 187) and (14%), and a cannot be
2014 (n = 220) preference for excluded; lacks
eLecture due analysis of
to the ability whether the
to replay it approach affects
digitally mastery of
(11%); material,
conflicting comparison of
commitments method versus
were reported traditional
as reasons why content delivery
some students
did not attend
workshops and
activities
(16%);
comments
indicated a
preference for
instructional
learning (13%)
Harrington, Compared Experimental Convenience Examination Group with No statistical Mastery of Sparse
Bosch, learning outcomes sample of questions, quiz traditional face-to- significance content the same description of
Schools, of flipped versus undergraduate scores, and face lectures, found in with the activities used
Beef-Bates, traditional students (n = 82) semester overall compared with t h e scores traditional during flipped
& Anderson, pedagogy enrolled in a grades were flipped approach between versus flipped intervention
2015 medical–surgical analyzed using group, which groups classroom
nursing course multivariate received experiential approach
analysis of activities
covariance and
analysis of
covariance
techniques

 
Table B
Literature Review of the Flipped Classroom Approach in Nursing Education

Study, Year Purpose Type of Study Sample Measurement Treatment Results Findings Limitations

Mattis, 2014  Compared Quasi- Convenience Pretest–posttest, Control group: Significant Flipped Students in the
learning outcomes experimental sample of including the visual-only increase in approach experimental
and mental effort volunteer Perceived Mental instruction, textbook accuracy increased math group did not
of flipped versus undergraduate Effort Rating work; experimental found at accuracy at have ability to
traditional nursing students Scale with each group: instructional moderate moderate levels review
pedagogy within (n = 46) problem, results video levels of of complexity instructional
the context of instructed on analyzed using complexity, no and decreased videos, whereas
three levels of basic algebra analysis of significant mental effort at the control
content concepts variance and effects of higher levels of group had the
complexity Bonferroni treatment on complexity ability to reread
corrections mental effort; materials;
significant intervention
decrease in based solely on
use of mental one 13-minute
effort on video may limit
levels of high applicability
complexity
between pre-
and posttest
Missildine, Determined the Quasi- Convenience Comparable Three approaches Significant Higher Sparse
Fountain, effects of the experimental sample of examination items were evaluated: differences examination description of
Summers & flipped undergraduate and a 16-item lecture only, according to scores among activities used
Gosselin, 2013 classroom baccalaureate survey, using a lecture plus t h e method t h e flipped during the
approach on nursing students Likert satisfaction lecture-capture of teaching, classroom flipped
examination (n = 589) scale, with backup, lecture average cohort, although intervention
averages and enrolled in two internal reliability capture plus examination students w e r e
satisfaction courses—Adult assessed via flipped classroom scores significantly less
Health I and Cronbach’s alpha approach using significantly satisfied with the
Adult Health .98 simulation case higher in flipped
II— over three studies, games t h e flipped classroom
semesters classroom approach
approach,
significant
differences in
satisfaction
across three
methods (p <
.001)

 
Table B
Literature Review of the Flipped Classroom Approach in Nursing Education

Study, Year Purpose Type of Study Sample Measurement Treatment Results Findings Limitations

Ratta, 2015  Used team-based Descriptive  Convenience End-of-semester Voiceover No statistical Most students Lack of statistical
learning within a sample of course PowerPoint data provided  did not report data and
flipped classroom undergraduate evaluations, presentations and positive feedback significance of
setting to facilitate baccalaureate student scores on chapter readings as after the first intervention
active learning nursing students end-of-semester preclass work; semester, second
(n = 80) enrolled standardized classroom semester
in semester two course activities: readiness evaluations were
of a examination assurance tests “more positive,”
fundamentals of individually and in student
nursing course groups with examination
discussions, clinical scores were
scenarios, peer “significantly
evaluations higher” than
previous classes
Schlairet, Green, Foster autonomy Descriptive Convenience None stated Voiceover None stated Faculty felt prep Lacks analysis of
& Benton, 2014 and self- sample of PowerPoint work was time whether the
directedness in the undergraduate presentations as intensive flipped approach
undergraduate baccalaureate preclass work, affects mastery
baccalaureate nursing students classroom activities: of material,
nursing student (n = 80) peer instruction, comparison of
enrolled in a group work, class method versus
Fundamental discussion, group traditional
Concepts of presentations, content delivery
Nursing course audience response
over two devices for
semesters NCLEX®-style
questions, case
studies

 
Table B
Literature Review of the Flipped Classroom Approach in Nursing Education

Study, Year Purpose Type of Study Sample Measurement Treatment Results Findings Limitations

Schwartz, 2014 Implement the Descriptive Convenience Two surveys using Video recorded Average 3.9 Positive Lacks analysis of
flipped teaching sample of a Likert-scale to lectures as preclass to 5.0, with feedback whether the
approach in a postgraduate evaluate work, c lassroom 5 = strong regarding the flipped approach
research-based nursing students endorsement and activity: Small- agreement of flipped affects mastery
Doctor of enrolled in a favorability of group activities the flipped classroom of material;
Philosophy statistics course t h e flipped classroom approach comparison of
program to classroom approach; method versus
enhance the approach, end-of- average 4.5 to traditional
student learning semester course 5, with 5 = content delivery
experience e valuations, very favorable
p retest–posttest of the flipped
classroom
approach;
average 4.5 to
5, with 5 =
strongly
agree; course
evaluation as
excellent;
pretest 28%;
posttest 75%

 
Table B
Literature Review of the Flipped Classroom Approach in Nursing Education

Study, Year Purpose Type of Study Sample Measurement Treatment Results Findings Limitations

Simpson & Revision of a Descriptive, Convenience Two surveys: Voiceover No statistical Positive Lacks analysis of
Richards, 2015 population health exploratory sample of two faculty created a PowerPoint difference feedback whether the
course from a cohorts of Likert-type scale presentations, between the regarding the flipped approach
traditional undergraduate survey to evaluate teaching videos, previous flipped affects mastery
delivery format to nursing students: students’ interactive online traditional and classroom of material;
a flipped juniors (n = 64) perceptions modules, assigned current flipped approach revision changed
classroom format enrolled in a regarding the readings as preclass classroom course from
to enhance student public health flipped classroom work; classroom cohort on the traditional face-
engagement in the science course format; end-of- activity: case course to-face to hybrid
course and sophomores semester course studies, Web quests, evaluation format; authors
(n = 93) enrolled evaluations videos with response survey; did not discuss
in a population time, group- favorable the effects of this
health course developed comments on major change in
presentations survey content delivery
focusing on
the flipped
format