Nurse Educator
Nurse Educator Vol. 39, No. 6, pp. 321-325 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Flipped Classroom Strategies for an Undergraduate Nursing Course Maura C. Schlairet, EdD, MA, MSN, RN, CNL & Rebecca Green, DNS, RN, NCSN Melissa J. Benton, PhD, RN, GCNS-BC, FACSM This article presents the authors’ experience with flipping a Fundamental Concepts of Nursing course for students in an undergraduate baccalaureate program. Authors describe implementing a flipped class, practical strategies to transform students’ learning experience, and lessons learned. This article serves as a guide to faculty and programs seeking to develop and implement the flipped class model in nursing education. Keywords: active learning; flipped classroom; learning environment; nursing education; teaching methods
A
growing body of literature describes the need to develop nursing students who can learn in complex, unpredictable environments.1,2 The flipped classroom model has been described as an approach that may develop students as active agents of their own learning, rather than passive recipients of teaching.3 The model promotes information transfer in advance of (and outside) the classroom and student-centric, active learning strategies during class meetings.4 The flipped model incorporates active and collaborative learning or ‘‘high-impact approaches’’ to teaching/learning that have been widely supported in the literature.5-8 Although this approach is gaining popularity in many areas of education,9 and some evidence suggests it is an effective model for college students,10-12 a paucity of literature exists related to use of the flipped classroom model in prelicensure nursing education.13
Background Shifting the ownership of learning from educators to students was of great interest to faculty teaching in a first-semester, Fundamental Concepts of Nursing course. The aim was to facilitate learner self-directedness and autonomy among undergraduate students to foster the competence in lifelong learning necessary for today’s complex health care environAuthor Affiliations: Associate Professor of Nursing and Bioethicist (Dr Schlairet) and Assistant Professor of Nursing (Dr Green), College of Nursing and Health Sciences, Valdosta State University, Georgia; and Associate Professor (Dr Benton), Beth-El College of Nursing and Health Sciences, University of Colorado at Colorado Springs. This study was supported in part by a Valdosta State University Faculty Research and Scholarship Grant. The authors declare no conflicts of interest. Correspondence: Dr Schlairet, College of Nursing and Health Sciences, Valdosta State University, 1500 N Patterson St, Valdosta, GA 31698 ([email protected]). Accepted for publication: August 23, 2014 Published ahead of print date: October 6, 2014 DOI: 10.1097/NNE.0000000000000096
Nurse Educator
ment. Turning to the literature for pedagogic underpinnings to evolve teaching and learning in a beginning nursing course from pedagogy to andragogy, and ultimately to heutagogy,14,15 faculty were inspired to explore the flipped classroom model. Faculty believed the flipped class model fit well with expectations in prelicensure nursing education wherein students must become independent, self-directed learners capable of critical thinking and clinical decision making. Institutional administrative support and academic freedom to implement new strategies created an environment in which faculty were encouraged to try new pedagogical approaches and take creative risks. This belief and support encouraged faculty to step out of an andragogical comfort zone, in which faculty supported the adult learners’ growing self-directedness by helping students relate information to the learning experience,15 into a heutagogical approach toward teaching and learning. Heutagogy, or the study of self-determined learning, focuses holistically on development of learners’ competency (ie, skill and knowledge) and capability (ie, confidence in problemsolving ability) while requiring faculty to relinquish ownership of learning to the student.15
State of the Evidence Critical thinking is an essential component of clinical practice in a dynamic health care environment: knowledge alone is not sufficient. Clinicians also need to have the ability to think critically through comprehension, reasoning, and exploration of alternative frames of reference.16 Although a traditional, pedagogical teaching style can effectively transfer knowledge from teacher to student, it has been criticized for fostering student dependence rather than independent, selfdirected learning that promotes critical thinking.17 Initially proposed by Knowles,18 self-directed learning has long been recognized as the most appropriate learning style for adults. Rather than using classroom time for passive pedagogical knowledge transfer, the focus of nursing education should be Volume 39 & Number 6 & November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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on problem-based, self-directed learning3 that promotes critical thinking.19 A flipped classroom model, in which students assume personal responsibility for knowledge acquisition, supports self-directed learning and the unique needs of nursing. However, among educators in practice fields the potential value of the flipped classroom has long been overlooked. Burns20 was first to suggest the flipped classroom as an option to increase critical thinking skills in medical students. Burns’ suggestion was followed almost immediately by recommendations for implementation of the flipped classroom for general medical education21,22 as well as for anesthesia education.23 Despite growing interest in the flipped classroom, evidence to support its effectiveness in clinical education is limited to the disciplines of pharmacy and nursing. Among pharmacy students, a flipped classroom has been shown to improve examination scores, academic grades, the ability to work in teams, and student satisfaction.24,25 By comparison, among baccalaureate nursing students, the flipped classroom has been shown to improve examination scores and course pass rates but not student satisfaction.26 Further research is needed in the various clinical disciplines to identify appropriate settings and instructional techniques that enhance learning, promote critical thinking skills, and increase student satisfaction.
Implementing the Flip
Flipping the Classroom and the Learning
Strategies to Promote a Shift in the Learning Culture During a course orientation, students were informed they would be actively involved in learning and reviewed a handout designed to highlight essential elements of the model. The purpose of the handout was to help students understand the flipped model and the types of learning in which they would be involved, activities they would encounter, when/ where they would complete activities, and what form of learning they could expect on completion of activities. Students were reminded the orientation information was not exhaustive and that other types of activities and examples of learning would be discussed during class as they became familiar with the basic concepts of the flipped class model. The handout also was uploaded to the course learning management system for students’ review as needed.
Context The context for this experience was a required, 5-credit-hour Fundamental Concepts of Nursing course in an undergraduate BSN program, taken during the first semester of study in a college of nursing. The 15-week course has on average 40 students in the class. The didactic element of the course was a 4-consecutive-hour class meeting once per week. Before flipping the class, the class time consisted almost exclusively of lecture with a limited number of class activities to help introduce or help students engage with complex concepts. Prior to lecture, students were expected to complete assigned textbook readings and read PowerPoint slides that were posted in the course learning management system. In fall 2012, the first student cohort was oriented to the flipped class model. A second iteration of the flipped class occurred in spring 2013. Getting Started Faculty faced several challenges at the inception of the project. Along with a dearth of literature related to flipped classrooms in nursing education, no established methodology for flipping a course exists.27,28 Yet, key features essential for implementation of a flipped class have been described and include flexible learning environments, a shift in the learning culture, use of intentional content, and skilled educators.29 Although course redesign was guided by these elements, these were not viewed as prerequisites for implementation of the flipped course. Lacking prior experience with the model, these constructs represented a developmental continuum for course faculty. Faculty expected to learn during the first semester of the flipped model and anticipated a growing conceptual understanding and process fluency would guide revisions of the flipped class in subsequent iterations. 322
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Strategies Promoting a Flexible Learning Environment The classroom was outfitted with small tables and chairs that were easily moved and conducive to group work, so minimal rearranging of students’ physical learning space was necessary. On the first iteration, faculty allowed students to select 4-member work groups to promote collaboration and engagement30 during class time. Faculty discovered new classroom management techniques were needed to support learning in a noisy, multitasking classroom environment. For example, some students found the loud, unstructured environment distracting. And, more problematic, many students adopted a ‘‘divide and conquer’’ approach toward the in-class activities. Because engagement with other learners is one of the guiding principles of the model, maintaining a flexible learning environment while modeling ownership of learning presented a challenge for faculty. Wi-Fi access promoted flexibility in accessing learning resources via students’ portable devices. Students could access the electronic version of the course textbook and faculty’s PowerPoint slides for use during engaged learning activities. Dedicated instructional technology (IT) support was not available in the college during the first iteration, and faculty and students were occasionally challenged by IT issues (eg, device incompatibility) during implementation of the flipped classroom.
Intentional Content: Individual Learning Space Faculty wanted students to engage prior to class in their individual learning space27 with intentional content that would prepare them to fully participate during class. Twenty-six voiceover PowerPoint presentations were developed and made available to students via the university online learning management system. The philosophy for developing slide content was to focus on the ‘‘need to know’’ information; thus, content for the voiceover PowerPoint slides was selected using backwards design31 or reverse engineering. Voiceover slide presentations were typically 45 to 60 minutes in length. Students followed a detailed course schedule to identify prereading assignments from the course textbook and associated voiceover PowerPoint presentations. They were encouraged to rewind and replay these lectures as needed. Slides also included a notes page version that students could print and further annotate as they read the textbook. During the initial Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
iteration, lecture capture capabilities were limited and resulted in creation of multiple files for each lecture that were reported by students as difficult to locate and cumbersome to download and print from within the course management system. Course content viewed by faculty as more challenging was reserved for direct teaching during class time. This approach allowed faculty to model our thinking, demonstrate application of the more difficult material during in-class discussions, and engage students in higher-level cognitive activities as they matured and became more autonomous learners.
Intentional Content: Group Learning Space In our group learning space, faculty used an array of intentional content27 and classroom activities to promote classroom engagement. In an effort to unpack the material to be learned in class, faculty alternated among learning strategies such as peer instruction, small group work, short class discussion, and small group presentation. Other activities such as brief Knowledge Readiness quizzes developed from the voiceover PowerPoint lecture content were used at the beginning of class. Students used audience response devices (clickers) to answer between 5 and 8 NCLEX-style questions, and faculty led postquiz debriefing of answers with rationale. Students had no forewarning of quizzes, and the strategy encouraged them to develop a growing accountability for material from the course textbook and PowerPoint lecture slides. Faculty used problem-solving scenarios and case studies that allowed students to discuss solutions in their small groups and then to share the ‘‘thinking through’’ of the scenario32 with classmates. As follow-up, faculty facilitated classroom debriefing and responded to students’ expressed understanding of concepts. In the first iteration, these activities were all worksheet or handout based. In subsequent course iterations, in lieu of the worksheet/handout case studies, high-fidelity human patient simulators were brought into the classroom on hydraulic stretchers. Although full simulation scenarios were not run in the classroom, the mannequins were powered up and programmed to present students with a range of clinical parameters consistent with the problem-solving scenarios and case studies that were previously developed for the class. This allowed student groups to interact with the simulators to identify information they needed in problem solving the scenario or to use the simulators to demonstrate a concept embedded in the case study. Postsimulation discussions and debriefings of problem-solving scenarios and case studies were significantly more robust when students were able to engage with the course content using human patient simulators versus the worksheet/handout method. Collaborative decision-making opportunities were created using content-specific NCLEX-style question sets. Small groups discussed content, and peer teaching was encouraged so that students could use mutually informed consensus-style decisionmaking process to answer questions. Faculty facilitated a classroom review and discussion of answers with rationale supporting the best answers. Occasions to present as small groups to the entire class were greeted with much enthusiasm by students. Self-generated understanding of assigned content was shared via brief oral presentations delivered informally by groups in front of the Nurse Educator
class. Students shared their accumulated knowledge, along with textbook page numbers and slide numbers as references in support of their emerging understanding of course concepts. In the subsequent iteration, this activity evolved into creation of a shared learning map33 wherein students also cross walked the activity-related content against chapter learning objectives and shared their results with classmates. Most often follow-along worksheets and handouts were developed and used as learning scaffolds in small group work to help students focus on essential concepts and key ideas. To increase engagement and provide formative assessment of students’ understanding, faculty called on students to report their group’s responses. Complex or challenging topics provided an opportunity for faculty to summarize content for the whole class. Faculty contributed to the group learning space in intentional ways as well. Circulating around the student groups and listening and discussing content and the assignments helped faculty deconstruct student thinking (or errors in thinking) so that faculty could assess weaknesses and foster their strengths. This also helped faculty to identify students as they encountered roadblocks to learning in real time.30 In delivering personalized assistance, faculty could identify question trends that suggested the need for impromptu microlectures over complex material. On other occasions, this informal circulation and engagement revealed robust understanding of the day’s content and allowed for delivery of 3-minute challenge lectures to advance students’ understanding of topics to the next level.
Growing Faculty Skill Set and Course Iterations Reflecting on our early iterations of the flipped class and informed by analysis of mixed methods student-level data, faculty recognized growth in relation to both conceptual understanding and process fluency. Without doubt, the flipped class added a significant technological component to the course, and faculty gained a better understanding of the importance of quality lecture capture software and invaluable contributions dedicated IT personnel contribute to an initiative of this magnitude. Faculty gained the skill set needed to significantly improve voiceover presentations, saving these as smaller, single files that students could easily download for listening or printing in multislide-per-page format. Applying principles of group learning strategies (eg, assigning roles to group members) in the development and implementation of in-class learning activities helped faculty to gently but firmly move from a model in which students selected work group members to one in which faculty identified group membership. This technique appeared to promote peer-to-peer learning in our course among heterogeneous ability levels.9 In developing our first course iteration, faculty had not considered how to manage the rate of learning and progress during in-class activities and thus were initially unprepared to deal with small groups who repeatedly completed the in-class activities well ahead of the majority of class members. A few ‘‘bonus’’ items are now being added to each assignment for this purpose, and faculty are considering methods for allocating extra credit and ways in which students can disseminate this work to promote learning for the entire class. Volume 39 & Number 6 & November/December 2014
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Lessons Learned Lessons were learned from the pilot implementation. Although the central premise of the model is not complicated, the opportunities for design and implementation of specific activities significantly alter the type of learning that is possible.34 Although technology expertise simplified course iteration for faculty, redesign of the course as a flipped class was very time intensive up front—most of this associated with creation of the voiceover PowerPoint and classroom activities. Faculty expect subsequent iterations will require smaller amounts of additional time devoted to modification of in-class activities.
Future Directions Additional capabilities of our course learning management system allow us to plan for improvements in our flipped class model. For example, addressing our desire to assess students’ knowledge of the preclass assignment, students will complete short online quizzes after listening to the voiceover PowerPoint. In addition, faculty plan to use the system’s built-in analytics to identify patterns in time and task management as well as analyze students’ use of course learning elements. This should allow faculty to provide intentional guidance on development of self-regulated learning skills.35 Other robust learning resources could be incorporated into the course, but rather than creating additional strategies from scratch, faculty endorse the notion of ‘‘curating the best content for the subject matter.’’36(p36)
Conclusions In our setting, faculty identified 2 major facilitators that were essential to the development and implementation of the flipped classroom initiative. First, institutional administrative support and academic freedom to implement new strategies created an environment in which faculty were encouraged to try new pedagogical approaches. Second, the addition of an in-house dedicated IT specialist provided support in a subsequent iteration of the flip that allowed faculty to focus on concept and content while ensuring high-quality voiceover PowerPoint presentations. A significant challenge to implementation of the flipped classroom initiative included the dearth of literature specific to use of the flipped classroom model in nursing education. For today’s nursing students to become lifelong learners in complex, rapidly changing environments, heutagogical approaches to teaching and learning may support faculty who seek to trial new models and methods that may, at first, be uncomfortable and challenging to students, faculty, and administrators. The flipped classroom model may be an effective method for evolving teaching and learning in nursing from pedagogy to andragogy, and ultimately to heutagogy, and moving diverse groups of students toward developing the characteristics necessary for successful lifelong learning.
References 1. Bhoyrub J, Hurley J, Neilson GR, Ramsay M, Smith M. Heutagogy: an alternative practice based learning approach. Nurse Educ Pract. 2010;19(6):322-326. 2. Greiner CC, Knebel E. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003. 3. Barrows HS. Problem-based, self-directed learning. JAMA. 1983; 250(22):3077-3080.
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4. Bergmann J, Sams A. Flip your Classroom: Reach Every Student in Every Class Every Day. International Society of Technology in Education: Washington, DC; 2012. 5. Freeman S, O’Connor E, Parks JW, et al. Prescribed active learning increases performance in introductory biology. CBE Life Sci Educ. 2007;6(2):132-139. 6. Kuh GK. High-Impact Educational Practices: What They Are, Who Has Access to Them, and why they matter. Washington, DC: Association of American Colleges and Universities; 2008. 7. Kuh DG, Kinzie J, Buckley JA, Bridges BK, Hayek JC. What Matters to Student Success: A Review of the Literature. National Postsecondary Education Cooperative Web site. Available at http://nces.ed.gov/npec/pdf/kuh_team:report.pdf. Published 2006. Accessed June 2, 2014. 8. Prince M. Does active learning work? A review of the research. J Eng Educ. 2004;93(3):223-231. 9. Schwartz TA. Flipping the statistics classroom in nursing education. J Nurs Educ. 2014;53(4):199-206. 10. Lage MJ, Platt GJ, Treglia M. Inverting the classroom: a gateway to creating an inclusive learning environment. J Econ Educ. 2000; 31(1):30-43. 11. Frederickson N, Reed P, Clifford V. Evaluating Web-supported learning versus lecture-based teaching: quantitative and qualitative perspectives. High Educ. 2005;50(4):645-664. 12. Day J, Foley J. Evaluating Web Lectures: A Case Study From HCI. Montreal, Quebec, Canada: Paper presented at the Conference on Human Factors in Computing Systems; 2006. 13. Yensen J. Active learning flip with interaction and exploration (ALFIE)—a new model. OJNI. 2014;18(1). Available at http://ojni.org/ issues/?p=3089). 14. Canning N. Playing with heutagogy: exploring strategies to empower mature learners in higher education. JFHE. 2010;34(1): 59-71. 15. Blaschke L. Heutagogy and lifelong learning: a review of heutagogical practice and self-determined learning. Int Rev Res Open Dist Learn. 2012;13(1). Available at http://www.irrodl.org/ index.php/irrodl/article/view/1076/2087. 16. Fero LJ, O’Donnell JM, Zullo TG, et al. Critical thinking skills in nursing students: comparison of simulation-based performance with metrics. J Adv Nurs. 2010;66(10):2182-2193. 17. Knowles M. Self-directed Learning: A Guide for Learners and Teachers. Prentice Hall/Cambridge: Englewood Cliffs, NJ; 1975. 18. Knowles M. The Modern Practice of Adult Education (Vol 41). New York: Association Press; 1970. 19. Yu D, Zhang Y, Xu Y, Wu J, Wang C. Improvement in critical thinking dispositions of undergraduate nursing students through problem-based learning: a crossover-experimental study. J Nurs Educ. 2013;52(10):574-581. 20. Burns J. Critical care in the age of the duty hour regulations: circadian-based scheduling, standardized handoffs, and the flipped classroom? Crit Care Med. 2012;40(12):3305-3306. 21. Mehta NB, Hul AL, Young JB, Stoller JK. Just imagine: new paradigms for medical education. Acad Med. 2013;88(10): 1418-1423. 22. Prober CG, Khan S. Medical education reimagined: a call to action. Acad Med. 2013;88(10):1407-1410. 23. Kurup V, Hersey D. The changing landscape of anesthesia education: is flipped classroom the answer? Curr Opin Anaesthesiol. 2013;26(6):726-731. 24. Ferreri SP, O’Connor SK. Redesign of a large lecture course into a small-group learning course. Am J Pharm Educ. 2013;77(1):13. 25. Pierce R, Fox J. Vodcasts and active-learning exercises in a ‘‘flipped classroom’’ model of a renal pharmacotherapy module. Am J Pharm Educ. 2012;76(10):196. 26. Missildine K, Fountain R, Summers L, Gosselin K. Flipping the classroom to improve student performance and satisfaction. J Nurs Educ. 2013;52(10):597-599. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
27. Hamdan N, McKnight P, McKnight K, Arfstron KM. A review of flipped learning. Flipped Learning Network Web site. Available at www.flippedlearning.org/domain.r4. Published 2013. Accessed May 28, 2014. 28. Moore AJ, Gillett MR, Steele MD. Fostering student engagement with the flip. Math Teach. 2014;107(6):420-425. 29. Pearson & The Flipped Learning Network. Flipped Learning Professional Development. Pearson Education Inc. Web site. Available at http://www.pearsonschool.com/flippedlearning. Published 2013. Accessed May 28, 2014. 30. Mangan K. Inside the flipped classroom. Chron High Educ. 2013; 60(5):B18-B21. 31. Wiggins G, McTighe J. Understanding by Design. 2nd ed. Prentice Hall: Upper Saddle River, NJ; 2005. 32. Hase S, Kenyon C. From Andragogy to Heutagogy, Original URL: http://ultibase.rmit.edu.au/Articles/dec00/hase2.htm. Available at
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http://www.psy.gla.ac.uk/~steve/pr/Heutagogy.html. Published 2000. Accessed July 13, 2014. 33. Hase S. Heutagogy and e-learning in the workplace: some challenges and opportunities. Impact J Appl Res Workplace Elearn. 2009;1(1):43-52. 34. McDonald K, Smith CM. The flipped classroom for professional development: part I benefits and strategies. J Contin Educ Nurs. 2013;44(10):437-438. 35. Talbert R. Four things I wish I’d known about the flipped classroom. 2014. The Chronicle Blog Network Web site. Available at http://chronicle.com/blognetwork/castingoutnines/2014/06/ 05/four-things-i-wish-id-known-about-the-flipped-classroom. Accessed June 2, 2014. 36. Johnson L, Adams Becker S, Estrada V, Freeman A. NMC Horizon Report: 2014 Higher Education Edition. Austin, TX: The New Media Consortium; 2014.
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Nurse Educator Vol. 39, No. 6, pp. 321-325 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Flipped Classroom Strategies for an Undergraduate Nursing Course Maura C. Schlairet, EdD, MA, MSN, RN, CNL & Rebecca Green, DNS, RN, NCSN Melissa J. Benton, PhD, RN, GCNS-BC, FACSM This article presents the authors’ experience with flipping a Fundamental Concepts of Nursing course for students in an undergraduate baccalaureate program. Authors describe implementing a flipped class, practical strategies to transform students’ learning experience, and lessons learned. This article serves as a guide to faculty and programs seeking to develop and implement the flipped class model in nursing education. Keywords: active learning; flipped classroom; learning environment; nursing education; teaching methods
A
growing body of literature describes the need to develop nursing students who can learn in complex, unpredictable environments.1,2 The flipped classroom model has been described as an approach that may develop students as active agents of their own learning, rather than passive recipients of teaching.3 The model promotes information transfer in advance of (and outside) the classroom and student-centric, active learning strategies during class meetings.4 The flipped model incorporates active and collaborative learning or ‘‘high-impact approaches’’ to teaching/learning that have been widely supported in the literature.5-8 Although this approach is gaining popularity in many areas of education,9 and some evidence suggests it is an effective model for college students,10-12 a paucity of literature exists related to use of the flipped classroom model in prelicensure nursing education.13
Background Shifting the ownership of learning from educators to students was of great interest to faculty teaching in a first-semester, Fundamental Concepts of Nursing course. The aim was to facilitate learner self-directedness and autonomy among undergraduate students to foster the competence in lifelong learning necessary for today’s complex health care environAuthor Affiliations: Associate Professor of Nursing and Bioethicist (Dr Schlairet) and Assistant Professor of Nursing (Dr Green), College of Nursing and Health Sciences, Valdosta State University, Georgia; and Associate Professor (Dr Benton), Beth-El College of Nursing and Health Sciences, University of Colorado at Colorado Springs. This study was supported in part by a Valdosta State University Faculty Research and Scholarship Grant. The authors declare no conflicts of interest. Correspondence: Dr Schlairet, College of Nursing and Health Sciences, Valdosta State University, 1500 N Patterson St, Valdosta, GA 31698 ([email protected]). Accepted for publication: August 23, 2014 Published ahead of print date: October 6, 2014 DOI: 10.1097/NNE.0000000000000096
Nurse Educator
ment. Turning to the literature for pedagogic underpinnings to evolve teaching and learning in a beginning nursing course from pedagogy to andragogy, and ultimately to heutagogy,14,15 faculty were inspired to explore the flipped classroom model. Faculty believed the flipped class model fit well with expectations in prelicensure nursing education wherein students must become independent, self-directed learners capable of critical thinking and clinical decision making. Institutional administrative support and academic freedom to implement new strategies created an environment in which faculty were encouraged to try new pedagogical approaches and take creative risks. This belief and support encouraged faculty to step out of an andragogical comfort zone, in which faculty supported the adult learners’ growing self-directedness by helping students relate information to the learning experience,15 into a heutagogical approach toward teaching and learning. Heutagogy, or the study of self-determined learning, focuses holistically on development of learners’ competency (ie, skill and knowledge) and capability (ie, confidence in problemsolving ability) while requiring faculty to relinquish ownership of learning to the student.15
State of the Evidence Critical thinking is an essential component of clinical practice in a dynamic health care environment: knowledge alone is not sufficient. Clinicians also need to have the ability to think critically through comprehension, reasoning, and exploration of alternative frames of reference.16 Although a traditional, pedagogical teaching style can effectively transfer knowledge from teacher to student, it has been criticized for fostering student dependence rather than independent, selfdirected learning that promotes critical thinking.17 Initially proposed by Knowles,18 self-directed learning has long been recognized as the most appropriate learning style for adults. Rather than using classroom time for passive pedagogical knowledge transfer, the focus of nursing education should be Volume 39 & Number 6 & November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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on problem-based, self-directed learning3 that promotes critical thinking.19 A flipped classroom model, in which students assume personal responsibility for knowledge acquisition, supports self-directed learning and the unique needs of nursing. However, among educators in practice fields the potential value of the flipped classroom has long been overlooked. Burns20 was first to suggest the flipped classroom as an option to increase critical thinking skills in medical students. Burns’ suggestion was followed almost immediately by recommendations for implementation of the flipped classroom for general medical education21,22 as well as for anesthesia education.23 Despite growing interest in the flipped classroom, evidence to support its effectiveness in clinical education is limited to the disciplines of pharmacy and nursing. Among pharmacy students, a flipped classroom has been shown to improve examination scores, academic grades, the ability to work in teams, and student satisfaction.24,25 By comparison, among baccalaureate nursing students, the flipped classroom has been shown to improve examination scores and course pass rates but not student satisfaction.26 Further research is needed in the various clinical disciplines to identify appropriate settings and instructional techniques that enhance learning, promote critical thinking skills, and increase student satisfaction.
Implementing the Flip
Flipping the Classroom and the Learning
Strategies to Promote a Shift in the Learning Culture During a course orientation, students were informed they would be actively involved in learning and reviewed a handout designed to highlight essential elements of the model. The purpose of the handout was to help students understand the flipped model and the types of learning in which they would be involved, activities they would encounter, when/ where they would complete activities, and what form of learning they could expect on completion of activities. Students were reminded the orientation information was not exhaustive and that other types of activities and examples of learning would be discussed during class as they became familiar with the basic concepts of the flipped class model. The handout also was uploaded to the course learning management system for students’ review as needed.
Context The context for this experience was a required, 5-credit-hour Fundamental Concepts of Nursing course in an undergraduate BSN program, taken during the first semester of study in a college of nursing. The 15-week course has on average 40 students in the class. The didactic element of the course was a 4-consecutive-hour class meeting once per week. Before flipping the class, the class time consisted almost exclusively of lecture with a limited number of class activities to help introduce or help students engage with complex concepts. Prior to lecture, students were expected to complete assigned textbook readings and read PowerPoint slides that were posted in the course learning management system. In fall 2012, the first student cohort was oriented to the flipped class model. A second iteration of the flipped class occurred in spring 2013. Getting Started Faculty faced several challenges at the inception of the project. Along with a dearth of literature related to flipped classrooms in nursing education, no established methodology for flipping a course exists.27,28 Yet, key features essential for implementation of a flipped class have been described and include flexible learning environments, a shift in the learning culture, use of intentional content, and skilled educators.29 Although course redesign was guided by these elements, these were not viewed as prerequisites for implementation of the flipped course. Lacking prior experience with the model, these constructs represented a developmental continuum for course faculty. Faculty expected to learn during the first semester of the flipped model and anticipated a growing conceptual understanding and process fluency would guide revisions of the flipped class in subsequent iterations. 322
Volume 39 & Number 6 & November/December 2014
Strategies Promoting a Flexible Learning Environment The classroom was outfitted with small tables and chairs that were easily moved and conducive to group work, so minimal rearranging of students’ physical learning space was necessary. On the first iteration, faculty allowed students to select 4-member work groups to promote collaboration and engagement30 during class time. Faculty discovered new classroom management techniques were needed to support learning in a noisy, multitasking classroom environment. For example, some students found the loud, unstructured environment distracting. And, more problematic, many students adopted a ‘‘divide and conquer’’ approach toward the in-class activities. Because engagement with other learners is one of the guiding principles of the model, maintaining a flexible learning environment while modeling ownership of learning presented a challenge for faculty. Wi-Fi access promoted flexibility in accessing learning resources via students’ portable devices. Students could access the electronic version of the course textbook and faculty’s PowerPoint slides for use during engaged learning activities. Dedicated instructional technology (IT) support was not available in the college during the first iteration, and faculty and students were occasionally challenged by IT issues (eg, device incompatibility) during implementation of the flipped classroom.
Intentional Content: Individual Learning Space Faculty wanted students to engage prior to class in their individual learning space27 with intentional content that would prepare them to fully participate during class. Twenty-six voiceover PowerPoint presentations were developed and made available to students via the university online learning management system. The philosophy for developing slide content was to focus on the ‘‘need to know’’ information; thus, content for the voiceover PowerPoint slides was selected using backwards design31 or reverse engineering. Voiceover slide presentations were typically 45 to 60 minutes in length. Students followed a detailed course schedule to identify prereading assignments from the course textbook and associated voiceover PowerPoint presentations. They were encouraged to rewind and replay these lectures as needed. Slides also included a notes page version that students could print and further annotate as they read the textbook. During the initial Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
iteration, lecture capture capabilities were limited and resulted in creation of multiple files for each lecture that were reported by students as difficult to locate and cumbersome to download and print from within the course management system. Course content viewed by faculty as more challenging was reserved for direct teaching during class time. This approach allowed faculty to model our thinking, demonstrate application of the more difficult material during in-class discussions, and engage students in higher-level cognitive activities as they matured and became more autonomous learners.
Intentional Content: Group Learning Space In our group learning space, faculty used an array of intentional content27 and classroom activities to promote classroom engagement. In an effort to unpack the material to be learned in class, faculty alternated among learning strategies such as peer instruction, small group work, short class discussion, and small group presentation. Other activities such as brief Knowledge Readiness quizzes developed from the voiceover PowerPoint lecture content were used at the beginning of class. Students used audience response devices (clickers) to answer between 5 and 8 NCLEX-style questions, and faculty led postquiz debriefing of answers with rationale. Students had no forewarning of quizzes, and the strategy encouraged them to develop a growing accountability for material from the course textbook and PowerPoint lecture slides. Faculty used problem-solving scenarios and case studies that allowed students to discuss solutions in their small groups and then to share the ‘‘thinking through’’ of the scenario32 with classmates. As follow-up, faculty facilitated classroom debriefing and responded to students’ expressed understanding of concepts. In the first iteration, these activities were all worksheet or handout based. In subsequent course iterations, in lieu of the worksheet/handout case studies, high-fidelity human patient simulators were brought into the classroom on hydraulic stretchers. Although full simulation scenarios were not run in the classroom, the mannequins were powered up and programmed to present students with a range of clinical parameters consistent with the problem-solving scenarios and case studies that were previously developed for the class. This allowed student groups to interact with the simulators to identify information they needed in problem solving the scenario or to use the simulators to demonstrate a concept embedded in the case study. Postsimulation discussions and debriefings of problem-solving scenarios and case studies were significantly more robust when students were able to engage with the course content using human patient simulators versus the worksheet/handout method. Collaborative decision-making opportunities were created using content-specific NCLEX-style question sets. Small groups discussed content, and peer teaching was encouraged so that students could use mutually informed consensus-style decisionmaking process to answer questions. Faculty facilitated a classroom review and discussion of answers with rationale supporting the best answers. Occasions to present as small groups to the entire class were greeted with much enthusiasm by students. Self-generated understanding of assigned content was shared via brief oral presentations delivered informally by groups in front of the Nurse Educator
class. Students shared their accumulated knowledge, along with textbook page numbers and slide numbers as references in support of their emerging understanding of course concepts. In the subsequent iteration, this activity evolved into creation of a shared learning map33 wherein students also cross walked the activity-related content against chapter learning objectives and shared their results with classmates. Most often follow-along worksheets and handouts were developed and used as learning scaffolds in small group work to help students focus on essential concepts and key ideas. To increase engagement and provide formative assessment of students’ understanding, faculty called on students to report their group’s responses. Complex or challenging topics provided an opportunity for faculty to summarize content for the whole class. Faculty contributed to the group learning space in intentional ways as well. Circulating around the student groups and listening and discussing content and the assignments helped faculty deconstruct student thinking (or errors in thinking) so that faculty could assess weaknesses and foster their strengths. This also helped faculty to identify students as they encountered roadblocks to learning in real time.30 In delivering personalized assistance, faculty could identify question trends that suggested the need for impromptu microlectures over complex material. On other occasions, this informal circulation and engagement revealed robust understanding of the day’s content and allowed for delivery of 3-minute challenge lectures to advance students’ understanding of topics to the next level.
Growing Faculty Skill Set and Course Iterations Reflecting on our early iterations of the flipped class and informed by analysis of mixed methods student-level data, faculty recognized growth in relation to both conceptual understanding and process fluency. Without doubt, the flipped class added a significant technological component to the course, and faculty gained a better understanding of the importance of quality lecture capture software and invaluable contributions dedicated IT personnel contribute to an initiative of this magnitude. Faculty gained the skill set needed to significantly improve voiceover presentations, saving these as smaller, single files that students could easily download for listening or printing in multislide-per-page format. Applying principles of group learning strategies (eg, assigning roles to group members) in the development and implementation of in-class learning activities helped faculty to gently but firmly move from a model in which students selected work group members to one in which faculty identified group membership. This technique appeared to promote peer-to-peer learning in our course among heterogeneous ability levels.9 In developing our first course iteration, faculty had not considered how to manage the rate of learning and progress during in-class activities and thus were initially unprepared to deal with small groups who repeatedly completed the in-class activities well ahead of the majority of class members. A few ‘‘bonus’’ items are now being added to each assignment for this purpose, and faculty are considering methods for allocating extra credit and ways in which students can disseminate this work to promote learning for the entire class. Volume 39 & Number 6 & November/December 2014
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Lessons Learned Lessons were learned from the pilot implementation. Although the central premise of the model is not complicated, the opportunities for design and implementation of specific activities significantly alter the type of learning that is possible.34 Although technology expertise simplified course iteration for faculty, redesign of the course as a flipped class was very time intensive up front—most of this associated with creation of the voiceover PowerPoint and classroom activities. Faculty expect subsequent iterations will require smaller amounts of additional time devoted to modification of in-class activities.
Future Directions Additional capabilities of our course learning management system allow us to plan for improvements in our flipped class model. For example, addressing our desire to assess students’ knowledge of the preclass assignment, students will complete short online quizzes after listening to the voiceover PowerPoint. In addition, faculty plan to use the system’s built-in analytics to identify patterns in time and task management as well as analyze students’ use of course learning elements. This should allow faculty to provide intentional guidance on development of self-regulated learning skills.35 Other robust learning resources could be incorporated into the course, but rather than creating additional strategies from scratch, faculty endorse the notion of ‘‘curating the best content for the subject matter.’’36(p36)
Conclusions In our setting, faculty identified 2 major facilitators that were essential to the development and implementation of the flipped classroom initiative. First, institutional administrative support and academic freedom to implement new strategies created an environment in which faculty were encouraged to try new pedagogical approaches. Second, the addition of an in-house dedicated IT specialist provided support in a subsequent iteration of the flip that allowed faculty to focus on concept and content while ensuring high-quality voiceover PowerPoint presentations. A significant challenge to implementation of the flipped classroom initiative included the dearth of literature specific to use of the flipped classroom model in nursing education. For today’s nursing students to become lifelong learners in complex, rapidly changing environments, heutagogical approaches to teaching and learning may support faculty who seek to trial new models and methods that may, at first, be uncomfortable and challenging to students, faculty, and administrators. The flipped classroom model may be an effective method for evolving teaching and learning in nursing from pedagogy to andragogy, and ultimately to heutagogy, and moving diverse groups of students toward developing the characteristics necessary for successful lifelong learning.
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4. Bergmann J, Sams A. Flip your Classroom: Reach Every Student in Every Class Every Day. International Society of Technology in Education: Washington, DC; 2012. 5. Freeman S, O’Connor E, Parks JW, et al. Prescribed active learning increases performance in introductory biology. CBE Life Sci Educ. 2007;6(2):132-139. 6. Kuh GK. High-Impact Educational Practices: What They Are, Who Has Access to Them, and why they matter. Washington, DC: Association of American Colleges and Universities; 2008. 7. Kuh DG, Kinzie J, Buckley JA, Bridges BK, Hayek JC. What Matters to Student Success: A Review of the Literature. National Postsecondary Education Cooperative Web site. Available at http://nces.ed.gov/npec/pdf/kuh_team:report.pdf. Published 2006. Accessed June 2, 2014. 8. Prince M. Does active learning work? A review of the research. J Eng Educ. 2004;93(3):223-231. 9. Schwartz TA. Flipping the statistics classroom in nursing education. J Nurs Educ. 2014;53(4):199-206. 10. Lage MJ, Platt GJ, Treglia M. Inverting the classroom: a gateway to creating an inclusive learning environment. J Econ Educ. 2000; 31(1):30-43. 11. Frederickson N, Reed P, Clifford V. Evaluating Web-supported learning versus lecture-based teaching: quantitative and qualitative perspectives. High Educ. 2005;50(4):645-664. 12. Day J, Foley J. Evaluating Web Lectures: A Case Study From HCI. Montreal, Quebec, Canada: Paper presented at the Conference on Human Factors in Computing Systems; 2006. 13. Yensen J. Active learning flip with interaction and exploration (ALFIE)—a new model. OJNI. 2014;18(1). Available at http://ojni.org/ issues/?p=3089). 14. Canning N. Playing with heutagogy: exploring strategies to empower mature learners in higher education. JFHE. 2010;34(1): 59-71. 15. Blaschke L. Heutagogy and lifelong learning: a review of heutagogical practice and self-determined learning. Int Rev Res Open Dist Learn. 2012;13(1). Available at http://www.irrodl.org/ index.php/irrodl/article/view/1076/2087. 16. Fero LJ, O’Donnell JM, Zullo TG, et al. Critical thinking skills in nursing students: comparison of simulation-based performance with metrics. J Adv Nurs. 2010;66(10):2182-2193. 17. Knowles M. Self-directed Learning: A Guide for Learners and Teachers. Prentice Hall/Cambridge: Englewood Cliffs, NJ; 1975. 18. Knowles M. The Modern Practice of Adult Education (Vol 41). New York: Association Press; 1970. 19. Yu D, Zhang Y, Xu Y, Wu J, Wang C. Improvement in critical thinking dispositions of undergraduate nursing students through problem-based learning: a crossover-experimental study. J Nurs Educ. 2013;52(10):574-581. 20. Burns J. Critical care in the age of the duty hour regulations: circadian-based scheduling, standardized handoffs, and the flipped classroom? Crit Care Med. 2012;40(12):3305-3306. 21. Mehta NB, Hul AL, Young JB, Stoller JK. Just imagine: new paradigms for medical education. Acad Med. 2013;88(10): 1418-1423. 22. Prober CG, Khan S. Medical education reimagined: a call to action. Acad Med. 2013;88(10):1407-1410. 23. Kurup V, Hersey D. The changing landscape of anesthesia education: is flipped classroom the answer? Curr Opin Anaesthesiol. 2013;26(6):726-731. 24. Ferreri SP, O’Connor SK. Redesign of a large lecture course into a small-group learning course. Am J Pharm Educ. 2013;77(1):13. 25. Pierce R, Fox J. Vodcasts and active-learning exercises in a ‘‘flipped classroom’’ model of a renal pharmacotherapy module. Am J Pharm Educ. 2012;76(10):196. 26. Missildine K, Fountain R, Summers L, Gosselin K. Flipping the classroom to improve student performance and satisfaction. J Nurs Educ. 2013;52(10):597-599. Nurse Educator
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27. Hamdan N, McKnight P, McKnight K, Arfstron KM. A review of flipped learning. Flipped Learning Network Web site. Available at www.flippedlearning.org/domain.r4. Published 2013. Accessed May 28, 2014. 28. Moore AJ, Gillett MR, Steele MD. Fostering student engagement with the flip. Math Teach. 2014;107(6):420-425. 29. Pearson & The Flipped Learning Network. Flipped Learning Professional Development. Pearson Education Inc. Web site. Available at http://www.pearsonschool.com/flippedlearning. Published 2013. Accessed May 28, 2014. 30. Mangan K. Inside the flipped classroom. Chron High Educ. 2013; 60(5):B18-B21. 31. Wiggins G, McTighe J. Understanding by Design. 2nd ed. Prentice Hall: Upper Saddle River, NJ; 2005. 32. Hase S, Kenyon C. From Andragogy to Heutagogy, Original URL: http://ultibase.rmit.edu.au/Articles/dec00/hase2.htm. Available at
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