The Journal of Continuing Education in Nursing

Original Article 

The Flipped Classroom Format and Nursing Professional Development

Jobeth Pilcher, EdD, RN

Abstract

The flipped classroom is increasingly described in the education literature. In the most basic terms, the phrase flipped classroom refers to learners doing some type of preparatory work prior to attending a class. Class time is then spent applying the content. This article includes an overview of evidence related to the flipped classroom, as well as examples of how the flipped format has been used in nursing professional development. Hints are included regarding planning and implementing a flipped classroom. [J Contin Educ Nurs. 2019;50(10):449–454.]

Abstract

The flipped classroom is increasingly described in the education literature. In the most basic terms, the phrase flipped classroom refers to learners doing some type of preparatory work prior to attending a class. Class time is then spent applying the content. This article includes an overview of evidence related to the flipped classroom, as well as examples of how the flipped format has been used in nursing professional development. Hints are included regarding planning and implementing a flipped classroom. [J Contin Educ Nurs. 2019;50(10):449–454.]

What is the flipped classroom? What evidence supports use of the flipped format? Which types of learning strategies are used with this format? How can the educators develop learning activities using the flipped format in the workplace setting? This article includes answers to these questions and specific examples of how the flipped format has been used in work-place learning and nursing professional development. The article also provides guidance for nurse educators regarding how to plan and implement the flipped format.

Description of the Flipped Classroom

The flipped format is an active learning strategy with the potential to increase learner engagement, motivation, and ability to apply content (Zainuddin & Halili, 2016). The format includes prework (such as videos and reading material) that learners should complete prior to attending class, followed by in-class interactive and hands-on activities aimed at applying knowledge gained from the prework (Bergmann & Sams, 2012). The format offers the opportunity for both collaborative and personalized learning.

One of the first reported examples of the flipped format occurred in 2007, when two high school chemistry teachers wanted to develop a strategy for students who missed class (Tucker, 2012). The teachers, Jonathan Bergmann and Aaron Sams (2012), used screen capture software and PowerPoint® to record classes and post them on YouTube. The videos became so popular that even those students who had not missed class were watching them. This led the teachers to use class time differently. Their experience with the flipped format led to expertise, a book on the topic, and the development of the Flipped Learning Network (2014). Johnson, Adams Becker, Estrada, and Freeman (2014) specified that technology has allowed the flipped format to be used more readily, and many online classes may be considered as a variation of the format.

With the focus on technology as an integral aspect of flipped learning, the not-for-profit Khan Academy has been credited with serving an integral role in the adoption and ongoing use of the flipped format (Johnson et al., 2014). The Khan Academy offers free videos on an array of topics. Teachers can refer students to those materials, rather than having to develop content from scratch. This allows time in class for students to apply the knowledge gained. The Khan Academy began with content for Kindergarten through 12th grade and progressed to a variety of topics including nursing and medical issues.

Experts at the Flipped Learning Network (2014) specified the focus should be on flipped learning. They identified four pillars that educators should incorporate into their practice to ensure learning occurs when the flipped classroom format is used. The first pillar is the presence of a flexible environment that can be rearranged to support either individual or group work. The second is the need to promote a learning culture, with deliberate use of learner-centered approaches. The third is for educators to provide intentional content and always think about how the content can best be relayed to students to promote understanding. The final pillar is related to the professional educator role, where faculty “are reflective in their practice, connect with each other to improve their instruction, accept constructive criticism, and tolerate controlled chaos in their classrooms” (Flipped Learning Network, 2014, p. 2).

Evidence Related to Use of the Flipped Format

Most of the early studies related to the flipped format occurred in academia. For example, Zainuddin and Halili (2016) reviewed 20 research-based articles regarding the flipped classroom from 2013 to 2015 in varied fields of study ranging from science and math to humanities. Overall results indicated the flipped classroom positively contributed to leaner achievement and engagement. Challenges such as student and faculty adaptation were mentioned, as well as concerns regarding the quality and design of online content. Similarly, Presti (2016) performed an integrative review of 13 research articles regarding the flipped classroom in nursing education from 2010 to 2015. The reviewed studies included undergraduate, graduate-level, and doctoral courses. The research designs were varied and focused on different variables, such as improved test scores, responses to survey questions, and participant satisfaction. Overall, results were mixed, with only one study demonstrating a statistical significance in improving examination scores. Thus, Presti (2016) limited their conclusion to suggest that the flipped classroom may improve learner engagement.

More recently, Ward, Knowlton, and Laney (2018) conducted a literature review of 14 studies regarding the flipped classroom in nursing education. Four of the studies demonstrated an improvement in student performance. Concerns were related to the added preparation work on the part of both faculty and students, with students preferring traditional passive approaches. However, Ward et al. (2018) specified the importance of active learning in the development of problem solving and critical thinking, and thus recommended additional more rigorous studies regarding the influence of the flipped classroom on these skills. The content in the upcoming paragraphs of this article provides examples from the literature regarding flipped learning in the workplace and specifically for the education of nurses.

The Flipped Format in Workplace Learning

Flipping the classroom may seem to be more easily fit into the academic setting, rather than the workplace. However, Nederveld and Berge (2015) performed a review of the literature for examples of how the format had been used in the workplace. Prework included video lectures, interactive videos with knowledge checks, and online modules. Active learning in the classroom included problem-based learning, concept exploration, meaning-making activities, and collaborative learning. Benefits were identified as having more class time to apply knowledge, higher level learning, support to diverse learners, and increased resources. The authors suggested additional potential benefits could include reduced travel costs, improved outcomes, and improved return on investment. Nederveld and Berg (2015) also identified challenges with the flipped classroom, such as the need for instructors to learn new skills, unprepared students, and varied learner access to technology.

The Flipped Format to Educate Nursing Professionals

McDonald and Smith (2013) recommended use of the flipped classroom for nursing professional development and indicated the flipped format could provide nursing staff on all shifts with “access to consistent instructional content prior to in-class sessions” (p. 438). Several examples regarding use of the format with practicing nurses have been published. Although most articles are anecdotal (rather than research based), they provide insight as to how educators have used the flipped format for orientation, ongoing education activities, and workshops.

An early example of the flipped classroom occurred in a nurse internship program for new neonatal intensive care nurses (Pilcher, 2011). In an effort to increase learner engagement and vary learning strategies, new nurses were assigned prework for several of the topics, with live class time being used for application. For example, for the topic of neonatal ventilation, the nurse interns completed three online modules prior to class, which consisted primarily of reading material with pictures. Afterwards, they spent time in the unit with a respiratory therapist for hands-on experience with the different types of ventilators. Live class time was used for interpreting blood gases and solving case examples in which learners anticipated what ventilator changes might be needed (Pilcher, 2011). Although results were not compared to prior nonflipped results, preceptors reported the new graduate nurses who participated in this learning format demonstrated a better understanding of neonatal ventilation and blood gases than prior groups who had lecture for this content. The primary challenge that arose was logistical (rather than educational). According to the Fair Labor Standards Act, nonexempt employees should be compensated for off-the-clock work. This includes required training, such as self-study work. To address this, the average time to complete the modules was calculated to determine the amount of time to pay the nurse interns for the time they spent completing the prework.

More recently, Bishop and Wackler (2017) described using the flipped format, along with increased interactivity and simulation, to improve engagement of Generation Y nurses attending a nurse residency program. The authors reported learner satisfaction, improved confidence, and retention of content. Similarly, McPherson and Talbot (2018) described use of the flipped classroom for orientation and skills fairs for acute care nurses. Content was provided through use of online modules, with builtin real-time remediation, followed by a skills fair with hands-on demonstration. The authors reported a savings of $28,737 during the first 2 years after the flipped format was initiated. They also reported unexpected results related to increased staffing flexibility and staff reporting that the learning “added value that was not previously present” (McPherson & Talbot, 2018, p. E2).

For ongoing education, Costanzo, Ehrhardt, and Gormly (2013) described a blended flipped dysrhythmia course for new nurses. Prework included online content, which allowed nurses to spend as much time as they needed to complete modules. The live class was used for problem-solving activities. Costanzo et al. (2013) reported that the nurses successfully completed the course in a shorter time frame than with the prior traditional model, with an estimated annual savings of $40,000. Similarly, Johnson (2016) described the flipped classroom format as a strategy for promoting professional development through journal clubs. Interested participants were notified regarding specific articles to read before attending a class. The class time was then spent with participants discussing how to incorporate evidence into their practice.

Butlar, Pilcher, Flanagan, and Haley (2017) described use of the flipped classroom in a workshop for 104 nurse educators. The purpose of the workshop was to advance the skills and practices of nurse educators, as well as to model the flipped format. Prework included reading materials, brief lectures with voice-over narration, online modules, spreadsheets, FAQ sheets, an electronic book, and Word® documents designed as just-in-time resources. The live session included participant application of content learned. Participants worked in small groups to solve a multifaceted case study that incorporated all the topics from the prework. A facilitator presented the case study to each group and assisted participants with staying on track. Participants reported overall satisfaction, with some indicating excitement regarding the flipped format and the learning that had occurred. A challenge was described related to technology firewalls at some of the participant's facilities, which blocked access to some of the prework content (such as YouTube videos and content developed using Prezi®).

The flipped format can also be used for advanced training. For example, Zwerneman, Tolentino, and Pilcher (2019) described changing from a traditional lecture-based format to the flipped classroom, along with a problem-based learning strategy, to provide training for new clinical leaders. Prework included reading materials, hint sheets, how-to videos, and online modules. During the class time, participants worked in small groups to solve six multifaceted case studies focused on “realistic and complex problems that participants would likely face in their new leadership roles” (p. 31). The class time was facilitated by subject matter experts who had undergone training regarding how to facilitate learning using the flipped format. Although initial cost of module and resource development was significant, the authors reported that the costs were offset by a decrease in the number of actual classroom days and a decrease in commuter hours per person, resulting in an estimated annual salary savings of $18,240. Participants reported increased perceived competence when performing common management tasks, such as reading finance reports and applying content to practice.

Planning and Implementing a Flipped Class

The actual planning, implementation, and evaluation of a flipped class requires new ways of thinking and additional steps beyond the typical traditional lecture-based learning activity. Yet, as with any educational activity, planning should begin by conducting a learning needs assessment and by identifying desired outcomes. Initial decisions need to be made regarding the content to cover in the prework, how the prework will be delivered, who will facilitate the live class, the activities that will be included in the class, and how learning will be measured.

Planning

A common strategy for determining the content to cover in the prework is to examine what would have historically been presented in the classroom (Bergmann & Sams, 2012). Prework content can be delivered by a variety of methods, including readings, hint sheets, how-to videos, or online modules (Table 1 provides a more extensive list). If lecture is needed for the purpose of presenting new information or explaining difficult concepts, it should follow best practices. It is not appropriate to simply make a voice-over PowerPoint presentation of a lecture and place it online. Content should include only the need-to-know information (rather than the nice-to-know information) and should focus on information that learners will need to help them to meet the desired outcome (Pilcher & Bradley, 2013). Verbal delivery of content should be limited to a time frame of 20 minutes or less to minimize information overload and to help promote retention of content (Smith & McDonald, 2013). Additional best practices for designing online content include using a mixture of visuals to coincide with content, limiting numbers of words on the screen, and avoiding unnecessary text (Clark & Mayer, 2011). Doing so can occur with voice-over PowerPoint or with specialized software, such as Articulate Storyline and Adobe Captivate, depending on the budget, desired quality, and available time frame to develop modules. Additional decisions could be related to where to place online content if the facility does not have their own intranet. Some choices may include YouTube, Google Classroom, and open-source learning management systems such as Moodle and Dokeos.

Prework Learning Strategies

Table 1:

Prework Learning Strategies

Another planning step includes choosing content, activities, and strategies for the live classroom session. Research has demonstrated that classes “with the highest level of student engagement were those courses with the highest level of interactivity” and “the most well-received activities were those that required students to create their own learning tools” (Kuhlenberg, 2017, p. ii). Table 2 includes a list of potential activities that can be used for the live session. The activities should be aligned with the content and the desired outcome. In cases where the desired outcome includes skills demonstration or competence, simulations and role-playing may provide the best strategy. Whereas if ability to problem solve a realistic situation is the desired outcome, problem-based learning (PBL) is an option. PBL is commonly used in conjunction with the flipped format and provides learners with the opportunity to work in groups to solve complex realistic case studies involving multiple issues (Pilcher, 2018).

Classroom Learning Strategies

Table 2:

Classroom Learning Strategies

An additional factor to consider when planning a flipped course is deciding who will facilitate the live sessions and how they will be prepared for the role. Facilitation of learning, as opposed to lecturing, is not intuitive and is often difficult even for experienced educators. Kowalski and Horner (2015) stressed the importance of preparing educators for the change in their role and the need to practice, as well as to learn how to facilitate the live session. In some cases, subject matter experts may be the best choice to facilitate the live sessions. For example, subject matter experts served as facilitators for a flipped PBL activity in which new nurse leaders worked to solve a case related to management issues (Zwerneman et al., 2019).

Facilitator training can include content regarding the difference between teacher-centered and learner-centered strategies, evidence related to the flipped learning format, how to assist learners in finding answers, examples of how to avoid reverting back to lecturing when participants ask questions, details regarding the planned classroom activities, expectations of the facilitators, and resources available to assist them (Zwerneman et al., 2019). A portion of the facilitator training can include a group activity during which the facilitator role is modeled. A guidebook can also be developed for the facilitators and can include case studies, questions to ask participants, recommended activities, and additional resources.

Planning also needs to include consideration regarding how the classroom is set up. Rooms with flexible arrangement are optimal, with enough space to move around (Eby & Lukes, 2017). Round tables are considered as more likely to promote collaboration. Laptops should be available so that participants can look up resources or refer to their prework. Another option is to have participants bring their own devices.

If continuing nursing education credit is desired for the flipped class, a time frame needs to be calculated to determine how much credit is awarded (American Nurses Credentialing Center, 2015). One strategy for estimating time for the prework could include conducting a pilot test, in which three to four potential participants are asked to document their start and end time for each of the prework learning activities. The average time for each activity can be calculated. Next, the averages can be totaled and divided by 60 minutes to determine the contact hours to be awarded.

Implementation

When implementing the flipped classroom, it is important to let participants know ahead of time what to expect and why the flipped format is being used. Provide them with plenty of time and easy access to the prework. Send reminders. If completing the prework content is required and they are nonexempt employees, specify how they will be paid (as described earlier in this article).

Cord (2018) recommended implementation steps by using a team-based learning approach, which included the following elements: groups, accountability, feedback, and assignment design. Although his example was designed for an accounting class, the strategies can also be applied when implementing the flipped format in health care workplace learning activities. Cord (2018) began by collecting demographic information on the first day of class, and then groups were formed with students who had different characteristics with a goal of helping them to develop interpersonal and teamwork skills. Depending on the topic and the desired outcomes, nurse educators may choose to either place participants with similar skill levels together or place novices and experienced nurses together.

For the accountability element, Cord (2018) conducted individual testing at the beginning of each learning activity as a strategy to hold each student accountable for the reading assignments and to increase likelihood that the prework would be completed. The groups also completed a separate pretest together promote accountability to each other. In the workplace setting, Zwerneman et al. (2019) used a different strategy for accountability related to some learners arriving unprepared. Those learners were turned away and not allowed to attend class. Instead, they were offered the option to use a nearby room to complete the prework. Afterward, they registered for the next available classes. News travels fast, and the issue of unprepared learners was nominal afterward.

Cord (2018) provided immediate feedback through use of online automatic grading of homework, which provided both grades and explanations. During class, feedback occurred during class discussion and by walking “through the problem and answer until everyone understands” (Cord, 2018, p. 57). Additional strategies can include use of interactive online modules that provide integrated feedback, as well as input from facilitators during the live class.

For the final element, Cord (2018) designed assignments that could be completed during class time, with an emphasis on making a decision. This reportedly resulted in students being willing to work together to come to a consensus. Common strategies for designing an assignment in flipped classes for nursing can include simulation, debates, and problem-based learning. The designed assignments element also alludes to the importance of measuring outcomes. Strategies for measuring the flipped classroom could include formative strategies (such as learner satisfaction, group input, and monitoring for visual cues), summative input (such as pre- and posttesting, observation of skill performance, monitoring learner involvement, and responses during problem-solving activities), or confirmative strategies (such as by measuring quality of care indicators, staff turnover, or return on investment) (Garafalo, 2016). Cord (2018) indicated improved student teamwork and interpersonal skills, higher attendance, and improved grades. Cord also reported that although most students were initially critical of team-based learning, they embraced it by the end of the semester.

Conclusion

The flipped format is an active learning strategy with the potential to increase learner engagement, motivation, and ability to apply content. The format includes prework followed by in-class activities aimed at promoting application of knowledge. The flipped format can be used for orientation classes, clinical courses, and workshops and may be limited only by the educator's imagination. This article has provided insights and evidence to assist educators as they consider how the flipped format might be used in their setting. Hints were provided regarding planning and implementation of the flipped format in the health care workplace. However, more research is needed regarding planning, implementation, and effectiveness of the flipped classroom in nursing professional development.

References

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Prework Learning Strategies

Strategy
Blogs
Collecting artifacts
Concept mapping
FAQ sheets
Hint sheets
How to videos
Internet links
Journal articles
Online modules
Online message boards
Reading material
Recorded lectures
Self-assessments
Training manuals
Word documents
Worksheets
Wikis
Questions
Quizzes
Video demonstrations
Virtual simulations
Virtual scavenger hunts

Classroom Learning Strategies

Strategy
Case studies
Concept mapping
Creating posters/drawings
Games
Group-developed presentations
Hands-on practice
Peer discussion
Peer instruction
Peer evaluation
Problem-based learning
Quizzes
Question and answer sessions
Role-playing
Simulations
Solve realistic problems
Small-group activities
Video with response time
WebQuests
Authors

Dr. Pilcher is Faculty, Capella University, Minneapolis, Minnesota.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jobeth Pilcher, EdD, RN, 8992 Texas Trail, Terrell, TX 75160; e-mail: jobethp@att.net.

Received: February 28, 2019
Accepted: April 24, 2019

10.3928/00220124-20190917-06

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