Student-centered teaching is increasingly taking into account the traits of tech-savvy Millennial students (e.g., desiring convenience and immediacy, being heavy consumers of technology, being individualistic, and having a short attention span), who are digital natives of the smartphone generation (Montenery et al., 2013; Roehl, Reddy, & Shannon, 2013; Shatto & Erwin, 2017). Millennial students prefer gamification classes, technology, experience-based courses, and teamwork. They are accustomed to multitasking, instant and automatic feedback, and positive reinforcement (McCurry & Martins, 2010).
The flipped learning model addresses traits of this generational group because it encourages learning by enabling interactions between learners and by presenting and communicating class content through reading, questions, discussions, debates, explorations, problem solving, and projects (Goodwin & Miller, 2013). When flipped learning was used with such students, they perceived the university environment to be more innovative and task oriented, with a greater degree of collaborative learning, compared with the group that learned through traditional teaching methods (Strayer, 2012).
Educators have postulated that the flipped learning model will be useful in nursing, medicine, and pharmacology because it can narrow the gap between theory and actual practice (Hawks, 2014). As with other types of medical instruction (Prober & Khan, 2013), nursing education requires radical transformations of teaching approaches to include new models and pedagogies (Benner, 2015). The psychiatric mental health nursing practicum (within which this research was conducted) is an important course that familiarizes students with their role as future nurses by allowing them to implement face-to-face therapeutic communication with patients experiencing mental disorders, make psychopathologic observations, and implement and evaluate nursing interventions in the clinical setting. Students often experience particular challenges because this is their first clinical experience in treating patients with mental disorders. According to recent research, flipped learning may help enhance higher cognitive functions, such as problem solving and critical thinking, which are important competencies to have in real-life clinical practices (Anolak, Coleman, & Sugden, 2018; Njie-Carr et al., 2017). Therefore, a flipped pedagogical model that takes the smartphone generation's learning style into consideration can be a good strategy in clinical practica to maximize learning from clinical experience and enhance competencies.
The purpose of this study was to verify the effectiveness of the flipped learning method in a mental health nursing practicum using a retrospective survey.
The retrospective survey that was used to compare teaching methods was conducted during one semester on two groups of students—one receiving practicum using traditional learning methods, and the other receiving practicum in mental health based on flipped learning. This study included 70 third-year undergraduate students who were the first to take part in the nursing practicum for mental health in the college of nursing at a university in South Korea. Practica took place in eight small groups of eight to 10 students. Groups 1 to 4 were placed into the traditional learning group (36 students), whereas groups 5 to 8 were placed into the flipped learning group (34 students). Data were collected from October 2015 to January 2016. Using the data gathered, the differences between the two groups were compared to assess the effects of flipped learning. The institutional review board reviewed and approved the study.
The researchers used an iPad® application called Explain Everything (version 188.8.131.52) to create a flipped learning preconference video module that included six episodes on the following topics: practicum orientation, therapeutic communication, schizophrenia, antipsychotic drugs, communication among the medical team and nursing records, and depression and antidepressants. Each of the six video modules was in an MP4 format and lasted approximately 20 minutes (for a total of 120 minutes). The videos were saved in an Internet cloud service. The week before the practicum, a link to the material was sent to students via the messaging application. This preconference configuration was offered to only the flipped learning group; the lecture was thus ubiquitously accessible for self-initiated learning.
During this practicum (90 hours completed over 2 weeks in the clinical settings), students in the flipped learning group attended four conferences, lasting 2.5 hours each, with the researcher. These in-conference sessions involved various activities based on the six video modules. Activities included maintaining a reflective journal, participating in small-group topical debates, think-pair-share activities, therapeutic communication simulations, gamification, role-playing, and case study. On the other hand, the traditional learning group students attended four conferences lasting 3 hours each. Other activities were the same, except the researcher conducted mini-lectures on six topics for 30 minutes at the beginning of every conference (for a total of 120 minutes) that corresponded to the preconference for the flipped learning group.
To assess competencies, the core competency tool for Korean university students (Kang, Kim, Yoo, & Kim, 2014) was used. This self-reported, 5-point Likert-type scale (1 = not at all to 5 = very much) included 33 questions covering six subdomains: socialization, responsibility-practice ability, problem solving, knowledge construction, information management, and identity value. The program outcomes for the psychiatric mental health nursing practicum are related to these core competencies. Clinical and academic performance was assessed through a therapeutic communication simulation and a quiz. Satisfaction with the course was measured at the end of the semester via an overall course evaluation score. All pretest measures were collected just before the practicum began, and the posttest measures were collected immediately after it finished.
The data were analyzed using SPSS® 24.0. Descriptive statistics were calculated, and independent t tests and chi-square tests were performed. Cohen's d was calculated to measure effect size.
The prehomogeneity for demographic characteristics, academic performance, and core competencies between the traditional learning and flipped learning groups were verified. The average age of the traditional learning and flipped learning groups was 22.41 (SD = 1.81) and 21.81 (SD = 1.01), respectively (t = 1.74, p = .086). In the flipped learning group there were seven men, (20.6%) and 27 women (79.4%), and in the traditional learning group, three men (8.3%) and 33 women (91.7%; χ2 [1, 68] = 2.145, p = .182). The grade point average of the traditional learning and flipped learning groups prior to the practicum was 3.18 (SD = 0.66) and 3.34 (SD = 0.60), respectively (t = 1.091, p = .279).
When flipped learning was applied in the clinical practicum, core competencies significantly increased; the flipped learning group showed a mean increase of 11.26 points (SD = 5.32), whereas the traditional learning group showed a mean increase of 1.86 points (SD = 7.50; t = 6.022, p < .001). A before-and-after comparison of the six subdomains demonstrated that there were significant increases in socialization, responsibility-practice ability, problem solving, identity value, and information management. In other words, significant growth occurred in all subdomains except knowledge construction. The difference in the total score changes for the core competencies between the two groups showed a large effect size (Cohen's d =1.45).
The outcomes of the therapeutic communication simulation evaluation of flipped learning group (M = 87.25, SD = 4.56) was statistically significantly higher than it was for the traditional learning group (M = 84.35, SD = 4.88l), t(68) = 2.558, p = .013. This difference showed a medium effect size (Cohen's d = 0.61). There was no significant difference in the quiz scores of the flipped learning group (M = 71.22, SD = 11.53) and the traditional learning group (M = 70.73, SD = 11.64), t(68) = 0.175, p = .862. The overall course evaluation score (satisfaction with the course) of the flipped learning group (M = 93.24, SD = 7.00) was significantly higher than that of the traditional learning group (M = 89.13, SD = 7.05), (t = 2.44, p = .017), showing a medium effect size (Cohen's d = 0.59).
This study found that five domains of university students' core competencies (i.e., socialization, responsibility-practice ability, problem solving, information management, and identity value) were strengthened in a sample of undergraduate nursing students through the use of flipped learning. This is consistent with the findings of previous studies that examined the growth in competency associated with flipped learning in nursing (Kim & Jang, 2017; Oh, Kim, Kim, & Vasuki, 2017). Additional studies have demonstrated positive outcomes from undergraduate and graduate students (Critz & Knight, 2013; Njie-Carr et al., 2017). This study's greatest significance is that it applied a student-centered teaching method that reflected the characteristics of the clinical practicum students. The current findings demonstrate that flipped learning could be positively applied to a clinical practicum.
The group that was taught via flipped learning showed significantly greater academic improvement compared with the group that was traditionally taught. This is consistent with the findings of previous studies that examined the effectiveness of flipped learning (McLaughlin et al., 2013; Missildine, Fountain, Summers, & Gosselin, 2013; Wong, Ip, Lopes, & Rajagopalan, 2014). However, there were no significant differences in the final quiz results. This is likely because the quiz was a multiple choice test designed to test understanding and memorization. In Bloom's taxonomy, these are lower hierarchical learning areas that the traditional teaching method also targets; therefore, no significant differences were found between the groups in terms of their improvement of knowledge construction (e.g., quiz results and the subdomain of core competency). This coincides with the findings of a comprehensive review article (Waltz, Jenkins, & Han, 2014) concerning the previous 13 years of nursing education research in relation to active learning techniques (i.e., flipped learning method), which showed that variables related to knowledge retention and course passing rates were similar to traditional learning.
Through flipped learning, the students in this study were able to learn about psychiatric drugs and mental disorders whenever, wherever, and as often as they wanted. Moreover, because practice occurred simultaneously, they found this instructional approach to be useful and satisfactory. Previous studies that surveyed recognition after implementing various technologies, such as using a student response system, simulation, virtual experience class, and computer-based tests for university nursing students, found that students preferred the changes (Roehl et al., 2013). Implementing various technologies and allowing students to participate in experience-based learning and teamwork activities fulfills the needs of millennial students, who are adept at using scientific technology. Hence, these students are more satisfied with the learning environment and educational system. To teach more effectively, teachers must accept the challenge (Montenery et al., 2013) to develop new techniques.
This study faced certain limitations. First, this was not a randomized, controlled experimental research design; therefore, future research must exercise caution before generalizing these results. Second, this is a retrospective study, so the authors were unable to control certain variables that might influence changes in academic progress and competence. In the future, owing to the increased interest in academic achievement and improving students' core competencies, we suggest that the flipped learning method could be applied to general nursing education courses in addition to clinical practicum courses. Additionally, a randomized study that controls for potentially confounding and spurious variables should be performed to reveal the effects of flipped learning.
This research assessed the effects of flipped learning on a clinical practicum by applying a teaching method that reflected the characteristics of millennial nursing students in South Korea. Flipped learning helped to improve the students' core competencies and academic progress in an undergraduate practicum course.
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