The complexity of patient care continues to increase as patients are living longer with acute and chronic diseases due to advances in health care technology. Equipping the next generation of master's-prepared nurses to care for this increased complexity is of the utmost importance. Graduate nursing education traditionally has relied on classical pedagogical methods such as classroom-based lecture; however, researchers have questioned whether this teaching methodology will adequately prepare the next generation of nurses to develop the critical thinking skills required for practice in an evolving health care system (Hessler, 2016). The flipped classroom (FC) model, first developed by Bergmann and Sams (2012) in 2007, recently has generated interest in nursing education. This model has been viewed as an innovative teaching strategy that can potentially develop the required high-level reasoning skills being sought. This integrative review examines the current body of research on FC, the use of FC in graduate nursing education, and the effects this teaching modality has on graduate nursing students' academic performance and program satisfaction.
The FC model is one pedagogical methodology that can result in a more active learning experience for students. The FC model transitions students from passive learning via teacher-delivered content to active student-directed learning. In a traditional classroom, students learn passively by taking notes while the instructor delivers content using lectures. In an FC, students take a more active role in the classroom; students complete asynchronous, online lectures prior to attending class, then engage in teacher-facilitated, higher order and interactive classroom activities. In other words, the teacher shifts from the “sage on the stage to the guide on the side” (King, 1993).
The Flipped Learning Network (2014), a consortium of educators implementing such pedagogical strategies, has formally defined flipped learning as:
…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 these concepts and engage creatively in the subject matter.
The FC, as a model of flipped learning, allows instructors to become facilitators of learning, rather than drivers of learning. In turn, this allows students to take on a more interactive and responsible role in their learning process.
Although the FC model manifests differently in each classroom, students typically initiate low-level learning activities prior to coming to class; for example, students may watch online recorded lectures, read designated materials, or listen to podcasts. Students then present to the classroom, where the instructor engages them in higher order activities that are structurally aligned with preclass activities (Reidsema et al., 2017). This method of presenting the material achieves several purposes. First, the FC results in increased responsibility of students to pursue new knowledge. Because they are required to engage with material prior to coming to class, students must become active learners who construct, rather than simply receive, their own knowledge (Reidsema et al., 2017). Second, valuable class time can be reserved for interaction among students, peers, and faculty rather than for delivery of lecture content. Third, the FC model requires intentionality from instructors, with increased conscientiousness toward activity design and student engagement (Reidsema et al., 2017).
Grounded in research on adult learning and pedagogical theory, the FC design intends to use collaboration, emulation, and authentic learning to allow students to practice higher order thinking tasks (Reidsema et al., 2017). To be effective, classroom activities must allow students to apply and integrate new knowledge to solve practical problems under the guidance of the content expert (in this case, the instructor) (Reidsema et al., 2017). Among the questions surrounding the FC method is whether instructors are ensuring that their activities are rigorous enough to allow for the construction of this high-level knowledge.
Several authors have evaluated the impact of the FC in undergraduate nursing education. Bernard (2015) found the FC model resulted in statistically significant gains in academic performance in a variety of studies of various quality. However, although academic performance may increase, student satisfaction may not increase, particularly if the clear anticipatory guidance for success is not provided from the beginning (Bernard, 2015; Nije-Carr et al., 2017). Faculty across studies noted an increased upfront workload to prepare for the FC (Hawks, 2014). The most common measure of academic performance across studies is student grades, which is problematic from a research quality perspective, especially with regard to replicability (Bernard, 2015; Betihavas et al., 2016; Geist et al., 2015; Missildine et al., 2013). Not all studies across the nursing literature demonstrated an improvement in student performance with the FC, although most studies did note improvement (Ward et al., 2018).
As the U.S. population ages and health care costs continue to skyrocket, nursing has stepped up to the challenge by preparing a new generation of bedside nurses and advanced nursing practitioners to meet shifting systemic paradigms (Salmond & Echevarria, 2017). Graduate-level nurses require skills in the application of knowledge, integration of competing demands into care planning, political savvy to influence systems, and collaboration with interprofessional teams (American Association of Colleges of Nursing [AACN], 2011). To adequately prepare these nurses, educators must adapt the graduate curriculum to use “imagination, transformative thinking, and evolutionary change” (AACN, 2011, p. 3). The FC seeks to do just this: prepare students to meet the practical demands of the awaiting world by providing opportunities to practice these skills within the safe environment of the classroom.
It is of the utmost importance that graduate programs equip the next generation of master's-prepared nurses to care for an increasingly complex population of patients. Graduate nursing education traditionally has relied on classical pedagogical methods such as classroom-based lecture; however, Hessler (2016) questions whether this teaching methodology will adequately prepare the next generation of nurses to develop the critical thinking skills required by the current health care system. The FC model, first developed by Bergmann and Sams (2012) in 2007, recently has stirred interest in nursing education. This model has been viewed as an innovative teaching strategy that could potentially develop high-level reasoning skills in nurses. The FC model transitions students from passive learning via teacher-delivered content (i.e., lecture and note taking) and instead provides opportunities for student-led learning via teacher-assisted, higher order instructional activities.
This integrative review examines the current body of research on FC and the effect this teaching modality has on graduate nursing students' performance and satisfaction. The purpose of this integrative review was to determine whether the use of the FC increases student satisfaction and academic performance compared with traditional classroom modalities in graduate nursing education. For the purposes of this review, graduate nursing programs were defined as postbaccalaureate programs including Master of Science in Nursing (MSN), Doctor of Nursing Practice (DNP), and Doctor of Philosophy Degree in Nursing (PhD).
A literature review was performed using CINAHL® Plus with Full Text. Key words included graduate nursing education and teaching methods, information technology and graduate nursing education, graduate nursing education and flipped, graduate nursing education and hybrid, graduate nursing education and web-based, graduate nursing education and satisfaction, graduate nursing education and web-based and satisfaction, graduate nursing education and inverted. This search yielded a total of 352 articles. Abstracts were evaluated, and articles were eliminated if they did not meet the following inclusion criteria: published from 2000 to 2019, referenced nursing educational strategies at the master's level, and met the operational definition of the FC methodology (i.e., lower level activities performed prior to the class meeting, during which time higher order learning tasks were performed with faculty guidance).
Specific exclusion data were articles that were non-English language, non-FC focus, dissertations, editorials, blogs, commentaries, or reviews, or that focused on the incorrect population (e.g., continuing education, postbaccalaureate nurse residents, or undergraduate nurses). Articles without available abstracts or without enough information in their abstracts were read in their entirety (n = 157). At the completion of the literature search, a total of five articles were included. The PRISMA flowchart (Figure 1) by Moher et al. (2009) was used to organize and detail the literature search process. At the completion of the literature search, a total of five articles were included.
PRISMA 2009 flow diagram.
Data Extraction and Analysis
Using a literature matrix format, each study was reviewed individually and classified by study design, sample population, major variables, data collection and analysis methods, results, and themes. Each study was assessed for quality using six indicators as specified by Shavelson and Towne (2002): significant question, relevant theory, direct investigation, chain of reasoning, replication, and dissemination (Table 1). An appraisal of each study's overall contribution to the body of evidence was performed. A secondary literature matrix was created to compare study purpose, nursing population, methods, and outcomes specifically related to student satisfaction and academic performance (Table A; available in the online version of this article). Outcomes from each study were synthesized to aggregate findings regarding satisfaction and performance within the FC.
Quality Appraisal Table
A total of five articles were included in this integrative review. These articles were reviewed to determine FC course structure and to gauge the effect FC had on student academic performance and satisfaction (both faculty and student) in the graduate nursing classroom. Of the five articles, three used mixed methods, one was retrospective nonexperimental, and one was a cross-sectional descriptive study (Table A). All of the studies used online materials for preclass work, although these materials varied in terms of video length and content, as well as additional materials (i.e., current peer-reviewed articles, text readings, etc.). Student satisfaction was studied in four of the articles, whereas only two articles studied academic performance (Table B; available in the online version of this article). One article commented specifically on faculty satisfaction with the FC method (Table B). Overall, current research shows that an improvement in student academic performance and student satisfaction can be observed when FC methodology is used.
Flipped Classroom Synthesis Table
The structure of the FC classroom varies a great deal. In part, this may be due to the varied course content included in the studies in this review. Studies were performed in varied graduate nursing classrooms, including a statistics course, a pharmacology course, two pediatrics courses, an evidence-based practice course, and a qualitative research course. Preclass activities were highly varied but included both text and journal readings, online videos or recorded lectures, and case studies. Some courses included quizzes to hold students accountable for preclass work. In-class activities also varied, including discussion, student presentations, group work, and case studies. Future studies could expand on this body of literature by comparing classroom structures to determine whether specific structures are more effective than others or whether this varies by course content.
Academic performance was measured in three of five studies and was seen to improve or remain consistent compared with the traditional classroom in each of these studies. Several authors suggested this was related to the use of classroom time for more “meaningful” activities (Critz & Knight, 2013; Lancaster et al., 2012; Schwartz, 2014). Furthermore, the FC method allowed professors to assess their students' comprehension in real time, a benefit not typically available in the lecture format. Multiple studies commented on students' assessment that recorded lectures improved access to course materials and allowed for increased autonomy in learning the material. Student performance was measured primarily in studies using nonstandardized, teacher-created instruments, and thus operational definitions of academic performance varied significantly. This limits reproducibility of study findings and reduces the applicability of results to other classroom types. Future studies should consider using standardized testing instruments to measure student performance pre- and postimplementation of the FC method.
The relationship between academic performance and higher order learning is variable and primarily depends on assessment techniques used by the instructor. Brookhart (2010) writes that assessment of higher order thinking requires that faculty incorporate specific elements into the design of the assessment. Examples of design elements include the use of novel materials that require new thinking (e.g., not materials discussed in class) and the application of assessment formats that hone in on the higher order skill in question (Brookhart, 2010). Shraw and Gutierrez (2012) remind educators that faculty must consider whether an assessment is focused on a single skill or multiple skills simultaneously, is content-dependent, and the outcomes being appraised by each assessment measure.
The findings related to student satisfaction were mixed, and analysis proved challenging. However, several authors offered possible explanations for their student satisfaction results (Mudd & Silbert-Flagg, 2016; Schwartz, 2014; Vetter & Latimer, 2017). Schwartz (2014) observed a disconnect between student satisfaction and student performance, noting that an improvement in student academic performance may not necessarily lead to increased satisfaction. Multiple authors presumed that student satisfaction was impaired because students were not adequately prepared to take on the increased workload and responsibility associated with the FC methodology (Mudd & Silbert-Flagg, 2016; Schwartz, 2014).
Although not all students expressed satisfaction in these studies, several studies noted that students found coursework to be meaningful or helpful. Interestingly, one study noted that students expressed difficulty keeping up with the preclass work, despite the fact that the assignment did not differ from the assignments from prior course offerings in the traditional format (Mudd & Silbert-Flagg, 2016). Mudd and Silbert-Flagg (2016) postulated that students feel more accountable to doing the assigned work before class in the FC model and thus felt distressed by not having time to complete it. Educators who use the FC model should take care to adequately prepare and support students as they embark on this learning journey; this finding echoes findings from prior studies involving undergraduate nursing students in FC classrooms. Furthermore, educators should seek the buy-in of administrators to ensure that they remain supported throughout the FC transition process, even if student satisfaction scores decrease initially.
The relationship between student satisfaction and achievement of higher order learning has yet to be fully explored within the literature. However, as higher education shifts toward a more business-oriented model, student satisfaction has been increasingly used as a key performance indicator of educational quality (Duque, 2014). The data to support the direct relationship between student satisfaction and student learning behaviors remain equivocal; although student satisfaction may have an impact on motivation for learning, there are likely intermediate variables that have yet to be fully explicated (Duque, 2014; Griffioen et al., 2018).
Faculty satisfaction was a theme that resonated across two of the included articles in this review and was explicitly discussed in one study (Critz & Knight, 2013; Mudd & Silbert-Flagg, 2016). Schwartz (2014) found that although faculty seemed to like the FC approach, they did not like the effect it had on their workload. Faculty noted they had to spend more time preparing online content and preparing for classroom activities compared with the traditional classroom. The authors noted that faculty felt this caused increased stress at times. However, the faculty thought the FC had a positive effect on student overall performance and this motivated the faculty to continue with their use of the FC. All of the authors indicated they believed the FC model provided some benefit to their students, which may provide satisfaction to faculty (Critz & Knight, 2013; Lancaster et al., 2012; Mudd & Silbert-Flagg, 2016; Schwartz, 2014; Vetter & Latimer, 2017).
Traditional Classroom Versus Flipped Classroom
Previous studies have discussed the FC model in contrast to the traditional classroom model. However, it is important to note that this may create a false chasm, suggesting the two methods are oppositional rather than complementary. It is important to consider the FC as a strategy that augments, rather than fully replaces, the components of the traditional classroom. When transitioning students from a more traditional classroom model to the FC model, educators should consider building on the strengths that students have developed in the traditional classroom. The need to adequately orient students to the FC model was a key theme identified from the literature; this orientation allows students to lay the groundwork in setting appropriate expectations, contributing to both success and satisfaction in the FC.
Although the FC method has existed since 2007, the evidence for its efficacy and desirability is still in its infancy. This is especially true with regard to graduate-level nursing education. Although there has been much experimentation with FC in primary and secondary education, research has been limited among adult learning populations. Current studies tend to use small sample sizes and lack randomization, control, and standardized outcome measures. Future research should be designed specifically to address these deficiencies.
Several limitations were noted during completion of this integrative review. First, the FC has been inconsistently operationalized throughout studies on the model's efficacy. Although all surveyed research included the basic FC setup in which lower order preclass lectures and assignments were followed by in-class, higher order activities geared toward solidifying knowledge, the exact structure of these activities varied. Many studies included traditional classroom activities, such as lectures accompanied by note-taking and after-class assignments. This traditional setup was fairly consistent. Preclass work within the FC models ranged from home viewing of recorded video lectures, to completion of assigned readings, to podcast recordings, and integrative technologies such as online quizzes and discussions; in-class work ranged from case studies to group work. No one FC methodology was used across any pair of studies, and many studies failed to adequately describe the exact modalities used to the point that they could be replicated. It is apparent that further research concerning the FC methodology should use a standardized definition of the model. Additional research regarding how a standard model can be integrated across diverse graduate nursing classrooms is needed.
A second limitation noted in this integrative review was a lack of research specific to graduate-level nursing education. Most of the articles found in the initial literature search were related to undergraduate nursing. There is a noticeable lack of research on the FC within graduate-level nursing programs. Research included in this review covered multiple content areas within nursing, such as pharmacology and research. Only one article included participants from graduate-level family nurse practitioner students, the primary population of interest to the authors of this review. This gap in the literature proved challenging when attempting to extrapolate findings to our population of interest.
Finally, the available body of evidence regarding the FC model in nursing was noted to be low in scientific rigor. Studies tended to be few, had small sample sizes, and were of low-level construction (i.e., nonexperimental, nonrandomized, or uncontrolled). The low quality of the overall body of literature on FC in nursing makes it difficult for reviewers to draw firm conclusions regarding the efficacy of the model, as well as the best ways to implement this model as part of an evidence-based strategy for graduate nursing education.
Despite a thorough search and review of the literature, some relevant research likely was not discovered. Although the key words and key phrases used in this literature search allowed for selection of appropriate articles, the lack of a consistent operational definition for the FC model means that key search terms likely were overlooked. It is possible that other available research pertaining to nursing education and the FC therefore was not included in this integrative review.
The FC model shows potential in improving student satisfaction and academic performance within nursing education. However, the current body of evidence lacks scientific rigor and specificity for graduate-level nursing education. Future studies should seek to address a lack of consistency in operational definitions and use standardized measures to ensure replicability. Future studies also should standardize the delivery in which the FC method is undertaken in the graduate-level nursing classroom to allow for direct comparison of methods.
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Quality Appraisal Table
|Reference||Significant Questiona||Relevant Theoryb||Direct Investigationc||Chain of Reasoningd||Replicatione||Disseminationf|
|Critz & Knight (2013)||Yes||Yes||Yes||Yes||No||Yes|
|Lancaster et al. (2012)||Yes||Yes||Yes||Yes||No||Yes|
|Mudd & Silbert-Flagg (2016)||Yes||Yes||Yes||Yes||No||Yes|
|Vetter & Latimer (2017)||Yes||Yes||No||Yes||No||Yes|
|Citation Author/Year/Title||Design||Sample and Study Population/Setting||Purpose/Major Variables Studied and Their Definitions||Data Collection||Data Analysis/Methods of Analysis||Results/Themes||Appraisal; Worth to Practice|
|Critz, C.M., & Knight, D. (2013). Using the flipped classroom in graduate nursing education. Nurse Educator, 38(5), 210–213. https://doi.org/10.1097/NNE.0b013e3182a0e56a||● Cross-sectional|
Sample size: N=20
Focused on graduate students in an FNP program (pediatrics course)
|● Test an FC model to boost student engagement and satisfaction.|
10-item Survey (5 question Likert style; 5 question open-ended)
Survey assessed student satisfaction with FC
Followed students for 2 semesters Survey administered at the end of 2 semesters
Preclass material can include recorded lectures (20–40 min max), case studies, EBP articles, textbook readings, quiz
In-class activities can include intensive case studies, role-playing, group problem-solving exercises, differential diagnosis activities, student lectures presentations
60% of students felt the material covered was extremely worthwhile, 40% reported it was very worthwhile
Test responses were overall positive
Current EBP articles and short recorded lectures were noted to be the most helpful
Specific toward graduate nursing
Suggest that recorded lectures be no more than 30 minutes in length
FC is encouraged in graduate nursing
FC allows for better identification of students strengths and weaknesses
More research is needed in graduate nursing to determine what classes are appropriate for FC
|Lancaster, J.W., Wong, A., & Roberts, S.J. (2012). “Tech” versus “talk”: A comparison study of two different lecture styles within a Master of Science nurse practitioner course. Nurse Education Today, 32, e14–e18. doi: 10/1016/j.nedt.2011.09/018||● Retrospective case-control quantitative study with additional qualitative feedback|
23 students in traditional lecture (control) and 29 students in blended section (case)
|● To determine whether there was a difference in course grades in a pharmacotherapeutics course at Northeastern University's Nurse Practitioner program|
3 noncumulative course examinations
Participation scores for class activities
End of semester course feedback
|● t test to determine statistical difference between study outcomes|
Primary outcomes: course grade in pharmacotherapeutics course
Scores significantly higher for blended group on the 1st and 3rd exam but not the 2nd
Secondary outcomes: differences in exam scores for students in each section
Overall unadjusted scores for participation did not vary significantly
Blended learners expressed a higher agreement that the in-class activities and discussions were valuable, as were the classroom technology
Students in the blended section performed at a higher level than students in the traditional format on 2 of 3 exams
Authors speculate on the reasons that students performed more highly, including more in-class time of higher-order activities, which allowed for better retention and comprehension
Students noted the utility of online lectures as a contributor to learning and increased personal satisfaction
|Mudd, S., & Silbert-Flagg, J. (2016). Implementing the flipped classroom to enhance nurse practitioner clinical decision-making in the care of the pediatric asthma patient. Nursing Education Perspectives, 37(6), 352–353.||● Mixed||● Sample: N = 31 PNP and FNP students in a pediatric diagnostics course|
Student perception of the value of the FC method
Student perception of the FC's ability to improve learning
Specific details regarding data collection were not included (format, anonymity, etc.)
Preclass start survey was given to students, as well as a postclass student survey
|● Not explained|
More than 80% of the students surveyed said they agreed or strongly agreed that the content given in the classroom helped them meet course objectives and also helped them use info in new ways
Several students commented on the amount of work and the increased time the work required
Students reflected that sometimes they did not come to class having completed the online material
Comments on evaluation forms indicated that students found the FC to be more work than a normal week; incidentally, the required materials were the same as those USED in prior traditional lectures; authors postulated that the FC methodology pushed students to engage more fully in the material; creates a sense of accountability for students to prepare for class
Very little structure or rigor in design
|Schwartz, T.A. (2014). Flipping the statistics classroom in nursing education. Journal ofNursing Education, 53(4), 199–206.||● Mixed|
N = 12 PhD Students over the course of 2 classes (2 semesters)
Statistics class meets weekly for 3 hourrs
To determine student perception and satisfaction of an FC
To determine if knowledge increases with FC
An anonymous questionnaire was given to students after the 3rd week of class and then again during the last month of class
Students also given randomly assigned pre- and posttest quizzes
|● Analysis not discussed in detail|
Overall perception of class was positive with most responses stating that the class was helpful
Overall quiz scores improved from 1st quiz to 2nd
|● Uses both qualitative and quantitative data to show that FC increases satisfaction and knowledge of students|
|Vetter, M.J., & Latimer, B. (2017). Tactics for teaching evidence-based practice: enhancing active learning strategies with a large class of graduate EBP research in nursing students. Worldviews On Evidence-Based Nursing, 14(5), 419–421.||● Mixed|
N = 99 graduate nursing students.
Enrolled in a qualitative research course
|● To explore student perceptions about the effectiveness of FC and to see whether online activity was helpful|
Preclass work used groups of 5 to 6 students to facilitate learning activities instead of didactic lecture.
Links to YouTube videos provided (content = 60 minutes of students' time)
Class presentation used
Case studies used
Not described in detail
Used a 5-point Likert-type scale as well as the Critical Incident Questionnaire format with open-ended questions
Of the 99 students, 58 completed the survey.
91% of students agreed preclass work was helpful
85% agreed class presentation was helpful
83% agreed group review was helpful
93% agreed in-class discussion was helpful
Sheds light on specific activities that are helpful when implementing the FC
Gives tips to consider when transitioning to FC
Flipped Classroom Synthesis Table
|Reference||Flipped Classroom Structure||Academic Performance||Student Satisfaction||Faculty Satisfaction||Comparison with Traditional Classroom|
|Critz, C.M., & Knight, D. (2013)|
Recorded lecture videos
|Overall, improvement was seen in testing scores||IT support improved student experience
EBP articles and video lectures were helpful to students; quizzes were considered “worthwhile”
19/20 students found in-class case studies worthwhile
85% of students satisfied with student presentations
75% of students thought volume of materials was appropriate
25% of students thought coursework was too much||Preparation of the preclass modules was time consuming
IT support improved experience for faculty
Faculty perceived increased student engagement||Increased student engagement perceived by faculty in FC compared with traditional classroom
Faculty described the FC model as “an overwhelming success”|
|Lancaster, J.W., Wong, A., & Roberts, S.J. (2012)|
Recorded lecture videos
Discussion of real-life scenarios
Question and answer
|Average overall class score was 96.6% in FC classroom compared with 92.7% overall score in traditional classroom||Not examined||Not examined||Students in FC classroom performed at a statistically significant level compared with students in traditional classroom; FC classroom required more preclass work than traditional class|
|Mudd, S., & Silbert-Flagg, J. (2016)|
Recorded lecture videos
|Not examined||More than 80% of students agreed or mostly agreed FC helped them meet course objectives
Some students voiced the FC required more preclass work||Not specifically measured, but faculty noted more students attended class due to in-class work||Student satisfaction was elevated in FC classroom
Students felt “busier” in FC classroom than in traditional
Increased workload for faculty|
|Schwartz, T.A. (2014)|
Recorded lecture videos
Khan Academy videos
Small group work
|Overall quiz scores improved from 1st quiz to 2nd quiz||Overall student perception and satisfaction of FC was positive
Most responses stated the class was helpful||Not addressed||Time burden for faculty
Required strict organization on faculty's part for FC to be successful
Increased student engagement was noted by author|
|Vetter, M.J., & Latimer, B. (2017)|
|Not examined||91% of students agreed preclass work was helpful
85% agreed class presentation was helpful
83% agreed group review was helpful
93% agreed in-class discussion was helpful||Not addressed||Of 99 students, 58 completed the survey
Overall, positive satisfaction and perception toward FC|