Nursing students' experiences of flipped classroom teaching method in higher education: a systematic review

Historically, teaching has been populated by a traditional teacher-centred approach, where students focus on the knowledge imparted by the lecturer (Tularam and Machisell, 2018). However, due to social distancing measures during the COVID-19 pandemic, traditional face-to-face teaching was replaced with blended learning (Imran et al, 2023), an educational approach that combines traditional face-to-face teaching with online or digital learning methods. Through interviews and questionnaires, the Office for Students (OfS) reviewed blended learning in 2022, concluding that students thrive best when they are active participants in their learning. The OfS (2022) encouraged universities to ensure that students' perceptions are used to inform course design enhancements.

As a student-centred approach teaching method, the flipped classroom has grown in popularity due to its combination of content delivery methods and active learning strategies (Erbil, 2020). It does, however, require students to engage in independent study activities. A mix of remote and in-person tuition leads to enhanced skills development in most areas, including independent learning, critical thinking, personal values and understanding others' perspectives (Dziuban et al, 2018; UK Engagement Survey (UKES), 2021).

The flipped classroom approach appears to be an effective teaching method for enhancing critical thinking skills (Strelan et al, 2020). It helps bridge the gap between theoretical knowledge acquired in the classroom and practical application in real-world scenarios (Anderson et al, 2014). Studies (Dehghanzadeh and Jafaraghaee, 2018; Hew and Lo, 2018) have discussed the positive impact on learners' critical thinking of the use of the flipped classroom approach within health professional education, showing that it significantly enhances their learning compared with traditional teaching methods. However, the research has also pointed to a gap in understanding how this teaching method affects the learner experience.

Aims

The review sought to answer the question: What are pre- and post-registration nurses' experiences with the flipped classroom method in higher education institutions? It sought to identify which characteristics of nursing students' experience contribute to a better learning experience, higher satisfaction and better learning outcomes.

Methods

This review's protocol is available on IDESR (International Database of Education Systematic Reviews) under the registration number IDESR000067. The interpretivist approach allows analysis of students' experience of the flipped classroom teaching method, which argues that knowledge is subjective and based on the understanding of lived experiences (Smith, 2013). Following the Joanna Briggs Institute (JBI) systematic review guidance (Lockwood et al, 2020) an interpretivist transcendental phenomenology approach was used in this review, with the findings placed in categories based on similarity of meaning in addressing a similar phenomenon, from which the synthesised findings could be formulated.

Inclusion and exclusion criteria

Specific inclusion and exclusion criteria were guided by the Population, Phenomena of Interest, Context, and types of Studies (PICoS) guidance (Table 1).

Search strategy

A three-phase search strategy and the PICoS framework were used to identify key search terms and synonyms. Terms analogous to ‘flipped classroom’ were considered, such as ‘inverted classroom’, ‘flipped learning’ and ‘inverted learning’. The terms ‘blended learning’ and ‘hybrid learning’ were also searched. The use of truncation allowed subject headings to be included with similar terminology. Adding broad terms to the PICoS elements, such as ‘qualitative studies’ and ‘interviews’ increased the sensitivity and specificity of the search. MeSH terms and Boolean operators (AND, OR and NOT) were used.

A search of databases was carried out between November 2022 and December 2022 and updated in May 2023. Databases searched were Academic Search Elite, British Education Index, CINAHL Complete, ERIC, Medline and APA PsycINFO. To search grey literature, ProQuest Dissertations was used. In addition, the reference lists of all studies included were screened and a full search strategy for each database is available from the authors.

Study selection and data extraction

Two authors (SM, ST) independently ran the database searches, reviewing and screening the titles and abstracts, followed by full-text screening of studies shortlisted for second-level screening. Conflicts were solved through discussion with the third author (HD). The authors conducted two levels of data extraction. The first extracted information on study description, population, context, culture, geographical location, methodology, phenomena of interest and data analysis (Lockwood et al, 2020) (Table 2). The second level extracted the findings for each study, alongside associated illustrations and page numbers, assigning one of three levels of credibility (unequivocal, equivocal or unsupported) (Munn et al, 2014).

Study quality assessment

The JBI Qualitative Assessment Review Instrument (JBI QARI) tool was used to assess the quality of included studies (Hannes et al, 2010). For mixed-methods studies a critical assessment of their qualitative component was undertaken, as ‘disaggregation’ of quantitative and qualitative data was possible (Atkins et al, 2012). To demonstrate methodological quality, each of the six studies included for review was assessed according to the JBI critical appraisal checklist for qualitative studies, using 10 questions, where five assess methodological quality and the remainder look at congruity between philosophical positions, methods, data extraction, interpretations and conclusions (Lockwood et al, 2020). Only studies that reported approval by local ethical bodies were included.

Data aggregation and synthesis

Frequent reference to all the included studies allowed the original meaning to be kept during the process of meta-aggregation. The first author (SM) extracted individual findings from the studies and grouped them into categories based on their shared meanings. Subcategories were created for clarity of meaning. All categories were agreed by consensus between all three reviewers and further aggregated into a generated set of statements.

Results

Following the search, 99 studies were identified across the selected databases. Before screening, 17 duplicates were removed using the RefWorks software tool. Initially, the title and abstract of 82 studies were screened, with 57 excluded because they either did not meet the inclusion criteria or were not relevant to the research question; 25 studies were extracted for full analysis, with five papers not being retrieved despite full-text requests via e-mail to the primary authors. On revision, 13 of the remaining 20 studies were excluded because they:

• Focused on different objectives (effectiveness or faculty experience)
• Included allied health professionals, rather than nursing students
• Used a quantitative rather than a qualitative approach, using a Likert scale to collect data
• The nursing education institutions in the geographical area studied were not comparable with UK nursing higher education institutions (HEIs). Thus, studies were excluded when not comparable with HEIs in the UK.

An additional study was identified through screening the reference lists of the final remaining five studies, and deemed suitable for inclusion.

Quality assessment of studies retrieved

All authors of all six studies failed to provide theoretical or philosophical statements, not locating the research either culturally or theoretically. This may be due to the word limits imposed by nursing journals compared with thresholds in designated qualitative research journals (Kim et al, 2017). This may lead to variations in the rigour and coherence of studies, introducing researcher bias, and may also affect the transferability of the findings to different contexts.

Three studies (Bingen et al, 2019; 2020; Nes et al, 2021) discussed the influence of the researcher on the research, improving their credibility. Two studies (Bingen et al, 2019; 2020) used a design-based approach popular among educational research, which allowed for the systematic development and evaluation of interventions in educational contexts (Anderson, 2005), demonstrating congruity between the research question and its aims. Green and Schlairet (2017) followed a phenomenological approach. The remaining studies used a qualitative descriptive design, which is commonly used in healthcare research due to its inherent simplicity and flexibility (Doyle et al, 2020).

All the studies represented the voices of the students, with results presented to support the conclusions drawn.

Study flipped classroom methods

A total of 107 undergraduate nursing students were recruited across the six studies included in the review. All studies explored the use of a flipped classroom method, in combination with activities undertaken on campus (in classroom) and off campus (out of classroom, ie online or self-directed).

In the study described by Nes et al (2021) students were introduced to the subject of patient care with a short traditional lecture, followed by an exploration of a case study presented digitally through animated videos. The case study was split into three episodes of care, which involved the use of a flipped classroom approach, which meant that the students engaged in off-campus individual work, group discussions centred around the collected data, and debates about their findings in a plenary session led by the teacher.

In another of the studies reviewed, Bingen et al (2019) emphasised off-campus activities, incorporating a ‘warm-up week’ to introduce the programme to students. This included activities such as ‘morning coffee’ and a live broadcast that guided students through their independent tasks. These tasks encompassed e-lectures, exercises with solutions, and a student forum. With the same student sample, Bingen et al (2020) shifted their focus to interactive on-campus activities, featuring group tasks, seminars and presentations. These activities utilised group dialogues and polls via the student response system to enhance engagement.

Hanson (2016) investigated the use of a structured design to deliver nursing pharmacology lectures using the flipped classroom approach, with students able to access pre-recorded e-lectures online during off-campus activities. On-campus lectures included quizzes and cases studies for assessing student preparation, followed by peer discussions. Real-time recordings were made of all sessions, concluding with summaries of key concepts.

The final two studies, by Telford and Senior (2017) and Green and Schlairet (2017), implemented e-learning within the flipped classroom. Off-campus activities featured e-lectures with tests and quizzes, enabling students to self-assess their preparedness, while on-campus activities involved groupwork and discussions.

Findings

A total of 106 findings were extracted and further aggregated into categories and subcategories by meta-aggregation (Lockwood et al, 2020). Two findings were omitted as their meaning did not meet any of the categories created or had an unsupported level of credibility. Based on similarity of meaning, seven categories emerged and were aggregated to generate three synthesised findings to answer the review question (Table 3).

Finding 1.

A positive overall experience

Thanks to a structured design and the use of technology to facilitate the activities, the flipped classroom approach was seen by many students as a positive experience (see Table 3). Adopting a structured design that helped guide the students' independent learning allows for identification of learning outcomes and how these can be achieved (Bingen et al, 2020). Conversely, allowing students flexibility regarding what to learn can create confusion, so the more structured approach was better received (Bingen et al, 2020). Offering a flexible approach within the flipped classroom may increase the transactional distance and may impact negatively on the learning experience of students (Chen et al, 2014). Thus, lack of structure can lead to dissatisfaction and confusion.

One of the studies under review reported that, during off-campus activities, independent study was better experienced when the link to on-campus activities was made more evident to students (Bingen et al, 2020). This is supported by others who have suggested that providing structure to a teaching activity promotes student engagement, allowing learners to become actively involved and engaged, increasing the potential to develop critical thinking (Hu and McCormick, 2012; Schlenker et al, 2013; Salter and Conneely, 2015).

Moreover, the findings of this review highlight that students appreciated how the activities they engaged with off campus were complementary to those they engaged with on campus (Telford and Senior, 2017), aiding their understanding of the subject (Bingen et al, 2019; 2020). Across the six studies, students' experiences with technology were positive, employing digital tools that matched students' learning styles. Studies, such as that of Brasca et al (2022), cited similar findings, reporting that over 60% of students welcomed the use of the different learning technologies, which had helped improve their learning and grades.

Some students, as reported in the studies in this review, did not appreciate the variety of learning tools used and missed face-to-face teaching (Telford and Senior, 2017; Bingen et al, 2020). The overuse of technology has been reported elsewhere as having negative outcomes (Greve and Tan, 2021), causing apprehension and dissatisfaction (Fuglseth and Sørebø, 2014). Bingen et al (2020) and Telford and Senior (2017) found that students wanted a balance between the use of digital tools and the traditional approach to teaching.

One digital tool mentioned in Bingen et al (2020) relates to student response systems, which gather learners' anonymous real-time individual interactions using on-screen quizzes (Dangel and Wang, 2008). A study by Walklet et al (2016) analysed the effectiveness of this digital tool in healthcare education, suggesting that this method can improve learning outcomes, enabling lecturers to gauge students' comprehension levels and facilitating the creation of review material. It has been suggested that, in higher education, the time spent in class should focus on knowledge application (Pluta et al, 2013), which aligns with the flipped classroom method, as students have the opportunity to actively apply concepts they have learnt off-campus. Finally, students appreciated seeing the links between what they had learnt and how they could apply their new knowledge in clinical practice (Hanson, 2016; Green and Schlairet, 2017; Bingen et al, 2020; Nes et al, 2021).

A scoping review (O'Flaherty and Phillips, 2015) found that students had a better experience when their learning was linked to practice; a lack of congruence between theory and clinical training is a known factor that affects students' performance in clinical practice (Saifan et al, 2021).

Finding 2.

Benefits and frustrations of groupwork

Across the studies, groupwork activities were reported by some students as frustrating, but by others as beneficial and helping to boost their confidence. However, they all emphasised that the group environment was important, offering the chance for human interaction. As the learners spend less time in the classroom, some may miss the social interaction with peers and with the teacher (Bingen et al, 2019). Loneliness can play a significant role in increasing prevalence of mental illness (Richardson et al, 2017; Kotera et al, 2021), something that was exacerbated during the COVID-19 pandemic (Leal Filho et al, 2021). In one of the studies reviewed (Bingen et al, 2020), students pointed out the importance of interacting with other students, a point that is supported in the literature, with studies showing that not only do students' relationships elicit positive experiences but that peer-support also aids the development of knowledge (Holst et al, 2017; Osborne et al, 2018).

Group activities were part of the flipped classroom method used in all of the six studies reviewed, with the finding that working in small groups seemed to be beneficial (Bingen et al, 2020; Nes et al, 2021). Peer learning in small groups enhances the learning experience by facilitating interaction and collaboration between peers (Hoppe et al, 2021). Studies not included in the review have indicated that students appreciate the opportunity to interact with their peers and to hear other students' perspectives during small group activities (Yazedjian and Kolkhorst, 2007). Learning to work in groups is paramount in nursing, with team effort and effective groupwork skills known not only to improve patient care (Babiker et al, 2014) but also to ensure the delivery of high-quality care (Rosen et al, 2018). Students mention how group interactions both benefit the development of their social skills, and also support the transferability of new skills to other groupwork situations (Gagnon and Roberge, 2012). Nevertheless, in the studies included in this review, some students expressed frustration about having to work with peers who were unprepared (Hanson, 2016; Telford and Senior, 2017; Bingen et al, 2020), while in other research (Gagnon and Roberge, 2012) students reported feeling frustrated with those they felt did not contribute equally to the work in the group activities. This led some students to argue over small details, while others struggled to trust fellow team members (Gagnon and Roberge, 2012).

Another factor identified across the six studies reviewed that influenced the overall group experience was familiarity among peers. The less familiar students were with one another, the lower their confidence in asking or answering questions.

Finding 3.

Confusing and challenging

Students found that they encountered new challenges when being taught using the flipped classroom approach and said that they missed learning through more traditional teaching methods. Students also perceived the implementation of the flipped classroom method as time consuming.

Some of the reviewed studies indicated that students were sceptical about self-directed study and preferred a more teacher-centred approach to knowledge delivery (Green and Schlairet, 2017; Bingen et al, 2019; 2020). However, despite lower student satisfaction compared with traditional teaching methods, one meta-analysis of the use of the flipped classroom method across a range of subjects concluded that grades had improved marginally using the flipped approach (Låg and Sæle, 2019).

In the reviewed studies, participants perceived their new learning strategy as time consuming (Bingen et al, 2019) and they struggled to keep up with the workload (Hanson, 2016). The time-consuming nature of the flipped classroom is well known (Hung, 2015), with students perceiving the need to study outside the classroom as an extra burden (Akçayır and Akçayır, 2018). Learners may be reluctant to embrace this teaching method because of their acquired passive learning habits from traditional teaching approaches (Chen et al, 2014).

Hanson (2016) pointed out that students viewed on-campus activities as substitutes rather than supplements to those they undertook off campus, because recordings of in-campus activities were available. This implies that students might not have been fully invested in their learning. Although research by Toppin (2011) suggested there were benefits to pausing and replaying lecture recordings for engaged learners, their availability can also detrimentally affect performance if students opt to use them as a substitute for attending class (Johnston et al, 2013).

Some students in the six studies reviewed reported feeling anxious: they did not feel comfortable asking question in front of their peers or taking part in online forums for fear of exposing their ignorance (Bingen et al, 2020). The implementation of a session such as that proven effective in Hew and Lo's (2018) meta-analysis, which demonstrated that quizzing students at the beginning of an in-class session boosts learning gains, could help alleviate such anxiety. The use of the flipped classroom has also been shown to reduce fear of examinations and related anxiety (Saba et al, 2019); however, when students do not engage and consequently fall behind with their studies this exacerbates their fear of participating (Akçayır and Akçayır, 2018).

Recommendation for practice

Pre-lesson planning

• Nursing programmes should facilitate interactive off-campus activities linked to on-campus classes, which need to be followed by formative feedback to the students
• Faculty should investigate individual student aptitude to learn online, assessing their IT skills, the availability of learning environments outside the classroom, available internet speed and devices used. When challenges are identified, the student should be signposted to relevant academic support
• The design of a nursing programme should accommodate a ‘warm-up week’ before the beginning of a module to allow students to familiarise themselves with the new learning strategy, digital tools and peer interaction
• Students should be introduced to, and supported to engage with, independent learning and flipped classroom methodology in a scaffolded way (Vygotsky, 1978). First-year students should be offered less independent learning and introduced to the flipped classroom approach gradually, so that by the third year this method is used across a majority of modules
• Nursing programmes should continue to teach core subjects using traditional teaching approaches, to ensure that students have the foundation knowledge to study independently and work in groups.

Flipped classroom on-campus

• Teaching sessions should incorporate chapter tests and pre-class quizzes to check students' preparedness and to improve students' engagement
• The student response system should be used during group on-site activities; however, it must not be used to score students on the activities, to avoid them competing against one another
• The sessions should facilitate smaller groups rather than larger ones, although there is no set threshold for participants per group.

Flipped classroom off-campus

• Students should also be allocated to groups for off-campus activities, identifying those who do not engage and addressing any perceived obstacles, as their non-engagement can lead to feelings of frustration among others
• It is important to establish clear links between learning outcomes and all on-site and off-site activities.

Limitations

Students who took part in these primary studies are likely to be more engaged with studies and the flipped classroom methodology, thus potentially skewing the data. The moderators were sometimes known to students, so they are likely to have responded in a socially desirable way (Telford and Senior, 2017). Participants' characteristics (age, gender or ethnicity background) were not reported, but may be relevant when analysing the students' experience.

Younger generations are likely to be more receptive of technologies and active learning (Gillispie, 2016). Globally, 70% of the health and social workforce are women (World Health Organization, 2021) and white/Caucasian (Kippenbrock and Emory, 2022). Understanding how minority groups perceive the flipped classroom methodology is important to address possible barriers and create an inclusive environment. Studies focusing on students' characteristics and acceptance of flipped classroom are required to understand the phenomena of interest fully. There are no studies on postgraduate students and because this cohort has clinical experience and often studies part time, the flexibility of flipped classroom has the potential to produce positive outcomes, but more research is needed. Internet access, speed, its availability, and appropriate devices and IT skills were not surveyed in the studies reviewed; these are issues that might impact the overall student experience, especially when the use of digital tools is experienced negatively. Further research on students' use of digital tools within the flipped classroom in nursing higher education is needed.

Conclusion

In this systematic review, the primary aim was to understand students' experiences of the flipped classroom method in nursing higher education. Although the effectiveness of this teaching approach has been discussed extensively in the literature, there remains a distinct lack of insight into the nuanced perspectives of students. This review has shown that a structured and well-guided design, combined with technology integration, positively impacts students' engagement and learning outcomes. A structured approach aids students in identifying learning objectives and how to attain them, resulting in a more favourable experience. In contrast, the lack of structure can lead to confusion and dissatisfaction. It is vital to make clear the connections between off-campus and on-campus activities, as this promotes understanding and application of the knowledge learnt in clinical practice.

Students' perspectives on groupwork activities within the flipped classroom method are mixed. Some perceived the implementation of the flipped classroom method as time-consuming and frustrating, while others saw it as beneficial and confidence-boosting. Regardless of these differences of opinion, the importance of human interaction remained a common theme.

Although the flipped classroom has been shown to be effective in improving learning outcomes, students' preferences may not always align with what is the most effective delivery method. This discordance can lead to students feeling overwhelmed by the workload and, in some cases, anxious about participation in group sessions and wider interactions.

Overall, it is clear that the flipped classroom approach is a valuable teaching method, positively impacting students' engagement and learning outcomes. However, it is essential for educators to adopt a reflective approach while actively considering students' feedback into their practices. The use of digital tools and a balanced use of technology within this teaching approach are crucial elements that should be carefully navigated.

Group activities, when effectively structured, can contribute to the development of essential social and teamwork skills in nursing education. Nevertheless, there are challenges, such as the potential for frustration and disparities in attitude towards group participation.

In the authors' opinion, this review encourages a balanced consideration of the pros and cons outlined above to determine whether the flipped learning approach aligns with individual pedagogical goals. As the educational landscape continues to evolve, it is essential to place students' experiences and voices at the forefront of teaching methodologies, ensuring that they remain engaged and well-prepared for the demands of clinical practice in nursing education.

KEY POINTS

• Clear guidance on independent learning activities supports students to adapt digital tools to their learning styles, and to identify and achieve learning objectives effectively
• There was a mixed response to groupwork activities: for some students, they were beneficial and confidence-boosting, while others felt frustrated because peers were unprepared or did not make an equal contribution
• Some students perceived the flipped classroom method as time consuming and frustrating, due to the workload associated with self-directed study outside class
• Human interaction remains a significant part of the learning process, despite varied opinions on groupwork. Structuring group activities effectively will enhance social and teamwork skills, while mitigating challenges

CPD reflective questions

• How effectively do I structure my teaching methods to facilitate independent learning among nursing students?
• How do I foster meaningful interaction and collaboration between students within groupwork activities?
• Am I mindful of the workload and potential frustrations experienced by students when implementing new teaching methodologies?