Mastery of clinical nursing
skills is one of the primordial concerns during college years of nursing
students to ensure that the nursing care services they may rendered is safe and
quality wise. With taking into consideration of the characteristics of millennial
students, the availability and accessibility of technology, clinical nursing
skills education could be reinforced with flipped classroom method. Students in
the 21st century are technology savvy generation which then,
integrating flipped classroom in the learning process is like opening a portal
of making connectivity and engagement with them as it may also address learning
gaps particularly in skills facilitation and acquisition.

The researcher used a
systematic review methodology to assess the effects of flipped classroom in the
clinical nursing skill education of nursing students. PICO questions have been
used as a guide. This review may suggest the use of flipped classroom and
computer assisted learning technology in the teaching-learning process of students’
to aid in the facilitation and acquisition of clinical nursing skills.

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Selection Criteria

systematic review included all relevant studies about “flipped classroom”
accessed from different databases namely Pubmed/Medline, Google Scholar,
ProQuest, Scopus, and Grey Literature that are written in English language. Related
literature that has no application or not centered in the academe and
non-health related courses has been excluded.  A total of sixty-nine (71) full text articles
were retrieved and fifty-seven (57) of which has been excluded after screening
of criteria. Using PRISMA checklist, studies were appraised and twelve (14)
articles were finally considered.


Study Characteristics

designs were randomized control design (n=2), randomized two-group parallel
study (n=1), systematic review (n=3), mix method (n=4), survey (n=1), action-based
research study (n=1), comparative pretest-posttest design (n=1), and one-group
pretest-posttest narrative design (n=1). Years of the studies retrieved were in
the year 2017 (n=4), 2016 (n=7), 2015 (n=1), and 2013 (n=2) from the countries
of USA, Canada, UK, France, Germany, Israel, New Zealand, Pakistan, China, Hong
Kong, and Singapore. Most of the participants of the study were students from
health related courses including nursing, pharmacy, and medicine.



A total of 12 relevant
studies with different designs were included in the review.

A randomized control trial
design (pre-and-posttest) of mobile-based video learning outcomes in the clinical
nursing skill education conducted by Lee et al (2016) among 71 nursing students
who were blind tested for their performance skills after participation in a
practice laboratory demonstrating urinary catheterization. Students participated
in the intervention group significantly reported higher levels of learning
motivation and class satisfaction than their counterpart and was more confident
in performing catheterization skills. This study proves that flipped classroom
can improve relevant clinical skills and learning outcomes.

A pretest/posttest and
pre-course/post-course survey at Texas, United States of America (USA) by Koo
et al (2016) determined if flipped classroom design would improve pharmacy
students’ performance and discernments of the learning experience when compared
to traditional lecture course design. A survey questionnaire was administered
before and after the intervention. A formative assessment and evaluation was
done and comparison of class performance of both flipped class and traditional
class for 2 years. Findings revealed that flipped class group has higher mean
scores in the posttest and were more satisfied in the course than the
traditional method. However students in the former expressed struggles with the
time requirement of the course.

Anderson et al (2017)
conducted a randomized two-group parallel study design on seventy-eight (78)
pharmacy students to compare calculation skills achievement under flipped
classroom model and the traditional lecture andragogy. The educational
structure experienced of both groups has been set as before, during, and after
the class. Result shows that participants in the flipped class andragogy class
have higher mean exam score than those in the traditional class andragogy.
However, the performance did not maintain over time.

An action-based research
study was designed by Holik (2016) to gather evidence from a technical
education program to determine if students perform better in the flipped
classroom or traditional classroom. Information was gathered both from students
and instructors to explore their perceptions, level of students’ engagement,
and course grade. Findings revealed a higher engagement perception in the
flipped classroom than the traditional; on the other hand, both final course
grades did not indicate difference between the two teaching model.

A dissertation comparative
study of flipped classroom (n=115) and traditional classroom (n=95) at Aurora
University retrieved from ProQuest written by Heredia (2015) about the effects
of the flipped classroom model with concerns centered on the students’
confidence, self-efficacy, attitudes, gender differences and key factors that relate
to their achievement using the model. Result of the study shows that gender,
major course of the study, and technology self-efficacy has no significant
difference and relationship with regards to students’ academic growth or

Moreover, a dissertation,
utilizing quantitative research design survey based research methodology at
Saint Louis University has been conducted by Grabau (2016) about undergraduate
students’ motivation and academic performance in a flipped classroom learning
environment. The researcher utilized Motivated Strategies for Learning
Questionnaire (MSLQ) to fourth (4th) year undergraduate students in
a biology course (n=23). Results revealed that most of the respondents were
born in the year 1995, Caucasian, female, freshmen, and have not been to
flipped classroom before. Further, report shows higher motivational beliefs
among students that they can earn higher grades using the model as there is
statistical significant relationship between motivation and self-efficacy.

A quasi-experimental
approach type of study by Missidline (2013) was utilized to compare three
approaches to learning such as traditional lecture only (LO), lecture and
lecture capture back-up (LLC), and the flipped classroom approach of lecture
with innovative classroom activities (LCI). A convenience sample respondents of
589 students has been recorded for a period of three semesters. Findings of the
study shows that examination scores were higher for flipped classroom LCI group
(M=81.89, SD=5.02). than for both the LLC group 
(M=80.70, SD=4.25). p = 0.003, and the LO group (M=79.79, SD=4.51). p
< 0.001. However, students reported less satisfaction in flipped classroom compared to other methods because of more work required and overlooking the value of interactive learning approaches. An action research was conducted by Schwankl (2013) investigated the impact of flipped classroom delivery method of instruction with regards to students learning and perception of the method. It was conducted in a rural southwestern Minnesota school ni two sections of Integrated II mathematics classes (n=17). A comparison of two (2) groups was employed, flipped classroom delivery (n=8) and traditional classroom delivery method (n=9), their scores in pretest and posttest in basic trigonometry concept. Results yielded higher score for students who received instruction in the flipped classroom method but, no significant difference in the quizzes scores of both methods. Furthermore, Hsu et al (2016) in Taiwan investigated the outcomes of Post Graduate Year (PGY) students' cognition of and persistent behavior in learning through the intervention of flipped classroom. Using purposive sampling of 39 PGY students receiving training in the General Surgery of Tri-Service General Hospital, flipped classroom has been introduced by clinical teacher uploaded core curriculum slides, unit teaching videos, and related learning information to the hospital intranet. The purpose of the study was to note change in the learning behavior and learning outcome of the students compared to previous students under traditional method of teaching. Results revealed an increase in the knowledge (3.26 increased of mean score), skills OSCE Objective Structured Clinical Examination (0.88 increased of mean score), and attitude (1.80 increased of mean score). Correlation of the study shows positive relationship between self-efficacy and behavioral intention which means there is positive effect towards behavior of the students to their performance with flipped class as an intervention. A one-group pretest-posttest narrative design was carried out by Lichvar et al (2016) using flipped classroom teaching format to evaluate integration of a virtual patient activity in a required therapeutics course. Using a pre-recorded video lecture downloaded in a website embedded in Blackboard made available for viewing of students in preparation before class time to work on case-based scenarios, group discussion, and pre-test. Results showed higher posttest scores (30% vs 50%), overall median examination scores (70% vs 80%), and scores on higher level of learning (67% vs 83%). About 68% of the students in the study expressed that the virtual patient helped them apply knowledge gained in a flipped classroom. A randomized control-group design study comparing flipped classroom and traditional method of teaching was conducted by Tang et al (2017) among fourth year medical students (n=95)  in an ophthalmology clerkship to investigate on the effectiveness and acceptability of flipped classroom approach. Two groups were divided to flipped group (n=48) and traditional group (n=47). The former group was asked to watch a recorded lecture video and read study material before face-to-face class meeting based on ocular trauma model. Questionnaires were given and completed to both groups to evaluate students' self-perceived competence and interest in ocular trauma. Findings revealed that flipped classroom helped promote students' learning motivation, improved understanding of the course materials, and enhanced their communication skill and clinical thinking.     A systematic review was conducted by Chen, Lui, & Martinelli (2017) to assess the effects of flipped classroom on medical learning of medical students utilizing flipped classroom teaching approach as collected from various countries namely: USA, Canada, Hong Kong, India, France, Germany, Israel, New Zealand, Pakistan, and Singapore. There were nine (9) controlled design articles that have been included in the study after critical review process. Findings of the study showed that students have positive perceptions of FC approach and its effects on changes in knowledge and skills were less conclusive which means no strong evidence that flipped classroom is better than traditional classroom method or approach. Another systematic review about the application of flipped classroom in nursing education and the outcome associated with it was carried out by Betihavas et al (2016). Visiting five (5) databases: PubMed, CINAHL, EMBASE, Scopus and ERIC has resulted in the retrieval of 21 papers that were peer reviewed and critically screened for inclusion and exclusion criteria as well as eligibility leading to only five (5) final studies. Result of systematic analysis has yielded themes centers on 'academic performance outcomes,' and 'student satisfaction implementing the flipped classroom.' There were two out of five papers (Geist et al., 2015; Harrington et al., 2015 as cited by Betihavas, 2016) found no difference in the performance scores between flipped classroom and the traditional method of teaching. In contrary, the three papers (Missildine et al., 2013; Simpson and Richards, 2015; and, Gritz and Knight, 2013 as cited by Betihavas, 2016) showed that flipped classroom as compared to traditional method is significantly effective in the improvement of nursing students performance. On the same note, a systematic review and meta-analysis of the effectiveness of flipped classrooms in nursing education was conducted by Tan, Yue and Fu (2017) to identify the robust available evidence. Studies were retrieved from English databases (PubMed, CINAHL, EMBASE, Science Director, and Google Scholar) and Chinese databases (Chinese National Knowledge Infrastructure CNKI, WangFang Data, VIP information, and Chinese Biomedical Literature CMB). Studies were appraised using the PRISMA model. There were 29 studies included in systematic review. Results showed an improvement in the academic performance, skills, and self-learning abilities as well as high fidelity in terms of nursing degree and research settings.   Discussion             This present review identified some effects on the application of flipped classroom method in the performance outcome of nursing students particularly in clinical skills acquisition. This also identified several studies about the perception on integrating flipped classroom in the classes and in the curriculum. In most of the studies reviewed showed that flipped classroom has increased their performance in school based on the comparison of pretest and posttest scores. Three of the studies that has integrated flipped class in skills facilitation and acquisition showed an improvement in the clinical skills.             Moreover, seven of the reviewed studies showed that the students who experienced flipped classroom method of teaching has increased their interest and satisfaction towards the course, boosts confidence, and perceived the method as effective and must be blended with other teaching method. It also allows students to become independent, more prepared, and comprehensive learner. However, two of the studies (Missidline et al., 2013; Koo et al., 2016) showed that performance is not relative to time and that students expressed a sense of loss of time and additional burden to their requirements in the class to comply.             Furthermore, systematic reviews studies all showed that flipped classroom method has positive effects to the performance of nursing students but lacks strong evidence that it is better than the traditional method. This review strongly suggest that flipped classroom must be blended with other pedagogy or teaching methods to maximize its purpose and in addressing the diverse needs of the millennial students.