Mastery of clinical nursingskills is one of the primordial concerns during college years of nursingstudents to ensure that the nursing care services they may rendered is safe andquality wise. With taking into consideration of the characteristics of millennialstudents, the availability and accessibility of technology, clinical nursingskills education could be reinforced with flipped classroom method. Students inthe 21st century are technology savvy generation which then,integrating flipped classroom in the learning process is like opening a portalof making connectivity and engagement with them as it may also address learninggaps particularly in skills facilitation and acquisition. The researcher used asystematic review methodology to assess the effects of flipped classroom in theclinical nursing skill education of nursing students. PICO questions have beenused as a guide. This review may suggest the use of flipped classroom andcomputer assisted learning technology in the teaching-learning process of students’to aid in the facilitation and acquisition of clinical nursing skills. METHODSSelection Criteria            Thissystematic 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.

Relatedliterature that has no application or not centered in the academe andnon-health related courses has been excluded.  A total of sixty-nine (71) full text articleswere retrieved and fifty-seven (57) of which has been excluded after screeningof criteria. Using PRISMA checklist, studies were appraised and twelve (14)articles were finally considered.

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 Study Characteristics            Studydesigns were randomized control design (n=2), randomized two-group parallelstudy (n=1), systematic review (n=3), mix method (n=4), survey (n=1), action-basedresearch study (n=1), comparative pretest-posttest design (n=1), and one-grouppretest-posttest narrative design (n=1). Years of the studies retrieved were inthe year 2017 (n=4), 2016 (n=7), 2015 (n=1), and 2013 (n=2) from the countriesof USA, Canada, UK, France, Germany, Israel, New Zealand, Pakistan, China, HongKong, and Singapore. Most of the participants of the study were students fromhealth related courses including nursing, pharmacy, and medicine.

 ResultsA total of 12 relevantstudies with different designs were included in the review. A randomized control trialdesign (pre-and-posttest) of mobile-based video learning outcomes in the clinicalnursing skill education conducted by Lee et al (2016) among 71 nursing studentswho were blind tested for their performance skills after participation in apractice laboratory demonstrating urinary catheterization. Students participatedin the intervention group significantly reported higher levels of learningmotivation and class satisfaction than their counterpart and was more confidentin performing catheterization skills.

This study proves that flipped classroomcan improve relevant clinical skills and learning outcomes. A pretest/posttest andpre-course/post-course survey at Texas, United States of America (USA) by Kooet al (2016) determined if flipped classroom design would improve pharmacystudents’ performance and discernments of the learning experience when comparedto traditional lecture course design. A survey questionnaire was administeredbefore and after the intervention. A formative assessment and evaluation wasdone and comparison of class performance of both flipped class and traditionalclass for 2 years. Findings revealed that flipped class group has higher meanscores in the posttest and were more satisfied in the course than thetraditional method. However students in the former expressed struggles with thetime 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 flippedclassroom model and the traditional lecture andragogy. The educationalstructure experienced of both groups has been set as before, during, and afterthe class.

Result shows that participants in the flipped class andragogy classhave higher mean exam score than those in the traditional class andragogy.However, the performance did not maintain over time.An action-based researchstudy was designed by Holik (2016) to gather evidence from a technicaleducation program to determine if students perform better in the flippedclassroom or traditional classroom. Information was gathered both from studentsand instructors to explore their perceptions, level of students’ engagement,and course grade. Findings revealed a higher engagement perception in theflipped classroom than the traditional; on the other hand, both final coursegrades did not indicate difference between the two teaching model. A dissertation comparativestudy of flipped classroom (n=115) and traditional classroom (n=95) at AuroraUniversity retrieved from ProQuest written by Heredia (2015) about the effectsof the flipped classroom model with concerns centered on the students’confidence, self-efficacy, attitudes, gender differences and key factors that relateto their achievement using the model. Result of the study shows that gender,major course of the study, and technology self-efficacy has no significantdifference and relationship with regards to students’ academic growth orperformance.Moreover, a dissertation,utilizing quantitative research design survey based research methodology atSaint Louis University has been conducted by Grabau (2016) about undergraduatestudents’ motivation and academic performance in a flipped classroom learningenvironment.

The researcher utilized Motivated Strategies for LearningQuestionnaire (MSLQ) to fourth (4th) year undergraduate students ina biology course (n=23). Results revealed that most of the respondents wereborn in the year 1995, Caucasian, female, freshmen, and have not been toflipped classroom before. Further, report shows higher motivational beliefsamong students that they can earn higher grades using the model as there isstatistical significant relationship between motivation and self-efficacy. A quasi-experimentalapproach type of study by Missidline (2013) was utilized to compare threeapproaches to learning such as traditional lecture only (LO), lecture andlecture capture back-up (LLC), and the flipped classroom approach of lecturewith innovative classroom activities (LCI). A convenience sample respondents of589 students has been recorded for a period of three semesters. Findings of thestudy 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 classroomcompared to other methods because of more work required and overlooking thevalue of interactive learning approaches. An action research wasconducted by Schwankl (2013) investigated the impact of flipped classroomdelivery method of instruction with regards to students learning and perceptionof the method. It was conducted in a rural southwestern Minnesota school ni twosections of Integrated II mathematics classes (n=17). A comparison of two (2)groups was employed, flipped classroom delivery (n=8) and traditional classroomdelivery method (n=9), their scores in pretest and posttest in basictrigonometry concept. Results yielded higher score for students who receivedinstruction in the flipped classroom method but, no significant difference inthe 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 offlipped classroom. Using purposive sampling of 39 PGY students receivingtraining in the General Surgery of Tri-Service General Hospital, flippedclassroom has been introduced by clinical teacher uploaded core curriculumslides, unit teaching videos, and related learning information to the hospitalintranet. The purpose of the study was to note change in the learning behaviorand learning outcome of the students compared to previous students undertraditional method of teaching. Results revealed an increase in the knowledge(3.26 increased of mean score), skills OSCE Objective Structured ClinicalExamination (0.

88 increased of mean score), and attitude (1.80 increased ofmean score). Correlation of the study shows positive relationship betweenself-efficacy and behavioral intention which means there is positive effecttowards behavior of the students to their performance with flipped class as anintervention.

A one-group pretest-posttestnarrative design was carried out by Lichvar et al (2016) using flippedclassroom teaching format to evaluate integration of a virtual patient activityin a required therapeutics course. Using a pre-recorded video lecturedownloaded in a website embedded in Blackboard made available for viewing ofstudents 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 oflearning (67% vs 83%).

About 68% of the students in the study expressed thatthe virtual patient helped them apply knowledge gained in a flipped classroom.A randomized control-groupdesign study comparing flipped classroom and traditional method of teaching wasconducted by Tang et al (2017) among fourth year medical students (n=95)  in an ophthalmology clerkship to investigateon the effectiveness and acceptability of flipped classroom approach. Twogroups were divided to flipped group (n=48) and traditional group (n=47). Theformer group was asked to watch a recorded lecture video and read studymaterial before face-to-face class meeting based on ocular trauma model. Questionnaireswere given and completed to both groups to evaluate students’ self-perceivedcompetence and interest in ocular trauma. Findings revealed that flippedclassroom helped promote students’ learning motivation, improved understandingof the course materials, and enhanced their communication skill and clinicalthinking.

   A systematic review wasconducted by Chen, Lui, & Martinelli (2017) to assess the effects offlipped classroom on medical learning of medical students utilizing flippedclassroom teaching approach as collected from various countries namely: USA,Canada, Hong Kong, India, France, Germany, Israel, New Zealand, Pakistan, andSingapore. There were nine (9) controlled design articles that have beenincluded in the study after critical review process. Findings of the studyshowed that students have positive perceptions of FC approach and its effectson changes in knowledge and skills were less conclusive which means no strongevidence that flipped classroom is better than traditional classroom method or approach.Another systematic review aboutthe application of flipped classroom in nursing education and the outcomeassociated with it was carried out by Betihavas et al (2016).

Visiting five (5)databases: PubMed, CINAHL, EMBASE, Scopus and ERIC has resulted in theretrieval of 21 papers that were peer reviewed and critically screened forinclusion 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 theflipped 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 theperformance scores between flipped classroom and the traditional method ofteaching. In contrary, the three papers (Missildine et al., 2013; Simpson andRichards, 2015; and, Gritz and Knight, 2013 as cited by Betihavas, 2016) showedthat flipped classroom as compared to traditional method is significantlyeffective in the improvement of nursing students performance.On the same note, asystematic review and meta-analysis of the effectiveness of flipped classroomsin nursing education was conducted by Tan, Yue and Fu (2017) to identify therobust available evidence.

Studies were retrieved from English databases(PubMed, CINAHL, EMBASE, Science Director, and Google Scholar) and Chinesedatabases (Chinese National Knowledge Infrastructure CNKI, WangFang Data, VIPinformation, and Chinese Biomedical Literature CMB). Studies were appraisedusing the PRISMA model. There were 29 studies included in systematic review.Results showed an improvement in the academic performance, skills, andself-learning abilities as well as high fidelity in terms of nursing degree andresearch settings.  Discussion            Thispresent review identified some effects on the application of flipped classroommethod in the performance outcome of nursing students particularly in clinicalskills acquisition. This also identified several studies about the perceptionon integrating flipped classroom in the classes and in the curriculum. In mostof the studies reviewed showed that flipped classroom has increased theirperformance in school based on the comparison of pretest and posttest scores.

Threeof the studies that has integrated flipped class in skills facilitation andacquisition showed an improvement in the clinical skills.            Moreover,seven of the reviewed studies showed that the students who experienced flippedclassroom method of teaching has increased their interest and satisfactiontowards the course, boosts confidence, and perceived the method as effectiveand must be blended with other teaching method. It also allows students tobecome independent, more prepared, and comprehensive learner. However, two ofthe studies (Missidline et al.

, 2013; Koo et al., 2016) showed that performanceis not relative to time and that students expressed a sense of loss of time andadditional burden to their requirements in the class to comply.            Furthermore,systematic reviews studies all showed that flipped classroom method haspositive effects to the performance of nursing students but lacks strongevidence that it is better than the traditional method. This review stronglysuggest that flipped classroom must be blended with other pedagogy or teachingmethods to maximize its purpose and in addressing the diverse needs of themillennial students.