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Quantitative outcomes for nursing students in a flipped classroom.


The study aim was to objectively compare learning outcomes of two pedagogies as measured quantitatively through exam questions, quiz scores, and course grades. Eighty-two baccalaureate nursing students were randomly assigned to either the flipped or the traditional classroom. No statistically significant differences were noted between groups in outcomes measured, and the flipped classroom was found to be an effective strategy for nursing education.


Constructivism--Nursing Education--Flipped Classroom--Teaching Strategies


The integration of theory with clinical practice entails more than knowledge application. It requires productive thinking and clinical reasoning. The need for effective strategies to help nursing students integrate theory and practice requires a change in pedagogy that calls for faculty to step out from behind the podium and engage students in practice-based learning experiences (Benner, Sutphen, Leonard, & Day, 2010).

Faculty at our college of nursing used constructivist theory to create a flipped classroom with experiential activities designed to guide students in the recognition of salient and relevant changes in client situations across time. Application of constructivist theory through the flipped classroom supports students in building knowledge and reasoning skills based on learning preferences and the knowledge they acquired in earlier courses (Fosnot & Perry, 2005).


The modern flipped classroom began in 2007 in a high school chemistry course in Colorado (Bergmann & Sams, 2012). Flipping the classroom replaces the standard lecture-in-class format with interactive opportunities. This paradigm switch consists of students viewing lecture materials before class and attending class prepared to engage in faculty-guided learning activities. This methodology restructures and reorders the traditional classroom in a concerted effort to move students to the center of learning.

Quantitative research of student outcomes in a flipped classroom at higher educational levels is very limited. However, a substantial body of research supports the instructional foundations of a student-centered, active-learning approach. Active learning is associated with improved academic performance, increased learning and achievement, and greater engagement, improved critical thinking skills, and better attitudes toward learning (Chaplin, 2009; Gleason et al., 2011; O'Dowd & Aguilar-Roca, 2009). Therefore, the aim of the present quantitative study was to compare the learning outcomes of two groups of nursing students, in flipped and traditional pedagogies, as measured through exam questions (knowledge and application type questions), quiz (just-in-time) scores, and overall semester scores.


Faculty used an experimental design, randomizing a convenience sample of 82 undergraduate nursing students to two different teaching interventions. The human research review committee qualified the project as exempt based on normal practices in routine educational settings.

Students were in their second semester of a baccalaureate nursing program in a public university in the Midwest. Participation took place during January through April 2013 in a first-level medical-surgical nursing theory course, which used a concept-based curriculum to teach care of the adult. A unique online course site was established for each group, and students were randomly assigned to the traditional class or to the flipped classroom.

All students met at the same time and day of the week, for the same period of time, in different classrooms. Identical outcomes included three examinations, 24 quizzes, and a written paper. Examinations were given to both groups at the same time and in the same classroom.

Four faculty members taught course content based on their expertise in both the traditional and the flipped classroom. Both student groups completed identical, weekly online just-in-time quizzes, given for the purpose of reinforcing student learning and identifying areas warranting clarification. Students in the traditional classroom attended live lectures with minimal classroom activities, while those in the flipped classroom prepared prior to class.

Data were analyzed using SAS software version 9.3 (SAS Institute, Cary, NC). Descriptive and inferential statistics were used to compare scores between the groups. In addition to conventional hypothesis testing (/-tests and confidence intervals) to detect significant differences, the method of equivalence intervals was used to demonstrate similarity between groups. Finally, multivariate analyses of covariance (MANCOVA) techniques were employed to further investigate potential differences between the groups while accounting for other pertinent variables.


Descriptive and inferential statistics results are found in the Table. For exam scores, the results are given overall and specifically for knowledge and application questions. Students in both groups performed similarly on all measures. All variable distributions were fairly symmetric and free of extreme outliers. No significant differences in means were found for any student outcome measure at a = .05. Effect sizes were all small except for exam 2 scores, which would be considered medium (Cohen, 1988). Observed power was computed for each 1-test, based on an effect size of 3 percent. Power was greater than 80 percent for the NUR 316 (current semester) grade, the NUR 266 (prior semester) grade, and Exams 1 and 3.

Equivalence intervals were used to show similarity between the groups (Patterson & Jones, 2006). A 3 percent difference, on average, between students in the traditional classroom and those in the flipped environment is considered meaningful since an increase of 3 percent raises a student to the next letter grade in nursing courses. Final and prerequisite course grades, Exam 1 score, Exam 3 score, and Exam 3 application questions score are equivalent with 95 percent confidence, on average, between pedagogies.

A MANCOVA was performed with overall scores on exams, quizzes, and the paper as dependent variables. Pedagogy type served as the independent variable, and the prerequisite course grade was included as a covariate. The difference between groups was not statistically significant (Wilks lambda = 0.882, p = .092).

Another MANCOVA was performed using exam scores specifically for knowledge and application questions as dependent variables. The difference between groups was not statistically significant (Wilks lambda = 0.851, p = .057). Finally, analysis of covariance (ANCOVA) was performed to detect a difference in mean course grade between groups after adjusting for prerequisite course grade. No significant difference was found (F = 0.002, p = .961).


Limitations of this study include lack of generalizability due to the small sample size and use of one institutional site. Students were also academically homogeneous, meeting similar admission requirements for entry into the nursing program. Faculty inexperience teaching in a flipped classroom, preparing screen casts, and interactive activities may also have influenced results. In addition, outcomes were assessed according to traditional measurements (test scores). A paradigm shift in the teaching methodology may require the development of a longitudinal assessment technique that measures clinical reasoning to better realize differences in outcomes.


The current study did not demonstrate statistically significant differences between pedagogies. However, the equivalence interval results imply that the novel approach of a flipped method was equally effective for student learning. Regardless of the pedagogy, students in both groups averaged 86.3 percent as a final grade, indicating mastery of content.

Comparison between the two approaches was based on short-term outcomes of test scores and course grades. The appraisal of a new pedagogy suggests that conceptual knowledge should be evaluated using novel tools, such as clinical reasoning measures (Benner et al, 2010).

The active assimilation of knowledge in the flipped classroom supported the cognitive constructivist theory by demonstrating mastery of content. This study was unique in that it was a randomized experiment, which demonstrated the effectiveness of the flipped classroom in nursing. Continued research will focus on improvements and accuracies in critical thinking assessments and problem-solving teaching methodologies.

We plan to follow these two randomized groups longitudinally through the remainder of the nursing program to see if any differences in clinical reasoning are detected. This could inform the effectiveness of a flipped approach in baccalaureate nursing education.

doi: 10.5480/13-1255


Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.

Bergmann, J., & Sams, A. (2012). Flip your classroom: Reach every student in every class every day. Washington, DC: International Society for Technology in Education.

Chaplin, S. (2009). Assessment of the impact of case studies on student learning gains in an introductory biology course. Journal of College Science Teaching, 39, 72-79.

Cohen, J. (1988). Statistical power analysis for behavioral science (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.

Fosnot, C. T., & Perry, R. S. (2005). Constructivism: A psychological theory of learning. In C. T. Fosnot (Ed.), Constructivism: Theory, perspectives, and practice. New York, NY: Teachers College Press.

Gleason, B. L., Peeters, M. J., Resman-Targoff, B. H., Karr, S.,

McBane, S., Kelley, K., ... Denetclaw, T. H. (2011). An active-learning strategies primer for achieving ability-based educational outcomes. American Journal of Pharmaceutical Education, 75(9), 1-12.

O'Dowd, D. K., & Aguilar-Roca, N. (2009). Garage demos: Using physical models to illustrate dynamic aspects of microscopic biological processes. CBE Life Science Education, 8, 118-122.

Patterson, S., & Jones, B. (2006). Bioequivalence and statistics in clinical pharmacology. Boca Raton, FL: Taylor & Francis.

Susan Ann Harrington, PhD, RN, is assistant professor, Kirkhof College of Nursing, Grand Valley State University, Grand Rapids, Michigan. Melodee Vanden Bosch, PhD, RN, is assistant professor, Nancy Schoofs, PhD, RN, is associate professor, and Cynthia Beel-Bates, PhD, RN, FGSA, is associate professor, Kirkhof College of Nursing. Kirk Anderson, PhD, is associate professor of statistics, Grand Valley State University,

Department of Statistics, Allendale, Michigan. For more information, write to Dr. Harrington at
Table: Statistics Comparing Student Outcomes by Instructional Method,
Traditional and Flipped

Student Outcome   Classroom       Mean (SD)    Power       95% Cl

Course Grade      Traditional    86.4 (3.3)     .945    (-1.5, 1.8) *
                  Flipped        86.2 (4.2)

Prereq Grade      Traditional    83.9 (2.7)     .995    (-1.2, 1.5) *
                  Flipped        83.8 (3.3)

Exam 1 Score      Traditional    60.2 (3.6)     .826    (-1.4, 1.7) *
                  Flipped        60.1 (3.4)

Exam 1            Traditional    19.9 (1.4)     .533     (-1.0, 0.3)
Knowledge         Flipped        20.2 (1.6)

Exam 1            Traditional    40.4 (2.6)     .743     (-0.7, 1.6)
Application       Flipped        40.0 (2.7)

Exam 2 Score      Traditional    57.6 (4.0)     .638     (-0.2, 3.6)
                  Flipped        55.9 (4.7)

Exam 2            Traditional    22.8 (2.2)     .378     (-0.2, 1.9)
Knowledge         Flipped        21.9 (2.6)

Exam 2            Traditional    34.8 (2.9)     .520     (-0.5, 2.2)
Application       Flipped        34.0 (3.2)

Exam 3 Score      Traditional    82.7 (4.0)     .803    (-2.5, 1.7) *
                  Flipped        83.1 (5.4)

Exam 3            Traditional    28.0 (2.1)     .520     (-1.5, 0.5)
Knowledge         Flipped        28.6 (2.4)

Exam 3            Traditional    54.7 (3.1)     .743    (-1.4, 1.6) *
Application       Flipped        54.6 (3.6)

Paper             Traditional    44.4 (3.0)     .687     (-2.0, 0.5)
                  Flipped        45.1 (2.4)

Quizzes           Traditional    44.0 (3.0)     .618     (-1.9, 0.7)
                  Flipped        44.6 (2.7)

Student Outcome   Classroom         Equiv.      Effect
                                   Interval      size

Course Grade      Traditional    (-3.0, 3.0)     0.04

Prereq Grade      Traditional    (-3.0, 3.0)     0.05

Exam 1 Score      Traditional    (-2.3, 2.3)     0.04

Exam 1            Traditional    (-0.7, 0.7)     0.21
Knowledge         Flipped

Exam 1            Traditional    (-1-6, 1.6)     0.16
Application       Flipped

Exam 2 Score      Traditional    (-2.3, 2.3)     0.40

Exam 2            Traditional    (-0.9, 0.9)     0.37
Knowledge         Flipped

Exam 2            Traditional    (-1.4, 1.4)     0.28
Application       Flipped

Exam 3 Score      Traditional    (-3.0, 3.0)     0.09

Exam 3            Traditional    (-1.0, 1.0)     0.24
Knowledge         Flipped

Exam 3            Traditional    (-2.0, 2.0)     0.04
Application       Flipped

Paper             Traditional    (-1.5, 1.5)     0.27

Quizzes           Traditional    (-1.4, 1.4)     0.21

Note. N = 82, 41 students per group

* A posteriori power computed for a 3 percent difference.
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Article Details
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Title Annotation:Research Briefs
Author:Harrington, Susan Ann; Bosch, Melodee Vanden; Schoofs, Nancy; Beel-Bates, Cynthia; Anderson, Kirk
Publication:Nursing Education Perspectives
Article Type:Report
Geographic Code:1USA
Date:May 1, 2015
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