The Flipped Classroom in Nursing Education

October 2013
David Vlahov

These days, all the talk in education is about the “flipped classroom” and about the work of the Khan Academy. The flipped classroom is a disruptive innovation in education that takes students out of the lecture hall and, instead, provides asynchronous (i.e., whenever it’s convenient for the student) online content, and synchronous (i.e., scheduled teacher and student group) online or in-person meetings during which teachers and students work through exercises to master content.

The Khan Academy takes disruptive innovation a step further by using an adaptive learning strategy for competency-based education. Students log on at their convenience. Regular quizzes test whether students are ready to progress to the next level; if they are not, they receive alternative presentations that move them toward mastery of that level’s content.

For teachers who have enjoyed filling lecture halls with students marveling at their presentations – or holding forth in seminar salons – the flipped classroom may be an uncomfortable change.

After one university made the simple move of taping lectures to post online for students, one teacher I met complained about the diminishing percentage of students who actually attended her lectures. Of those attending, most were idling on Facebook. The teacher’s threatened response was to email the class that attendance was mandatory and viewing Facebook during lectures was prohibited. According to this teacher, discussion sections to review problem sets were hardly better, as some irritated students summarily discarded problem sets and demanded answers. The teacher snarled that Generation Xers were raised with an overabundance of positive reinforcement for simply showing up. All but holding her nose, she exhaled that students today learn differently.

On that last point, she is right – and that’s important for us to understand. The current generation of students grew up with the Internet, video games and social networking; this is their context. To successfully teach such students, we should embrace instructional design that makes the best use of new educational technology.

And let’s remember that adaptive or mastery learning is not new. In elementary school, my silent reading time was occupied with short books and questions; if we answered the questions correctly, we progressed to the next level, and if we did not, we had another short book to complete at the same level before we could move on.

What is new is the mode of delivery. Take a look at lectures on the Internet. I wish that I could have watched, paused and repeated lectures at my convenience. Consider that our students often juggle family and work. Shouldn’t we reward their desire to improve themselves with structured discussion groups that they can join online from home? Isn’t it a positive and reassuring development that they can be guided to develop and progress through competencies at their own pace? Widespread use of the Internet has facilitated the development of tools that make education more accessible – and that’s a good thing.

That said, how the flipped classroom and adaptive learning work in nursing education needs some further thought. There are topics, such as pathophysiology and pharmacology, that would seem to fit neatly with the new educational technology and adaptive learning techniques. Other topics are either less obvious fits or clearly not appropriate. Practicing manual skills and clinical interactions, for example, demands a more direct human touch.

Recently, the American Association of Colleges of Nursing, the Jonas Center for Nursing Excellence and the Khan Academy have come together to work with nursing faculty to take on these challenges. We look forward to the development of these new and exciting approaches to nursing education.



Since 2007, Dr. Beth Wilson and I have been teaching N247 Management of Complex Health Problems in a flipped classroom capacity. All lectures are on-line, with quizzes and other learning activities (e.g. ECG interpretation modules)that can be repeatedly accessed through out the course. We have received favorable student reviews every year. Let us know if you want to visit our website and/or attend our in-class case discussion. Regards, JoAnne Saxe

Although I am an "older" faculty member...I really am interested in learning more about the flipped classroom. I would like to visit your website to visualize how you set up the site. Thank you. Linda Hickman (Alexandria, LA)

The midwifery program has been teaching the N281 and N282 series in a flipped classroom for the past 8 years. At first I missed the lecture time, but have found that having students view lectures at home and having time for case studies and clinical application has worked well for everyone. I know that in my course N281A the evaluations have been positive also. As JoAnne stated, you are welcome to look at my CLE site or attend seminar. Rebekah Kaplan

While the flipped classroom allows learners to enter and exit the system of learning as they master content, it seems to me that the flip classroom is fostering a unidirectional type of approach to teaching content- such as use of video postings and the handing down of content and then students take a quiz to pass on to the next level. Incorporating assignments which encourage the student to first master the content (through reading content), then demonstrate application of the content in a situational context (through group problem solving of issues) can foster more of a bi-directional approach to learning, where the educator provides guidance and feedback. For this reason I use case based and problem based learning scenarios to teach care of older adults, advance nurse practitioners and even in basic concepts of nursing research. Learners are expected to critically analyze scenarios and apply learned content- rather than taking a quiz or test on content. This type of approach is not based on use of individualized course units or sequential modules found in the flipped classroom approach to teaching/learning. Dr. Gray-Miceli, Rutgers College of Nursing

A minor point of correction: Gen X is the population that is now about 35 to 50 years old. Gen Y or the millenials are the younger group that got trophies for just showing up. Gen X mostly got to graduate from college into the deepest recession before that of 2008...

I am happy to read that the UCSF School of Nursing is lead by a dean that welcomes innovation and is working to see how it can fit into the program and better the quality of education. I plan to apply to the MEPN programs and this is definitely a positive and motivating reason to apply to UCSF. Thank you Dean Vlahov. Sincerely, Jessica Ponce

AS highlighted, our nursing students have been brought up with,and are very apt at engaging with technology. Perhaps our challenge as educators is to develop their human engagement skills accepting that nursing is a person/relationship centred profession. Video recorded lectures in themselves with low production value do not capture the spontaneous, unpredictable, planned and incidental learning that occurs with a whole class. On campus lectures have a scheduled time window to develop class engagement and address students' felt needs in real time. It is debatable whether modern lectures are teacher monologues. Students do not only attend lectures for curriculum content, they can identify and engage with their whole class not just the few in a tutorial or simulation lab. A flipped classroom for nursing students has potential if it is more than merely reducing face to face contact and replacing with recorded lectures. Unfortunately, in Australia, our 3 year UG nursing curricula are so choked with content, lectures, tutorials and laboratories cover different learning material. A flipped classroom may have excellent potential for mastery learning of clinical skills and for distance education students who choose that study mode, but those who choose to study on campus must also be engaged in this conversation. Regards Ron Kerr

I taught both OB for second semester AS students and Mental Health nursing for seniors. I provided audiocasts for the lectures and received many favorable comments. We used class time for case studies, videos, matching of terms, QSEN exercises. Students were really engaged. It was loud at times as students broke into smaller groups and then presented results of their assignments. I will be using this strategy next year as well. Donna Volpe Penn State

As an educator in a nursing program at a local college in Ohio, the flipped classroom concept with lectures available online does not take away from the human experience as a nurse. Instead of just utilizing the classroom time for case studies or other activities aside from a traditional lecture, the human aspect of caring, therapeutic communication and touch can still be fostered through concept-based teaching and facilitation. I am transitioning all three of the classes I lead into a flipped classroom approach with the facilitation of concept-teaching, instead of traditional lectures in the classroom setting. T. Manning-Fortis Westerville

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