Review ArticleAbstract
The present study aims at investigating the effect of teaching through flipped
classroom on learning level of students at basic science level in the medical faculty of
Iran University of Medical Sciences based on the evaluation model of Kirkpatrick. This
is a quasi-experimental study following the pre-test and pos test nonequivalent group
design. Census sampling was used due to the limitation of the statistical population.
The students were divided into two groups of experimental group and control group.
The experimental group was taught in flipped classroom and the control group was
taught through speech-based method. The experts in the general medical group were
consulted with regarding the selection of the lesson and the subject to be taught. When
both groups were taught, the level of students’ learning was evaluated in the study
using the evaluation model of Kirkpatrick.
The experimental group watched the electronic content of each session on a
CD, studied the textbook and attended the class prepared. However, no content was
available for the speech-based group and they attended the class as usual. Research tools
included a researcher-made learning questionnaire (with a reliability of 0.82) based on
the Kirkpatrick four-level teaching evaluation model which was once distributed among
the control and experimental groups before the classes begin and once again they were
distributed a month later among them. The data was interpreted after being collected.
Results of data analysis showed that teaching through flipped classroom has positive
effects on the students’ learning level. The stability of the contents in flipped classroom
was approximately twice as much as the speech-based method. The professors and the
faculty members are recommended to use this approach when teaching and to design
their lesson plan based on the flipped classroom model.
Keywords:Flipped Classroom; Kirkpatrick; Evaluation; Medical; Students
Introduction
Quality improvement is one of the major purposes of higher education throughout the world. According to the International Federation of Medical Education over the last two decades, the medical teaching has been expanding uncontrollably (at least at the level of general medicine) [1], while people’s expectations from physicians is increasing due to the increase in the level of their awareness. Accordingly, it can be stated that the condition of medical education in Iran is similar to what has been addressed in the report by the International Federation of Medical Education and this fact has made the educational officials in Iran to improve the educational quality by new methods of education in the field of general medicine [2]. In their study, Dent and Harden stated that a physician is a unit of abilities, while many medical universities might train physicians whose identity as a professional person is unknown [3]. A look at the changes in the higher education system of Iran over the last two decades in terms of student population indicates the quantitative growth and lack of sufficient attention to the quality of the universities and their improvement. Quality improvement calls for the establishment of an appropriate educational mechanism [4].
Different active and new learning methods include (case-based
learning, competency-based learning, discovery learning, experimental
learning, open learning, flipped classroom). One of the active
teaching methods that has become a new technology over the
last years is the “flipped classroom”. The flipped classroom is a pedagogical
model in which the group space moves toward individual
space and consequently, the learning environment becomes active
and interesting for learning through which the teacher’s guide the
students and students participate creatively in teaching the lessons
[5]. In fact, this is considered a learner-centered approach
in which the learners are more active than the teacher in learning
and the teacher acts as a facilitator to motivate, guide and receive
feedback from students’ performance [6]. In this method the house
and school change places, such that the teacher provides the learners
with videos on the lesson so that they can watch them at home
before coming to the school in order to use the class time to gain
knowledge.
Accordingly, in flipped classrooms, what used to be done in
the classrooms in the past is now done at home as an exercise. The
learners attend the classes with preparation and the teacher, and
the learners cooperate with each other to read, understand and
complete the exercises in the class [7]. Flipped learning includes
the following advantages: flexibility, improvement of interactions,
professional skills and learners’ participation In addition, Schiller
and Herreid stated that flipped classroom also develop thinking
skills among other advantages, while many educational experts
such as Gold and Sirantic believe that the sovereignty of traditional
teaching methods leads to poverty of thought in learners [8]. Therefore,
one of the reasons for active learning is that the information
and scientific knowledge advance fast and no learner can store
the produced information in mind. Hence, the learners should be
taught how to solve problems.
Today, many curricular designers and educational programmers
are dissatisfied with the common teaching methods and
consequently, they welcome innovation and creativity in teaching
methods. The effectiveness of methods such as speech-based teaching,
information transference from teachers to students and memorization
and focusing on memorization which are the bases of traditional
teaching methods have been questioned and criticized for
a long time. To compensate the shortcomings of such methods, a
number of experts recommend using new teaching assistant tools
and new teaching methods such as class discussions, problem solving
and etc. and some others have replaced the old methods by
discussion and question and answer sessions and individual and
group experiments [9]. Studying the interview of Shubert and Ralf
Tyler published in 1986, Mehr Mohammadi introduced the flipped
curriculum design as an innovative idea in higher education curriculum
design.
Discussing about his early experiences regarding the curriculum
design for applied sciences and engineering education in
mid-twentieth century, in the interview, Tyler mentioned that the
environmental experiences were prior to classroom topics in this
model. From his experience of curriculum designing for masters of
social sciences in Cornell University, Shubert emphasized that environmental
experiences are prior to class activities and topics. Of
course, the priority of clinical experiences to class topics and theories
in flipped classroom curriculum does not mean that theoretical
issues are neglected or are negligible; but the applicable content is
the main purpose. Flipped curriculum is the opposite of the common
and traditional curriculum. In traditional curriculum, the mere
priority is with the theoretical issues and the clinical experiences
are learned in the form of internship. However, in flipped curriculum,
the priority is with the clinical experiences and environmental
experiences and the class content are in line with the workplace
experience and issues with the applicable contents being the main
focus. Moreover, the content is not predetermined.
In this type of curriculum, the theoretical knowledge is not superior
to the practical knowledge, but it owes itself to the mind mingled
with issue and is disposed with its exploitation [10]. It also emphasizes
the perceived necessity against the necessity-dependent
approach. That is, it is not dependent on the idea of transferring
knowledge to be applied in the future, but the nature of the problem
determines what type of knowledge and content is required
[11]. Flipped classroom is an educational and a compound learning
strategy that converts education to a student-centered model
in which the class time is spend on deeper subjects and on creating
interesting learning conditions [12]. Indoor lesson in a flipped
classroom might include learning based on activities that were considered
homework in traditional education. On the other hand, in
this type of learning, more time is dedicated to thinking skills in
class and the learners are more active in the process of learning and
creating more knowledge, meanwhile evaluating their knowledge
[13]. In a study conducted in 2017 by Hong in the National Taiwan
University on two groups of 20 English students, it was concluded
that flipped classrooms can provide interactive learning opportunities
that increase the learners’ tendency to establish communication
and help others. In addition, the verbal skills are developed and
the satisfaction level increased.
This method increased the motivation of learners who are less
inclined to interact with others and establish communications with
their teacher and peers. Hence, the learners’ motivation increased
in the class activities in this method [14]. In a study conducted in
2017 by Robby Yang in Hong Kong on 57 learners, it was concluded
that the learners had a positive idea about flipped classrooms.
The teachers stated that flipped classroom is a creative method that
might only be useful to teach English grammar [15]. In the study
conducted in 2017 by Key Van Lou and Fun Hue on twelfth grade
students in mathematics class, it was concluded that after the examination
of the students’ scores in the pretest and post-tests of
t-test, their scores had significantly improved in the post-test and
the learners’ idea about the flipped classroom was positive in general
[16]. According to a study by Karjanto and Lee in Sungkyunk wan University in South Korea at algebra class, it was found that
the learners taught in flipped classrooms outperformed in problem
solving and social skills [17].
According to the study that Halili and Zeinaldin conducted in
2016 based on the content analysis of 20 articles on flipped classroom
done from 2013 to 2015, it was found that flipped classrooms
had positive effects on learners’ learning activities such as their
success, motivation and interactions [18-20]. The main purpose
of flipped classroom is to improve the learning experience of the
learners and the teachers’ teaching experience before, during and
after teaching [21]. Implementing flipped classroom requires a target
educational content and distributing it to the learners’ outside
the educational environment so that they will be prepared for what
they have studied when they attend the class. Since flipping the
class takes place by a focus on learners’ active learning, the learners
need to study the lesson deeply before they attend the class [21-
23]. As it was mentioned earlier, considering the significance of the
medical education through new methods, attempts were made to
use the method to increase the quality of education in Iran University
of Medical Sciences. In other words, the purpose of this study
was to investigate the effect of teaching through flipped classroom
on the learning of students at basic science level in Iran University
of Medical Sciences according to Kirkpatrick Evaluation Model.
Methodology and Materials
This is a nonequivalent quasi-experimental study whose statistical population included all the medical students at Iran University of Medical Sciences.
Sampling: The samples entered the study through census, and they were divided into two groups of control groups and experimental group via blocked randomization.
Procedure: This is a nonequivalent quasi-experimental study and census method is used due to the limitations of the statistical population. The students were divided into two groups of control group and experimental group in this study. The experimental group was taught using flipped classroom method and the control group was taught using the speech-based method. Experts in the field of general medicine were consulted about the class selection and the teaching subject. When both groups were taught, the level of participants’ learning was evaluated in the study using Kirkpatrick Evaluation Model. The experimental group watched the electronic content of each session on a CD, studied the textbook and attended the class prepared. However, no content was available for the speech-based teaching group and they attended the class as usual (Table 1).
Table 1: Features of methodology.
Ethical Considerations:
a) Obtaining permission from the Research Center officials
of Iran University of Medical Sciences and the medical faculty of
Iran University of Medical Sciences
b) Obtaining permission from the ethics committee
c) Providing research subjects with the necessary explanations
and research objectives
d) Obtaining the informed consent
e) Confidentiality and anonymity of the information
Findings: The information about the research questions is used in this section in descriptive level (frequency, percentage, mean and standard deviation) and inferential level in Kolmogorov–Smirnov test to test the normalization of the statistical sample and the analysis of covariance was used to test the research hypotheses.
Descriptive Statistics of The Groups
(Tables 2 & 3) The data presented in the above table indicate the age of subjects in both groups and it shows that most of the subjects are in the age range of 22 years old. (Table 4). The data presented in the above table shows the gender of the subjects in both groups which indicates that 55 percent of the subjects in the flipped classroom were girls and 45 percent of them were boys, while 50 percent of the subjects in the speech based group were girls and 50 percent were boys (Table 5). According to the data, the mean of learning level in pretest and post-test in the control group was 28.55 and 56.36, respectively and the mean of learning level in the pre-test and post-test in the experimental group was 54.39 and 92.28, respectively (Table 6). According to the results of the above table, the significance levels for the research variables were greater than 0.05. The data related to all variables were normal and parametric tests can be used to test each of the variable (Table 7).
Table 2: Distribution of the statistical sample in terms of gender.
According to the results obtained from Levene test, it can be stated that the obtained significance level (0.458) was greater than the critical value at level 0.95 (0.05). Therefore, the homogeneity of the variance is confirmed. Determining and Comparing the Students’ Learning Level at Basic Sciences One Month after the Intervention in Control and Experimental Group The independent t-test was used to test this hypothesis. The results are presented in the following table (Table 8). According to the above table, it is observed that after one month, the mean value of learning for the first group (speech based group) was 20.1628 and the mean value of learning after one month for the second group (flipped classroom) was 43.0724. In addition, the standard deviation of the first group was 0.45160 and the standard deviation for the second group was 0.50073. Moreover, the standard mean for the first and second groups was 0.3285 and 0.6814, respectively. The significance level of this test shows that there is a significance difference in the learning level between the two groups after a month (Table 9).
Table 3: Distribution of the statistical population in terms of age in the groups.
Table 4: Distribution of the statistical sample in terms of gender in the groups.
Table 5: Comparison of the mean and the standard deviation in pre-test and post-test in experimental group and control group in terms of the learning level variable
Table 6: Kolmogorov-Smirnov test.
Table 7: Results of Levene test to investigate the homogeneity of variance between the (experimental and control) groups.
As it can be seen in the table above, the knowledge scores of the students in experimental and control groups at 4 dimensions of Kirkpatrick Evaluation Model were significantly different and the difference was also statistically significant (p = 0.0001) (Table 10). The results of the analysis of covariance in the above table show that there is a significant difference in the learning level between the experimental group and the control group (p > 0.01 and F = 20.83). The square root of this value is 0.86; that is, 86 percent of the learning level is related to teaching through flipped classroom. In other words, it can be stated that teaching through flipped classroom has a significant effect on the students’ learning level.
Table 8: Independent t-test.
Discussion and Conclusion
The aim of the present study was to investigate teaching through flipped classroom on the students’ learning level at basic sciences of the medical faculty in Iran University of Medical Sciences based on Kirkpatrick Evaluation Model. Results of data analysis showed that teaching through flipped classroom had positive effects on students’ learning level. In a study in 2012 in line with the comparison between the effectiveness of flipped classroom and speech based method, Johnson concluded that when the content is prepared and provided for the learners, the flipped classroom method can be more effective in giving a deeper understanding of the contents compared to the speech based method [12]. In another study conducted by Zurideh in 2014 on the perception of the learners’ and teachers’ idea about the better method (speech based or flipped classroom), results indicated that the participants in the study had a higher tendency to use the flipped classroom method [13] Jafar Aghaei et al. conducted a study titled “Nursing Students’ Experience in a Flipped Classroom Method”.
Table 9: Paired sample t-test to investigate the difference between the four important levels of Kirkpatrick Evaluation Model among the students of the two groups.
Table 10: Results of analysis of covariance in experimental and control groups for the learning level..
Research results showed that most students (79.1%) preferred
flipped classroom method over the traditional method in which
most of the class time is spent on the teachers giving speeches.
This study which was the first step in applying the flipped classroom
method on nursing students in Iran showed that the students
had positive experiences and views of applying this method. The
present study showed that students recognized flipped classroom
method important in gaining knowledge and found the activities
before and during the class beneficial for their learning. The professors
of medical sciences are recommended to use short recorded
speeches as supplements for the reference books when using this
method. Considering the fact that this teaching approach is new,
further studies are required to investigate its effect on learners’ different
learning factors [20].
Expansion of student-centered teaching methods like the
flipped classroom in medical sciences can help to improve the
learners’ learning process. Advocators of this approach believe that
what happens in a classroom has a constructivist nature, such that
the learners play an active role in gaining knowledge outside the
class and what happens in the class focuses on the social and cooperative
learning processes. Fulton with implementing the flipped
classroom method in Byron High School in the U.S. and Abeysekera
found out in his research that flipped classroom method has a positive
effect on learners’ learning. Despite its special advantages,
flipped classroom method calls for accurate educational planning
and design. Flipped classroom is a teaching strategy and a compound
learning method that converts teaching to a student-center
model in which the class time is spent on learning subjects at a
deeper level and creating interesting learning opportunities.
The lessons inside a flipped classroom might include learning
based on the activities that were considered homework in traditional
teaching methods [14]. On the other hand, in this type of
learning, more time can be spent on thinking skills and the learners
can be actively involved in learning and creating knowledge while
evaluating their knowledge simultaneously [15]. In the field of
teaching medical sciences, considering the continuous changes in
the information and the importance of the knowledge being up-todate
in the field, it is necessary to teach students that will be continuously
learning during their education and after that. The students
being equipped with the self-directed learning abilities will turn
them into lifelong learners because they will be trained to identify
their needs and take steps to overcome them. Self-directedness
in learning makes students take educational barriers as challenges
and treat them successfully. Students prefer to have an active role
in the class and learning. Nowadays, few students are found who
prefer passive roles in class.
On the other hand, learning tools and conditions have also
changed and students prefer to follow their learning process via
electronic tools such as cell phones, tablets, laptops and other related
tools. Furthermore, case studies have shown that with their
audiovisual features, these tools engage more of the human senses
(seeing and hearing). Consequently, they lead to deeper learning,
while learning through textbooks where the content is provided in
text format, the focus is more on one human sense (mostly hearing).
Accordingly, considering the changes that have been made at
the moment, one of the most important issues that need to be taken
into consideration in university learning approaches in the field of
medical sciences is the creation of interesting learning opportunities.
This can be achieved by the use of audiovisual technologies
and application of objective examples of the content.
The reverse class creates educational change; in the form of a
teacher-centered classroom transforming into a student-centered
classroom, and based on constructivism theory, learning is personalized
and personalized rather than collectively. This study showed
that the reverse-class approach makes the teacher and coach more
active in comparison with the traditional classroom. The inverse
class requires more time from the instructor and the professor. In
the end, the reverse class as a sustainable learning pattern can be
used for other teacher training courses. Reversing the design of the
classroom will increase the learning experience of teachers and enhance
their future teaching. As a result, much work has still to be
done in this regard.
Acknowledgement
The authors would like to express their sincere gratitude to all the participants in this study for their efforts and cooperation during this study.
Conflicts of Interest
No conflicts of interest were reported by the authors.
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