This document discusses the implementation of a flipped classroom model in nursing education, emphasizing the importance of active learning through low-fidelity simulations. Studies referenced indicate that students experience improved satisfaction and effectiveness in learning when engaged in structured online lessons and in-class simulations. Recommendations include creating well-designed online course materials and utilizing face-to-face classes for guided practice.

1. Flipping the Classroom with Low-
Fidelity Simulation
Lynne Massaro & Andrew Wolf

2. Background
Results of a Carnegie Foundation study (Benner, Sutphen, Leonard, & Day,
2010) indicated that nursing education programs lack opportunities for students
to apply basic scientific theoretical knowledge in real life settings prior to
program completion. Current educational formats provide students with facts
and concepts to memorize without allowing opportunities for active engagement
in synthesizing or application. The authors recommend that nursing programs
restructure classroom environments to provide students practice in clinic-like
experiences.
Results of a study by Deslauriers, Schelew, and Wieman (2011) compared a
flipped classroom to standard lecture delivery in 2 groups of an undergraduate
physics class. The students in the flipped classroom had improved test score
results with an effect size of 2.5%.
A randomized trial by Schroedl et al. (2012) evaluated the learning of clinical
skills in traditional lecture based education versus simulation for training
residents prior to MICU rotation. The simulation training resulted in significantly
better results in bedside tests of applied clinical skills such as respiratory
mechanics, ventilator management, and circulatory resuscitation.

3. Background
Flipping the classroom moves traditional lecture content to a structured
online learning environment. This opens up the classroom for face-to-face
active learning opportunities including problem sets, writing exercises, case
based learning, or simulation exercises.
Question for evaluation: Does the redesign of a traditional lecture based
course with structured online lessons and in-class low-fidelity simulation
increase satisfaction and impressions of learning effectiveness from
students and faculty?

4. Program Methods
Specific required online learning activities were completed outside of the
classroom prior to a three-hour active learning in-class session.
The face-to-face class began with a 10-minute lecture summarizing the key
concepts of management and treatment of the common complaint.
The in-class low-fidelity simulations of provider/patient interactions were designed
around the learning outcomes. One student enacted the role of patient while
another enacted the role of the nurse practitioner (NP). The NP completed a full
patient history and physical while other students provided guidance.
Students then worked in small groups to think through the presenting symptoms
to develop a list of differential diagnoses and a workup and treatment plan using
critical thinking and decision-making skills.
After completing their individual group work, the class debriefed in a large group
about the process of diagnosing and managing the patient.

5. Evaluation Methods
The quantitative data from student course evaluations was compared from
courses taught in 2011 and 2013. In 2011 the course was a traditional lecture
based course. In 2013, the classroom was “flipped” and included low-fidelity
simulation.
Qualitative data was collected from student course evaluations and emails in
2013 to determine themes on student satisfaction and impressions of learning
effectiveness.
Qualitative data was collected from a faculty debriefing about satisfaction and
impression of student learning.

6. Results
Student course evaluation data comparing a traditional lecture based classroom in 2011 with a
“flipped” classroom in 2013.

7. Results
Student course evaluation data comparing a traditional lecture based classroom in 2011 with a
“flipped” classroom in 2013.

8. Student Qualitative Data
Case Studies Improved Learning:
“I was wondering if we will be doing more examples of how to write a HPI's in
class, like we did the first few weeks? I felt those were helping me become
more precise”
“…the case study discussions really help pull things together. I have learned
so much, yet feel not so stressed as in previous classes”
Pre-tests Helped Student Prepare for Low Fidelity Simulation:
“The pre and post test on line were wise. Case studies in class were helpful”
“ I loved the testing layout with pre-tests based on the reading and post-tests
based on the lectures. It forced me to stay on track with the material.

9. Appreciated Learning Opportunities:
“. . . thank you for the excellent semester of education. . . .This semester, by
far, has been superior to the rest in the Masters program.”
“Thanks so much I learned a great deal in the class”
“I am humbled and appreciative of my experiences this semester.”
“I just have to write and tell you how much I love your class! . . . I learned so
much . . . Just wanted to tell you both! (and no, I’m not trying to get extra
credits! . . . )”
Student Qualitative Data

10. Faculty Observations
Student attendance remained high throughout the entire semester.
Students were engaged and intrinsically motivated. They frequently
requested additional learning activities to support their academic and
professional goals.
Students appreciated the opportunity to practice role behaviors in a
non-threatening environment and expressed confidence in their skills in
patient evaluation and management using evidence-based treatment
plans.
Clinical papers demonstrated improved proficiency in applying scientific
and theoretical knowledge.
Students voiced decreased anxiety in role transition from RN to NP.

11. Recommendations for Practice
Provide well designed structured online lessons with outline, readings,
lecture materials, practice problems, and quizzes.
Low-tech works great. Simple text based lessons can be as effective as
multimedia.
Employ low-stakes pre-tests to provide formative assessment of
comprehension prior to face-to-face classes.
Online discussion is not always necessary in a course with rich face-to-face
interaction.
Use face-to-face courses for guided practice activities in which faculty and
peers can provide formative feedback and assistance.
Mini-lectures in a face-to-face class can provide an opportunity for students
to ask for clarification prior to starting practice activities.

12. References
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A
call for radical transformation. San Francisco, CA: Jossey-Bass.
Deslauriers, L., Schelew, E., & Wieman, C. (2011). Improved learning in a
large-enrollment physics class. Science, 332(6031), 862-864.
doi:10.1126/science.1201783
Schroedl, C. J., Corbridge, T. C., Cohen, E. R., Fakhran, S. S., Schimmel, D.,
McGaghie, W. C., & Wayne, D. B. (2012). Use of simulation-based education
to improve resident learning and patient care in the medical intensive care
unit: A randomized trial. Journal of Critical Care, 27(2), 219.e7-219.e13.
doi:10.1016/j.jcrc.2011.08.006