Create an educational module (8 slides 5 min long) for the evidence-based proposal.
Slide 1: Title
Slide 2: Project/Problem/PICO
Slide 3: Blooms Taxonomy learning objectives X3
Slide 4: Background of the Problem
Slide 5: Review of the Literature
Slide 6: Solution to the Problem
Slide 7: Summary Takeaways
Slide 8: References
Introduction
Graduate nursing education programs have come to the point where traditional teaching techniques need to evolve in order to address current educational requirements of a new generation of learners, but still need to make students safe and competent. Students in graduate nursing programs are being taught advanced didactic material, while also being in the clinical setting providing patient care in high stake settings. Traditional lecture methods with passive learning may not be enough to successfully prepare students for the cognitive levels they need to achieve. A recent study showed that 91% of graduate nursing students are from generation Z or generation Y, which are both do better with active, student focused learning methods.1 this change in generation compared to faculty shows a possible gap between teaching practices and student preferred learning styles that influence academic performance.
Background
Graduate nursing educational programs are intense and require structured instructional methods to facilitate efficient learning, critical thinking, and individualized understanding.
Knowledge of physiology, pharmacology, and pathophysiology are all incorporated into graduate nursing education to help students make clinical decisions in constantly changing environments. The conventional delivery of material through lectures, although once effective, puts the student in an inactive learner role which might not prepare them for the necessary cognitive skills.2 The flipped classroom teaching method involves having students work through materials to prepare them before attending class, where now most of class time can be used to facilitate active learning.3
A recent systematic review study using a multiple-choice assessment, showed that the flipped classroom method with pre-class activities, compared to traditional teaching methods,
significantly improved the knowledge gained in health science students with a standardized mean difference of 0.41.3 It has been showed that specifically in nursing education, the flipped classroom method resulted in better student satisfaction, engagement, and knowledge retention. In another study, medical students who received flipped classroom learning had better exam results and better comprehension than the students taught with traditional lectures.3,4
Any implications in graduate nursing education are significant due to the high stakes of the profession. In a study on the implementation of the flipped classroom method in graduate nurse anesthesia students, the researcher concluded that both the flipped and traditional learning methods both demonstrated improved quiz scores before and after the material was learned, but the flipped method was an effective alternative to the traditional method.5 Another study generalized the results to patient safety competencies and demonstrated that the nursing students receiving the flipped classroom method achieved substantial improvements over skills in patient safety compared to the students that received traditional lecture, the flipped classroom students also were able to detect and treat medical errors in clinical practice better.6
Being able to critically think is a fundamental skill that should be gained at the completion of graduate nursing programs. A study conducted by Erden et al. researched online flipped classroom learning in nursing students and found that there was an increase in critical thinking dispositions and academics when compared to traditional online teaching method.7 Another study found that nurses who received the flipped classroom method during their education scored higher on theoretical knowledge tests, clinical skills, and self directed learning ability when compared to nurses who received traditional education.8 These results are very significant to graduate nursing students because they should have strong self directed learning skill to stay up to date on current evidence based practice.
Even with the effectiveness of the flipped classroom teaching method being shown through increasing evidence, implementation into graduate nursing education is minimal. A recent quality improvement project involving professors in a graduate nurse anesthesia program showed that only 1% of professors used the flipped classroom teaching method, and only 50% showed understanding of generational learning styles of millennial and generation Z students.1 This gap in implementation is a lack of opportunity to match the evidence based educational approaches and students learning styles. In another study, the knowledge gaps in generational learning preferences was also found in faculty, where knowledge gains of 39.29% was shown in graduate nursing students and learning preferences when reviewing post educational modules.9
Problem Statement
Graduate nurse anesthesia programs largely rely on a traditional lecturing format, while the inclusion of a flipped classroom technique can be a net benefit to a newer generation of students enrolling now. Flipped classroom learning has demonstrated a benefit in knowledge acquisition, satisfaction for the learner, and development of critical thinking. This misalignment between teaching methods can lower academic achievement and clinical judgement needed to practice anesthesia safely. The proposed quality improvement initiative would be to introduce the flipped classroom approach, to both faculty and students in nurse anesthesia, with the goal of introducing new strategies to successfully increase knowledge.9,10
Organizational “Gap” Analysis of Project Site
The setting of the project is to be a public university in South Florida, particularly in the Department of Nurse Anesthesia. An initial gap analysis, identified significant considerations of current practice. The faculty staffing of the current department consists largely of generation X and “Baby Boom” classes, that were educated or instructed in traditional lecture-based teaching
methods. Conversely, the student population of the department consists of mainled Millennial and generation Z students that have shown interest in technology-enhanced interactive learning. Departmental curriculum has focused on traditional lecturing as its main modality of instruction, with little adoption of interactive techniques, such as the flipped classroom style. Current availability of resources to identify generational learning preferences and interactive teaching styles are; the learning management system (Canvas), and expertise of the faculty regarding clinical material. The threat to faculty time, differences in technological competency, and possible resistance to a fundamental change of teaching techniques are potential obstacles. These would be addressed through flexible agreements of training sessions, access to technological resources, and focus on evidence-based effectiveness in flipped classroom methodologies.2,4
Review of the Literature
A comprehensive literature search was conducted to evaluate the effectiveness of the flipped classroom model compared to traditional lecture-based instruction in health professions education, particularly graduate nursing programs. Databases that were searched included PubMed, CINAHL, and Google Scholar. The searches were conducted using keywords such as flipped classroom, flipped-classroom pedagogy, nursing education, graduate education, active learning, and traditional lecture. The search was limited to English language, and a time frame of studies conducted within the past five years. Inclusion criteria consisted of studies evaluating flipped classroom methods in nursing, medical, or graduate-level education and reporting learning outcomes such as knowledge acquisition, academic performance, or student satisfaction. The exclusion criteria included studies without comparison groups, a lower level on the hierarchy of evidence, or those unrelated to healthcare education. The search initially provided
over 110 articles, from which a total of 12 were ultimately selected by each of the researchers based on relevance, methodological rigor, and applicability to graduate nursing education.
A growing body of literature suggests that flipped classroom models enhance student engagement and learning outcomes compared with traditional lecture methods. The flipped classroom consists of pre-class preparation and content acquisition while leaving classroom time to application, discussion, and problem-solving activities. Multiple randomized-controlled trials (RCTs) have evaluated this approach across health professions education and consistently showed improvements in knowledge acquisition, engagement, and satisfaction showing that it is an effective pedagogy method. Chan et al.,4 conducted an RCT that involved 216 medical students comparing flipped classroom case-learning to traditional lecture instruction during an ophthalmology rotation. Results of this study showed that the flipped-classroom group had greater engagement, higher exam scores, and improved knowledge retention compared with those receiving traditional lectures. Similarly, Al-Mugheed and Bayraktar,9 evaluated flipped classroom instruction in a venous thromboembolism course for nursing students, and their findings showed significantly higher post-test scores and improved knowledge of VTE risk assessment and prevention among students taught using the flipped classroom model. Additional studies further support the benefits of the flipped classroom method in education. Budak et al.,6 examined nursing students participating in a patient safety training program and found that those in the flipped classroom group not only showed higher patient safety competency scores, but this group also demonstrated greater satisfaction with the learning process. Erden and Kaya7 evaluated an online flipped classroom model in a chemotherapy symptom management course and reported improved academic performance and critical thinking skills compared with traditional online instruction.
Other investigations confirm these findings across diverse academic disciplines. For example, Djamàa11 showed improved exam performance among graduate students learning through a flipped classroom model compared with traditional lectures. Similarly, Wang et al.,12 reported that dental students in flipped classroom settings accessed course materials more frequently and achieved higher scores on readiness assurance tests than students taught through traditional lectures. Harris et al.,13 also found that the flipped classroom format improved exam scores and reduced failure rates in a biochemistry course, especially for students who struggled with complex concepts. Some studies indicate that while flipped classrooms improve engagement and satisfaction, differences in academic performance may not always reach statistical significance. Farina et al.,5 compared flipped classroom instruction with traditional lecture methods among graduate nurse anesthesia students and found similar academic performance outcomes between groups, proving that the flipped classroom was considered an effective alternate teaching strategy. Likewise, Sourg et al.,14 reported that both flipped and traditional methods of pedagogy enhance learning outcomes, although students expressed a greater level of satisfaction and motivation when participating in the flipped classroom methodology. Lastly, research further showed benefits of flipped classroom models in clinical skill development and professional competencies. Shikino et al.,15 found that flipped classroom simulation training improved interprofessional collaboration competencies among healthcare professionals and improved critical thinking and teamwork skills. Similarly, Lu et al.,8 further reported that hemodialysis nurses trained using flipped classroom methods showed higher theoretical knowledge scores, improved clinical skills and greater self-directed learning abilities compared to those receiving traditional lecture instruction. Overall, the literature consistently suggests that flipped classroom learning promotes active engagement, knowledge acquisition,
and learner satisfaction in healthcare education. While some of the studies mentioned, report similar academic outcomes between teaching models, the majority demonstrate advantages in student engagement, skill development, and learning experience. These studies support the implementation of the flipped classroom pedagogy as an evidence-based educational intervention for graduate nursing education.
Evidence Based Practice: Verification of Chosen Option
According to the literature review, the flipped classroom educational method was chosen as the evidence-based technique that has proven effectiveness in educational outcomes in various health sciences, including graduate nursing education. The significant presence of randomized control trial, level II evidence confirms the effectiveness of the flipped classroom method in improving attainment of knowledge, critical thinking development, student satisfaction, and improved clinical skills. This evidence, along with the gaps in faculty knowledge in generational learning preferences, and that implementation into graduate nursing programs is scarce, all support the selection of a faculty based educational intervention to propose the introduction of the flipped classroom teaching method as an evidence-based option to use in this quality improvement project.
Theoretical Framework or Evidence Based Practice Model
The Kirkpatrick Model of Educational Evaluation is the theoretical basis for this quality improvement project. This framework is based on the assessment of educational programs proposed by Donald Kirkpatrick on four levels, reaction, learning, behavior, and results.16 Level one is reaction and measures how the participants are satisfied with the educational experience, and how they perceived it. Level two is learning and uses assessments to gauge knowledge, skills, and attitudes.16 The third level is behavior and determines how much of what was learned
was applied to clinical work. Level four is results and focuses on the organizational or patient outcomes of the educational intervention.
The Kirkpatrick model provides a structured approach to evaluating the immediate and prolonged effects of faculty development interventions, which is why it is appropriate for this project. The model takes into account that it is necessary to assess educational effectiveness past simple satisfaction measures. Level one will be assessed using post educational session
satisfaction surveys that inspect the faculty’s insight of the educational models quality and value. Level two will be evaluated through pre and post assessment tests that evaluate faculty knowledge of flipped classroom methodology, generational learning preferences, and strategies for implementation. Level three is beyond the scope of this project, but could be assessed in upcoming studies that evaluate faculty implementation of the flipped classroom teaching method. Level four could be evaluated through research on the student outcomes after implementation of flipped classroom methods.
Many recent studies also acknowledge applying the Kirkpatrick Model into evaluating graduate nursing education. Razi et al.17 incorporated the first two levels of the Kirkpatrick Model to determine the effectiveness of the flipped classroom method in a nursing research course for a masters program, and revealed that student satisfaction (reaction) and knowledge attainment (learning) were improved substantially with the implementation of the flipped classroom teaching method. See Appendix A for a diagram of the Kirkpatrick Model.
Goals, Objectives and Expected Outcomes
Goal 1: Enhance faculty’s clinical knowledge of flipped classroom methodology and its strategies to be applied to nurse anesthesia education via 2 forty-five minute presentations and a link to resource page for these methods. Upon completion:
- Faculty should achieve a 90% proficiency rate in defining flipped classroom concepts and their components through a post-session assessment.
- A mean score increase of 25% from pre- to post- flipped classroom session assessments to be seen in nurse anesthesia classrooms utilizing flipped classroom methods.
Goal 2: Increase faculty’s cultural competency in generation learning preferences and their application to the flipped classroom design. A baseline quiz regarding generational learning traits would be administered. Afterwards an instructional toolkit would be provided on evidence-based learning preferences and alignment with flipped classroom methods. Upon completion:
- 80% of faculty will correctly identify student generational profiles
- Average faculty scores on post assessment will increase by 25% over baseline quiz.
Goal 3: Promote faculty acceptance and adoption of flipped learning methodologies. Through
use of satisfaction surveys and “Intent to Practice” contracts:
- 80% of faculty will rate training and presentations a 4 out of 5 or higher in satisfaction.
- 70% of participants will file a formal intent to practice the flipped classroom techniques in their courses.
Project Design
This project will use a quality improvement educational intervention using a search of the literature to evaluate and compare the effectiveness of a flipped classroom educational module versus a traditional lecture-based learning. The goal of the intervention is to determine whether the flipped classroom approach improves knowledge acquisition, engagement, and perceived learning among Student Registered Nurse Anesthetists (SRNAs) in graduate nursing education better than the traditional method. The intervention will consist of searching the data available as described earlier, developing a virtual flipped classroom educational module, which will be
delivered through an online learning platform. Participants will complete pre-class learning materials including recorded lectures, assigned readings, and short instructional videos before the scheduled in-person class. A pre-intervention survey and knowledge assessment will be administered before participants complete the educational module. After completing the flipped classroom module, participants will complete a post-intervention survey and knowledge assessment to measure any changes in knowledge, engagement, and satisfaction with the educational format. Quantitative data will be collected through pre and post assessment scores, while qualitative feedback will be gathered through satisfaction surveys. Results will be analyzed through the use of descriptive statistics.
Project Site and Population
The project will take place at a public university in South Florida offering a graduate nurse anesthesia program. The institution provides advanced nurse education and clinical skill traning for registered nurses pursing specialization in nurse anesthesia practice. The program incorporates both didactic coursework and clinical experiences to prepare students for certification as Certified Registered Nurse Anesthetists.
The target population for this project will consist of SRNAs enrolled in the graduate nurse anesthesia program. These students are typically experienced critical care registered nurses who are completing advanced education to develop anesthesia knowledge, clinical reasoning, and patient safety competencies.
Participants will be recruited through communication channels such as email announcements and course announcements. Participation is voluntary. Inclusion criteria include SRNAs currently enrolled in the anesthesia program who consent to participate in the study.
Exclusion criteria will include students not currently enrolled in the program or those who
decline participation. Project will be conducted virtually, which allows participants to complete the flipped classroom educational module remotely. This format increases accessibility and flexibility while allowing students to review learning materials at their own pace before participating in the interactive learning session. Many sources will be available for support of the project implementation, including the university’s online learning management system, video conferencing platforms, and survey tools. Barriers include time constraints among students and varying levels of familiarity with flipped classroom learning.
Methods
The project shall be implemented in a systematic manner that will involve clearly defined phases. During the pre-intervention phase, project materials/instruments will be developed, to include; educational modules, a pre-module assessment, post-test knowledge assessment, “Intent to Practice” contracts, and satisfaction surveys. All pre-intervention materials will be assessed for content validity by faculty with expertise in nurse anesthesia education.
The next phase, the intervention phase, will have faculty from the department recruited via in-person meetings to explain the project’s purpose and procedures. Faculty will be provided with a link to complete an anonymous pre-session assessment via Qualtrics. The faculty will then attend two 45-minute educational presentations, completed over two days, at the university. The content presented will encompass: (1) definition and fundamental elements of the flipped classroom technique, (2) evidence-based reviews of flipped classroom effectiveness in teaching graduate students, (3) analysis of the generational learning preferences of graduate students, (4) practical implication of teaching the flipped classroom methodology within the context of nurse anesthesia, and (5) case studies on how to effectively integrate flipped classroom methods.
The post-intervention stage will have participants provided with a link to anonymously complete a post-session knowledge evaluation. Satisfaction surveys would likewise be sent via Qualtrics to participants upon completion of the course.
Measurement Instruments
To assess the results of the project, the following tools would be applied: A pre- session knowledge assessment instrument, satisfaction survey, and post knowledge assessment. The pre- and post-session assessments would consist of a 20-item multiple choice test designed by a
researcher, conducted to evaluate faculty’s knowledge related to flipped classrooms, its evidence base, and the preferences to learning based on a person’s generation. Contents of the exams would be as follows: (1) definition and components of flipped classrooms (5 questions), (2) characteristics of generational learning and preferences (5 questions), (3) evidence of effective learning through flipped classrooms (5 questions), and (4) implementation strategies to use when implementing the flipped classrooms (5 questions). Overall, knowledge change will be assessed with the use paired t-test.
The satisfaction survey will be a 10-item questionnaire developed by researchers to assess the faculty’s perception of the educational session on a 5-point Likert scale between 1(strongly disagree) to 5 (strongly agree). Questions will measure the relevance of content, presentation, utility of information, and willingness to adopt flipped classroom methods. Two open-ended questions will enable the faculty to provide qualitative feedback about strengths of the content and areas that could be improved upon.
Data Collection Procedures
The data collection process will be carried out in stages that correlate with the project schedule. Pre-intervention data collection will done two weeks prior to each of the educational sessions. The link to the Qualtrics survey will be emailed to faculty that are interested. The email will contain information for informed consent, and the pre-educational knowledge assessment test. There will be no gathering of any identifying information, and all responses will be anonymous. In order to keep tract of the pre and post test scores and answers, the participants will come up with a code that records the last four digits of their phone number along with their birth month to make sure that the answers and scores can be matched without compromising their identity.
The intervention stage will be given as a 45 minute online educational session.
Immediately after the educational session, the participants will be emailed another Qualtrics link to complete the post-educational session knowledge assessment test and satisfaction survey. The knowledge items that were on the pre-educational session assessment will be included on the post-educational session assessment test. The participants will use their unique code again to be able to match the assessment responses. All of the information and data will be collected and stored in Qualtrics, which is a secure platform. The data will then be exported from Qualtrics to the Statistical Package for the Social Science (SPSS) to be analyzed. There will be no identifiable participant information in any publication of findings or presentations, only combined, anonymous data will be reported.
Data Analysis – Qualtrics
Analyzing the data will be done using SPSS version 29 software. Descriptive statistics will be calculated for all variables, such as the frequency and percentages for categorical variables and means, standard deviations, and in ranges for ongoing variables. Descriptive
statistics will be used to summarize any demographic or professional characteristics of the participants. Paired t-tests will be done on the mean knowledge assessment scores of the pre and post-educational session tests to evaluate changes from pre-intervention to post-intervention. The statistical significance will be set at p<0.05. A secondary analysis will be done with independent sample t-tests that compares the mean of the group for participants not able to be matched due to incomplete identifier codes. There will also be subgroup analyses that will evaluate knowledge changes by the faulty teaching experience in years and prior exposure to flipped classroom teaching method.
The satisfaction survey data collected will be analyzed using descriptive statistics that includes mean scores, and standard deviations for each Likert-scale item. Content analysis to identify strengths of the educational sessions, any areas for improvement, implementation support will be evaluated using open-ended qualitative responses. All of the results will be presented in the final project report, to include pre-intervention and post-intervention test score comparison, results from satisfaction surveys, and a summary of the qualitative feedback.
Graphical representations such as bar charts of changes in knowledge and satisfaction ratings will be included as well.
Cost-Benefit Analysis/Budget
The proposed project would involve a greater time cost than direct costs. A predominant portion of the resources necessary consist of faculty time and project team time for development and implementation. Direct costs cover 90 minutes of the 20 faculty members participating in presentations amounting to a total of 30 faculty hours and an additional 40 hours for project team time. These hours are expensed through faculty development time and duties and fall within professional expectations.
The proposed project would provide the benefits of: increased faculty awareness to flipped classroom strategies, alignment of instructional techniques with student learning patterns, and improvement of student academic achievement and satisfaction. An additional benefit, seen through other studies, is that implementation of flipped classroom strategies have shown to save money in comparison to traditional methods. Appendix B provides a table with the cost-benefit analysis.
Timeline
The proposed timeline for this quality improvement project will be one academic semester which is a time span of 13 to 14 weeks. The last few weeks of the semester will involve preparing the final project report and presentation of findings. See table C in the appendix for more details.
Conclusion
Graduate nursing education curriculum is extremely rigorous and requires teaching strategies that promote critical thinking, retention of knowledge gained, and active engagement during class time. Traditional lecture-based teaching method has been the dominant educational model for a long time However, the current and emerging evidence suggests that flipped classroom teaching methods may provide a more effective approach for graduate nursing education.
The literature review revealed that the flipped classroom teaching methods improve student engagement, overall satisfaction, and knowledge attainment when compared with the long standing traditional lecture method. Multiple randomized controlled trials and quasi- experimental studies showed that the flipped classroom models improved student learning outcomes and encourage active participation and engagement in the educational process. This
quality improvement project proposes implementing a virtual flipped classroom educational intervention for SRNAs at a public University in South Florida. By evaluating the knowledge outcomes and satisfaction of students before and after the intervention, this project will be able to determine whether the flipped classroom instruction method can enhance graduate nursing education. If it is successful, this project can support broader application of flipped classroom teaching methods throughout nurse anesthesia programs and other graduate nursing education programs. This can contribute to improving educational effectiveness and preparing future graduate nurses with the knowledge and critical thinking skills that are necessary for safe clinical practice.
References
- Hernandez P. Implementation of the flipped classroom in nurse anesthesia curriculum: a quality improvement project. Doctor of Nursing Practice thesis. Florida International University; 2024.
- Zhang D, Huang A, Lei Y, et al. Nursing students’ experiences and perceptions regarding in-class flipped classroom: a mixed-methods study. BMC Med Educ. May 8 2025;25(1):675. doi:10.1186/s12909-025-07248-x
- Ødegaard N, Myrhaug H. Learning effects of combined digital and on-campus learning: an overview of systematic reviews. Sykepleien Forskning. 2025;20(101256): e-101256. doi:10.4220/Sykepleienf.2025.101256en
- Chan P, Lee V, Yam J, et al. Flipped classroom case learning vs traditional lecture-based learning in medical school ophthalmology education: A randomized trial. Academic Medicine. 2023;98(9):1053-1061. doi:10.1097/acm.0000000000005238
- Farina C, Hranchook A, Bittinger A, et al. The flipped classroom with case-based learning in graduate nurse anesthesia education. AANA journal. 2021;89(3):254-260.
- Budak V, Kılıç HF, Cevheroğlu S. The impact of a flipped learning on nursing students’ patient safety competencies and satisfaction with the education method: A randomized controlled trial. Nurs Health Sci. Mar 2025;27(1):e70068. doi:10.1111/nhs.70068
- Erden D, Kaya H. The online flipped learning model: effects on academic achievement, critical thinking, and self-directed learning skills in nursing students. Journal of Nursing Research. 2025;33(2):e384. doi:10.1097/jnr.0000000000000669
- Lu Z, Zhu J, Chen C. Performance of flipped classroom teaching method during hemodialysis training of nurses. Rev Esc Enferm USP. 2025;58:e20240276.
doi:10.1590/1980-220X-REEUSP-2024-0276en
- Al-Mugheed K, Bayraktar N. (2021). Effectiveness of a venous thromboembolism course using a flipped classroom with nursing students: A randomized controlled trial. Nursing forum, 56(3), 623–629. https://doi.org/10.1111/nuf.12573
- Golaki S, Kamali F, Bagherzadeh R, et al. (2022). The effect of flipped classroom through near peer education (FC through NPE) on patient safety knowledge retention in nursing and midwifery students: a Solomon four-group design. BMC Medical Education, 22(1), 112. https://doi.org/10.1186/s12909-022-03144-w
- Djamàa S. Lecture in the Living Room, Homework in the Classroom: The Effects of Flipped Instruction on Graduate EFL Students’ Exam Performance. Computers in the schools. 2020;37(3):141-167. doi:10.1080/07380569.2020.1795513
- Wang Z, Kohno EY, Fueki K, et al. Multilevel factor analysis of flipped classroom in dental education: A 3-year randomized controlled trial. PloS one. 2021;16(9):e0257208. doi:10.1371/journal.pone.0257208
- Harris EN, Schroder EA, Berks TJ. Student comprehension of biochemistry in a flipped classroom format. Smart learning environments. 2024;11(1):57-18. doi:10.1186/s40561- 024-00356-z
- Sourg HAA, Satti S, Ahmed N, Ahmed ABM. Impact of flipped classroom model in increasing the achievement for medical students. BMC Med Educ. 2023;23(1):287. doi:10.1186/s12909-023-04276-3
- Shikino K, Ide N, Kubota Y, et al. Effective situation-based delirium simulation training using flipped classroom approach to improve interprofessional collaborative practice
competency: a mixed-methods study. BMC Med Educ. 2022;22(1):408. doi:10.1186/s12909-022-03484-7
- Alsalamah A, Callinan C. Adaptation of Kirkpatrick’s four-level model of training criteria to evaluate training programes for head teachers. Education Sciences. 2021; 11(3):116. https://doi.org/10.3390/educsci11030116
- Razi M, Poodineh M, Taghi S, et al. Evaluating the effectiveness of the flipped classroom on student learning outcomes in the nursing research course: a quasi-experimental study based on Kirkpatrick’s model. Mod Care J. 2025;22(4):e162630. doi:https://doi.org/10.5812/mcj-162630
Appendix A: Kirkpatrick Model
Appendix B: Cost-Benefit Analysis Table
| Cost Category | Description | Estimated Value | Responsible Party |
| Faculty participant time | 30 hours | Department of Nurse Anesthesiology | |
| Project team development time | 40 hours × 3 team members | 120 hours | Project team |
| Educational materials development | PowerPoint, handouts, lesson plan | $50 (department supplies) | Department of Nurse Anesthesiology |
| Survey software | Qualtrics institutional license | Already an existing university resource | University |
| Virtual platform | Zoom institutional license | $0 (existing university resource) | University |
| Total Direct Costs | $50 + in-kind time |
| Benefit Category | Description | Estimated Value | Timeline |
| Enhanced faculty knowledge | Improved understanding of evidence-based teaching | Intangible, long- term educational impact | Immediate post- intervention |
| Instructional alignment | Better match between teaching methods and student preferences | Potential improvement in student outcomes | Future semesters |
| Educational efficiency | Potential for reduced classroom time through flipped methods | Cost savings per prior literature | Long-term |
| Faculty development | Satisfies professional development expectations | Intangible | Immediate |
Appendix C: Table for Timeline
| Project Phase | Timeframe | Activities |
| Project preparation | Weeks 1-2 | Finalize project proposal, develop educational module content, and create pre-post survey in Qualtrics |
| Participant recruitment | Weeks 3-4 | Once faculty approval is in place:Recruit SRNAs from the program, distribute emails, obtain consent, and administer the pre- intervention knowledgeassessment and survey. |
| Pre-class learning | Weeks 4-5 | Provide participants with pre- class materials including recorded lectures, readings, and instructional content required for the flipped classroom model. |
| Intervention implementation | Weeks 5-7 | Conduct the virtual flipped classroom educational session including case discussions, collaborative learningactivities, and application exercises. |
| Post-intervention assessment | Weeks 8-9 | Introduce post-intervention knowledge test and satisfaction survey using Qualtrics to evaluate theeffectiveness of the flipped classroom intervention. |
| Data analysis | Weeks 10-12 | Analyze collected data using descriptive statistics and graphical representationsthrough Qualtrics reporting tools. |
| Final project completion | Weeks 13-14 | Interpret results, prepare final report, and develop presentation of findings forfaculty and stakeholders. |
Appendix D
| Citation | Design/Meth od | Sample/Setting | Major Variables Studied and Their Definitions | MeasurementAnd Data Analysis | Findings | Results | Conclusions | Appraisal:Worth to Practice/Lev el |
| Chan et al,4 2023 | RCT between flipped classroom case learning and traditional lecture based learning during a 5 day ophthalmolog y rotation. | Sample size was 216 medical students in their final year ophthalmology rotation in Hong Kong. Half received the flipped classroom learning style and the other half received traditional lecture based learning. | The independent variables were the two teaching techniques used.The dependent variables were the exam performances, retention of information, and the learner opinions. | Scales used in the study include the 5-point Likert scale to measure the outcomes of subjective assessments, and an end of rotation 60 item multiple choice exam was used for the objective assessment to be compared between the two groups. | The study found that the flipped classroom learning students were more engaged and satisfied. They also scored better in the end of rotation questions and had more knowledge retention at the end. | The flipped classroom learning style showed more student satisfaction, had better exam grades, and retained the information better than the students in the traditional lecture based learning style. | The flipped classroom case learning model is an effective teaching approach that could also be used in other areas of learning not specific to medicine. | Strengths of the study were its RCT design, the large sample size, and that it included subjective and objective outcomes.Limitations were that there was no baseline knowledge assessment, and the follow up exam was voluntary.There was low risk of harm. |
| High feasibility, requires initial development time but materials are reusable.This being a RCT the evidence level is II. |
| Al-Mugheed et al,9 2021 | A RCT was done to test the effectiveness of venous thromboembo lism (VTE) course comparing a flipped classroom learning approach to a traditional lecture based approach. | Sample size was 118 nursing students in either their first or second year of school. 58 students received the flipped classroom learning style and 60 of the students received the traditional lecture based approach.There was no attrition in this study. | The two teaching techniques were the independent variables.The dependent variables were the opinions of the students, VTEawareness, prophylaxis, and risk factors. | VTE evaluation form that had 50 T/F questions which was nominal. The questions included VTE knowledge, risk factors, and prophylaxis.Cronbach’s alpha was 0.8 which indicated consistency and reliability.A comparison of pre and post test scores was used to compare the outcomes. | The pretest scores were similar in both groups. The posttest scores in the flipped classroom approach were higher than the traditional based learning group. | The students that received the flipped classroom teaching showed better knowledge in VTE risk assessment, and prophylaxis than the traditional lecture based students. | The study demonstrated that the group that used the method of the flipped classroom was effective teaching method to improve nursing students knowledge on venous thromboemb olism. The flipped classroom teaching method also proved to be a more credible and effective teaching method than thetraditional | Some of the studies strengths were its RCT design, the use of a pre and post test, and that it focused on an important patient safety topic.Limitations are that the study was done in a single facility, and it was only short term results. There was low risk of harm.This is feasible for nursing education with planning |
| lecture based method. | and faculty preparation.Level of evidence: level II evidence. |
| Budak et al,6 2025 | A RCT of the flipped learning method versus traditional learning based method within a six week patient safety training program for nursing students. | Sample size was 69 nursing students in their fourth year, taking nursing vocational courses at the university of Northern Cyprus.The nursing students were assigned at random to the intervention group of 34 students, and the control group of 35 students.12 students that did not attend one session were taken out. | The independent variables were the teaching method that was used, age of the students, gender, their patient safety knowledge, and skills when encountering a medical error in clinical practice.The dependent variable was the self evaluation to test patient safety competency. | Scales used in the study include the patient safety competency self evaluation tool (PSCSE), and the satisfaction questionnaire (SQ).Reliability was reported using Cronbach’s alphaPSCSE 0.94-0.96SQ 0.93-0.97The methods used were independent and dependent sample t-tests, chi-square tests, and multivariate linear regression analysis. | Study found that the group that the flipped classroom learning style demonstrated a big improvement in patient safety competency scores than the traditional lecture group did. | The flipped learning method improved nursing students patient safety skills and also improved patient satisfaction compared to the traditional lecture group. | The flipped learning method proved to be a efficient, student focused teaching method that should be used in nursing education to enhance positive patient safety outcomes. | Strengths of the study were validated measurement tools with high reliability, and the focus on student satisfaction, and patient safety.Limitations were the single institution study, and self reported outcomes.There was low risk of harm if implemented.Feasible with access to online learningplatforms and |
| faculty training.Level of evidence: level II |
| Erden et al,7 2024 | A single blind RCT of the online flipped classroom learning model compared to the traditional fully online learning based training in nursing students in a chemotherapy symptom management course. | Sample size was 68 second year nursing students at a university in Turkey.The students were assigned randomly to one of two groups, the experimental group or the control group selected from an app. Both the experimental group and control group consisted of 34 students each. | The independent variable was the teaching method, online flipped classroom learning, or traditional online based training.The dependent variables were the academic achievement, critical thinking disposition, and self directed learning skills. | The scales used were the chemotherapy symptom management knowledge test (CSMKT), KR-20 results: pretest 0/80, posttest 0.85, one monthfollow up 0.87Marmara critical thinking dispositions scale (MCTDS),Cronbach’s alpha score 0.91Self directed learning skills scale (SDLSS), Cronbach’s alpha score 0.93Methods used to answer the research question were Shapiro- Wilk test, Mann- Whitney U test,Friedman test, | The academic attainment, and critical thinking scores were significantly increased in the online flipped classroom learning group. The self directed learning difference was not considered relevant after training. | The online flipped classroom learning method showed more promise in improving academic performance and critical thinking in students than traditional online learning. | Online flipped classroom teaching method is effective for augmenting academic attainment and critical thinking in students and should be implemented into nursing education. | Strengths of the study were that it had multiple measures of outcomes, and validated measurement tools with high reliability.Limitations of the study are the single blind design, single institution, and the self directed leaking skills did not improve.There is a low risk of harm.Feasible with access to online training platforms and |
| Chi-square test, and descriptive statistics. | faculty training.Level of evidence: level II. |
| Citation | Design/Method | Sample/Setting | Major Variables Studied and Their Definitions | Measurement and Data Analysis | Findings | Results | Conclusions | Appraisal: Worth to Practice/Level |
| Shikino et al,15 2022 | Mixed “embedded” methods research design of qualitative and quantitative nature. | Population consisted of 9 healthcare professionals which consisted of 3 nurses, 3physicians and 3 pharmacists at Chiba University Hospital in Japan. | Independent variable (IV) = The type of educational intervention – Flipped classroom Quantitative Dependent variable (DV) = Interprofessional Collaborative Practice Competency (ICPC)measured using the Chiba Interprofessional Competency Scale (CICS29) scores – this is what was measuredbefore, after and | CICS29 scale before, after and at 3 months post educational intervention and analyzed scores using variance analysis (ANOVA) an t-test using IBM SPSS Statistics software. Data from focus group interviews and post-training questionnaires were analyzed using deductive content analysis guided by | The authors found a significant increase in ICPC scores after flipped classroom intervention and still higher after 3 months compared to before intervention. | This study showed that the flipped classroom approach improves competency, promotes critical thinking, enhances teamwork, and supports long-term learning. Immediate improvement with partial decline over time but with still better scores than the baseline | The authors concluded that simulation- based training using a flipped classroom approach is an effective method in education for improving collaborative practice competencies between healthcare professionals. | The sample used was very small consisting of only 9 subjects.It was conducted as a single-center design at a university hospital and doesn’t have a control group for comparison with traditional teaching methods.The use of mixed methods add strength to the interpretation of the results.This study is a randomized |
| at 3 months post intervention.Qualitative DV= Cognitive learning levels based on Bloom’s taxonomy (knowledge, comprehension, application, and analysis) | Bloom’staxonomy | (before intervention) | controlled trial (RCT). |
| Citation | Design/Method | Sample/Setting | Major Variables Studied and Their Definitions | Measurement and Data Analysis | Findings | Results | Conclusions | Appraisal: Worth to Practice/Level |
| Golaki et al,10 2022 | An RCT using the Solomon four- group design with 2 control groupsand 2 intervention groups. 1 with a pre-test and 1 without a pre-test. | 92 nursing and midwifery students divided into 4 groups of 23 each at Bushehr University in Iran | IV = Types of teaching methods used such as the flipped classroom through Near- Peer Education (FC through NPE) and a conventional teaching method.DV1=Knowledge retention on patient safety (PSKRE).DV2=Immediate post- intervention learning | The Patient safety knowledge retention exam (PSKRE) was the primary measurement tool used, which consisted of 32 multiple-choice questions. And assessed forknowledge retention immediately and at 2 months Data was analyzed by giving the subjects numbers rather than using the subjects’ real name and assigning letters ofthe alphabet to | The study found that students who received FC through NPEshowed a greater increase in knowledge immediately after the intervention compared with traditional teaching methods.Learning happened in both groups with no difference in long-term knowledge | Data gathered showed that the flipped classroom through NPEimproved immediate learning so right after the course when compared to students taught by traditional lectures.However, at the 2 month follow up knowledge had declined in | Flipped classroom through NPE improved short-term learning and increased scores but does not influence long-term retention. | Small sample size that only included 1nursing/midwifery school therefore, generalizability is limited. The outcomes were measured using only a multiple choice exam. This may not be valuable for SRNAs because it did not measure clinical performance, decision making under stress, or technical skills.This study is an RCT study. |
| knowledge acquisition. | their corresponding group. Other tools include the Shapiro-Wilk test, the Kruskal-Wallis test, the Chi-square test, and the Fisher’s exact test.T-tests ANOVASPSS Statistics software. | retention, meaning, knowledge declined in both groups (traditional and FC through NPE) | all groups as evidenced by the lack of statistical significant difference between the two methods. |
| Citation | Design/Method | Sample/Setting | Major Variables Studied and Their Definitions | Measurement and Data Analysis | Findings | Results | Conclusions | Appraisal: Worth to Practice/Level |
| Sourg et al,14 2023 | Quasi- experimental study, case-control design with pre- test and post-test comparison between intervention group (flipped classroom) and control group (traditional lecture). | The study recruited 63 second year medical students from the Al- Neelan University school of Medicine in Sudan. 30 students were assigned the flipped classroom method and 33 students were taught by traditional methods. | I V1=Flipped classroom method IV2=Traditional lecture methodDV1=Academic achievementDV2= Thestudent’s perception and attitudes toward learning which examines how the student’s felt about the | Pre-test and post- tests were the primary measurement tools: Learning was measured using a 10 multiple choice questionnaire for concept recall.In the flipped classroom group an online questionnaire with a 5-point Likert scale was used to assess satisfaction, motivation, engagement and attitudes toward the flipped classroom method.Data was analyzed using statisticalsoftware SPSS | Students in both groups showed improvement from pre-test to post-test. Group A (Flipped classroom group):mean improvement= -32.67Group B (Traditional lecture group): mean improvement= -26.97 Comparison of pre-test and post-test scores for | Both teaching methods were effective for learning which means that students learned regardless of format.In this study the flipped classroom method was not superior to traditional lectures for exam performance. Although post-tests scores were slightly higher in the | Flipped classroom did not improve exam scores more than traditional lectures and both methods were effective for learning. However, most students strongly preferred the flipped classroom approach | Some drawbacks for the lack of difference between the scores suggested by the authors include receiving study materials immediately before post-test and the novelty and limited study time beforehand. The authors also suggested that larger studies are needed, with longer follow-up and more settings.This study is a quasi- experimental RCT. |
| flipped classroom | Version 2.0, Shapiro-Wilk Test, and paired and independent- sample t-tests. | Group A and Group BPre-test: P=0.912Post-test: P=0.100 Post-test scoresGroup A: 78.0Group B: 71.8 | flipped classroom group, they were not statistically significant.Students did have positive perceptions of the flipped classroom approach with an 80% satisfaction rate and 90% expressing motivation. |
| Citation | Design/Method | Sample/Setting | Major Variables Studied and Their Definitions | Measurement and Data Analysis | Findings | Results | Conclusions | Appraisal: Worth to Practice/Level |
| Lu et al,8 2024 | Randomized controlled experimental design of comparing 2 teaching methods with no blinding. | 46 randomly allocated nurses, 23 assigned to each group (FC and traditional teaching methods) at a hemodialysis (HD) center in China. All participants were female with a bachelor’s degree in nursing with no prior HD experience. | IV1=Flipped classroom methodIV2=Traditional lecture methodDV1=Theoretical knowledge or how well nurses mastered HD theoryDV2 = Clinical practice skills or hands on competenceDV 3 = Howwell the nurses managed to learn on their ownDV4 = Howsatisfied | The theoretical knowledge was measured using a 100-point written exam with 60 multiple choice questions and 4 essay-style questions.The hands-on portion was measured using a skills assessment based on the Standard Operating Procedures for Blood Purification (2021 Edition) with each skill scored from 1-10.Self-learning ability was measured using a30 minute scale | FC method nurses learned theory more effectively, they demonstrated better skill set and more motivation, better planning and more engagement.Nurses felt more satisfied, showed better theoretical understanding and independent learning. | The study found that the FC group scored significantly higher than the traditional method of teaching group on theoretical knowledge, clinical practice skills, and self-directed learning ability which includes motivation. In addition, the FC group | The authors concluded that the flipped classroom approach is highly effective for hemodialysis nurses with better understanding than those taught by conventional lecture.The authors recommended that more studies are necessary with larger samples and in different settings. | This was a randomized two- group experimental study. So while this study was randomized, it still lacks the full rigor of a large RCT.This study has high educational and similar practice value to SRNAs because it encourages pre-reading, improves level of engagement, and builds on skills. Although this study in particular is not anesthesia specific. |
| participants were with the teaching method. | designed by Shanxi University of Traditional Chinese Medicine.Training satisfaction was assessed using an anonymous survey on a 5- point Likert scale.Data analysis was carried out using SPSS software, descriptive statistics, independent sample t-test, chi- square test and statistical significance levels. | reported a higher rate of satisfaction with the teaching method, and the learning experience. |
| Citation | Design/Method | Sample/Setting | Major Variables Studied and Their Definitions | MeasurementAnd Data Analysis | Findings | Results | Conclusions | Appraisal:Worth to Practice/Level |
| Wang Z, Kohno EY, Fueki K, et al.12 2021 | RCT conducted over three years analyzingeffects of | The sample was 137 final year dental students that were randomly chosen as either a flipped classroom (70 students) or traditional lecture (67 students). The study was conducted at Tokyo Medical and Dental University in Japan. | The independent variable was the instructionalstyle. The | The IRAT and TRAT consisted of 27 multiple choicequestions. | Study found that the flipped classroomgroup accessed | For the IRAT the study found thataccessing | The study found that the flippedclassroom was | This study is level II evidence with it being a 3 year long RCT.Worth to practice: This study indicates that the flipped classroom does lead to improved scores and increased study time.Limitation of this study involves the nuance observed with greater study hours on behalf of the flipped class group. |
| instructional | dependent | Attendance rates | study materials | materials | effective in | |||
| styles. | variables were | were also | more often | played a | obtaining | |||
| scores achieved | documented. The | than the | significant role | knowledge but | ||||
| on an Individual | data analysis | traditional | in flipped | was influenced | ||||
| Readiness | involved a | lecture group. | classroom | greatly by | ||||
| Assurance Test | multilevel linear | The flipped | scoring better. | individual | ||||
| (IRAT) and a | regression to | group scored | On the other | learning | ||||
| Team Readiness | identify dominant | higher on both | hand, the | online. | ||||
| Assurance Test | factors. | IRAT and | flipped group | |||||
| (TRAT). | TRAT. | was a | ||||||
| significant | ||||||||
| predictor of | ||||||||
| better team | ||||||||
| scores on the | ||||||||
| TRAT. |
| Citation | Design/Method | Sample/Setting | Major Variables Studied and Their Definitions | MeasurementAnd Data Analysis | Findings | Results | Conclusions | Appraisal:Worth to Practice/Level |
| Harris EN, | A quasi- | The sample for | The independent variable in this study was the instructional format (flipped vs traditional). The dependent variable was exam performance. Two exams were given in the first half and another two for the second half.These were compared to historical data on the course. This included failure rate, student perception of the course, and participation. | Four exams were used to gauge performance. In class quizzes were also used.Participation was followed using “iClicker” software. Student perception was determined through anonymous end of term evaluations. Data analysis was don using a Mann- Whitney U test and a one way ANOVA for statistical comparisons. | The first two flipped classroom exams were slightly different in outcomes. A slight decrease in average was seen for the first exam with a significant increase for the second exam. Likewise failure rate after the flipped classroom dropped significantly from previous years. | The researchers found that exams and failure rate both showed improvements after initiating the flipped classroom model. Student preference also indicated that the majority preferred a flipped classroom model to traditional lectures. . | The flipped classroom model was determined to be superior to traditional lectures when teaching difficult topics and for students struggling. In class activities played a heavy role in success. | This is level III evidence Worth to practice: This experiment showed that STEM courses with complex topics could directly benefit from adopting a flipped classroom model. Limitations: The student perception was limited by survey participation. |
| Schroder EA, | experimental | this experiment | ||||||
| Berks TJ.13 | experiment that | was 105 | ||||||
| 2024 | compared | university | ||||||
| cohorts. | students ranging | |||||||
| from junior | ||||||||
| undergraduates to | ||||||||
| A flipped classroom | graduate study students. | |||||||
| format was | ||||||||
| used for the | ||||||||
| first half of a | The study was | |||||||
| term and a | conducted in a | |||||||
| traditional | university in the | |||||||
| format was | Midwest of the | |||||||
| used for the | US. | |||||||
| second half. |
| Citation | Design/Method | Sample/Setting | Major Variables Studied and Their Definitions | MeasurementAnd Data Analysis | Findings | Results | Conclusions | Appraisal:Worth to Practice/Level |
| Farina C, | A mixed | Sample | The independent variable od this study was the instructional method.The dependent variables were: student academic performance measured through quizzes and exams. Course satisfaction was also dependent and measured through survey responses. | Measurement of | Both cohorts | Both flipped | The flipped | This study was a level III evidence. Worth to practice: Yes the flipped classroom showed it was an appropriate alternative. Limitations:The sample size was small and had a lack of randomization. |
| Hranchook | methods cohort | consisted of two | student | demonstrated | and traditional | classroom was | ||
| AM, Bittinger | comparison | cohorts of first | performance was | improvements | models saw an | a suitable | ||
| AC, Aebersold | design. | year nurse | done through pre- | on exams from | improvement | alternative to | ||
| M. 2021 | Compared | anesthetist | class and post- | pre/post class | in quizzes. | the traditional | ||
| student outcomes | students. | class quizzes. | quizzes. No | Exam scores | class model. | |||
| between a | Exams were also | significant | did not show | No direct | ||||
| flipped | given throughout | differences | significant | inferiority | ||||
| classroom model and a traditional lecture based model. | 17 of the students were in the flipped classroom style with 19 being in the traditional lecture model. | the semester. For student satisfaction a survey was sent. Data Analysis: Student t-tests and | were noted in student satisfaction or overall performance between class models. | differences between cohorts. | among models was noted.Student satisfaction was also similar between methods. | |||
| Wilcoxon ranked | ||||||||
| The setting for this study was a university in the US Midwest. | sums were used. |
