Comparing the effects of traditional lecture and flipped classroom on nursing students' critical thinking disposition: A quasi-experimental study
Introduction
Critical thinking is one of the essential skills which prepare nursing students for clinical practice (Kaya et al., 2017), because critical thinking enables them to effectively manage patients' problems, make best clinical decisions, have closer control over critical clinical conditions, and provide safe and quality care (Kaddoura et al., 2017). The National League for Nursing Commission for Nursing Education Accreditation expects nursing graduates to have competence in critical thinking (Romeo, 2010).
Critical thinking has two main components, namely critical thinking skills and critical thinking disposition (CTD). The skills component refers to the cognitive processes of thinking while the disposition component refers to personal desire and internal motivation for critical thinking (Zhang and Lambert, 2008). There is a significant positive correlation between CTD and critical thinking skills (Profetto-McGrath, 2003).
Nurses with critical thinking skills have abilities such as information seeking, data analysis, decision making, and reflection (Von Colln-Appling and Giuliano, 2017). Critical thinking is also a key predictor of academic achievement (O'Hare and McGuinness, 2009). Contrarily, poor critical thinking ability has different negative outcomes for Iranian nurses such as stagnancy in clinical settings, inability to solve patients' problems, and poor clinical reasoning (Hajrezayi et al., 2015). Studies in Iran showed limited critical thinking ability among nursing students, no significant differences among the students of different educational grades in terms of their critical thinking skills and CTD, and no significant correlation between students' grade point average (GPA) and their CTD (Mousazadeh et al., 2016; Poodineh Moghadam et al., 2015).
One of the major challenges in nursing education is to develop a nursing curriculum and effective instructional strategies which improve students' critical thinking skills (Simpson and Courtney, 2002). The most effective instructional strategies for the improvement of critical thinking skills are small group activities, question-and-answer, role performance, discussion and negotiation, case studies or clinical scenarios, written documents, concept mapping, learning cycle, and blended learning; however, these strategies are not routinely used in academic settings due to short amount of time for each course, which is mostly devoted to teachers' lectures (Chan, 2013; Von Colln-Appling and Giuliano, 2017).
Two key requirements for critical thinking promotion among nursing students are students' active involvement in teaching-learning process and teachers' ability to facilitate students' critical thinking and logical reasoning. In other words, teachers should act as facilitators to students' critical thinking and logical reasoning instead of simple information suppliers (Nelson, 2017). These requirements can be satisfied through active learning strategies, which facilitate cognitive processes and thereby, promote critical thinking.
Flipped classroom (FC) is one of the modern active learning strategies. Bergmann and Sams, two chemistry teachers, started to flip learning for the first time in 2007 and called their technique FC (McDonald and Smith, 2013). Now, blended learning and FC are interchangeably used, even though blended learning is a broader term to refer to the use of different types of technology for the promotion of active learning. FC is a more specific instructional framework and a subset of blended learning. In FC, learners use different technologies to learn educational materials before attending the class and then, they practice and use the learned materials in classroom under the guidance of their teachers (Graham and Burke, 2014).
FC is based on the self-regulated and socio-constructivist theories of learning. The self-regulated learning theory considers the learner as an active participant in the process of learning while the socio-constructivist theory puts greatly values the role of classroom discussions and interactions in promoting higher-order cognitive skills (Sun et al., 2018; Palinscar, 1998). FC divides education into two phases. In the first phase, students achieve an understanding about the intended concepts and in the second phase, they learn to use and evaluate the learned concepts in new situations (Jensen et al., 2015). This student-centered method helps students use learned knowledge in practice and thereby, prepares them for responding to the challenges of healthcare settings (Betihavas et al., 2016). In FC, teacher's lectures are provided to students in videos and are watched by students before classroom. Moreover, they are required to study educational materials before attending the class. Therefore, the valuable time of the class is spent on active learning activities, problem solving, evidence-based learning, group discussion, and knowledge application, analysis, and synthesis (McLaughlin et al., 2014). In this instructional strategy, each student learns concepts at his/her own learning speed, plays and pauses lecture videos based on personal preferences, and watches them for preferred number of times. Moreover, FC provides nursing students and nurses with the opportunity to learn materials in the preferred time and place and hence, it is a flexible instructional strategy (McDonald and Smith, 2013).
Section snippets
Literature
A systematic review showed that active and learner-centered strategies are needed to promote critical thinking skills. FC is one of these strategies (Carvalho et al., 2017). Previous studies reported the potential effects of FC on critical thinking. For instance, FC was used in a study to teach the principles of pharmacology to bachelor's nursing students. Results showed that from the perspective of the students, FC was effective in promoting their critical thinking (Hanson, 2016). Other
Design
This quasi-experimental study was done in 2016 using a nonequivalent control group pretest-posttest design.
Setting and participants
This study was conducted in the Nursing and Midwifery Faculty of the Rasht branch of Islamic Azad University, Rasht, Iran. At the time of the study, 450 nursing and midwifery students were studying in the faculty. Baccalaureate nursing program in Iran takes four years. During the first three years, nursing students receive both theoretical and clinical trainings, while in the fourth year,
Results
The number of eligible students was 85 and none of them were excluded from the study. The age mean of students was 19.87(1.35). Most students were female (83.5%), single (90.6%), and unemployed (95.3%), and lived with their families (68.2%). Their last-semester GPA was 15.44(1.46). The independent-sample t, the Chi-square, and Fisher's exact tests showed that the groups did not differ significantly from each other with respect to students' age, last-semester GPA, marital status, employment
Discussion
Study findings showed significant increases in the mean scores of overall CTD and its engagement domain in the FC group. These findings imply the effectiveness of FC in promoting students' CTD and thereby, critical thinking skills. Previous studies also reported that FC was associated with positive outcomes. For instance, a study showed that team-based learning through FC significantly improved sociology students' creative and critical thinking skills (Huggins and Stamatel, 2015). Studies on
Conclusions
This study suggests that while TL has no significant effects on CTD, FC promotes nursing students' CTD. FC actively involves students in learning activities both before and during classes. Of course, FC does not affect the maturity and the innovativeness domains of CTD. Teachers can enhance the effectiveness of FC by providing electronic contents to students at least 2–3 weeks before the course onset. Further studies are needed to produce more credible results.
Acknowledgment
The current study was supported by Rasht Islamic Azad University, Iran grant (no. 1179508260009). We express our sincere gratitude to all of the participants for their valuable collaboration.
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