The results of this flipped classroom teaching approach were promising with respect to students’ performance as assessed by the course-exam. Compared with historic controls, Excellent and Very good performances increased, while Satisfactory, Sufficient and Failed performances decreased. The results suggest that both students at the higher and lower levels of performance profited from the approach. However, there are at least two factors that should be considered in the interpretation of the results. Firstly, due the lack of a control group it is not possible to decide whether the observed effects were caused by other factors. For example, this may have been an exceptional student cohort. In addition, there were other changes made to the programme that may also have contributed to the improved outcomes, such as the authentic, group-based classroom activities that were not necessarily part of the flipped classroom approach. Furthermore, it cannot be completely ruled-out that the students modified their learning-behaviour in response to their awareness of being observed (Hawthorne-effect). Finally, the reliability and validity of course-grades as a measure for learning outcomes, is arguable. Nevertheless, considering these objections, we still think the results are important for educators who plan to alter their teaching methods in an attempt to develop higher order thinking skills in physiotherapy students. The improved grades observed in the present study are similar to findings in other studies: The flipping of an Engineering course resulted in improved performance (quiz, exam questions and open-ended design problems) and also allowed the educator to cover more material the first of these studies, students reported a preference for working in the smaller-class format in teams and also achieved significantly better course grades . Similar findings were made in a study in Pharmacy education, where flipping of a large self-care course resulted in better overall course grades and improved opportunities to develop verbal communication skills and tackle unfamiliar problems .
It has been shown that flipped classroom teaching has the potential to enhance higher-order thinking skills and self-regulated learning, among students [10, 11, 22, 24]. Although we did no systematic investigation of this, the assessors at the course exam thought that the students had been able to discuss and debate at a higher level than in previous courses. As has already been mentioned, effort had been made to develop assignments which reflected higher-order thinking skills. This is, however, not unique for flipped classroom teaching, and similar approaches to learning can be implemented in other types of teaching. Nevertheless, we would strongly argue that an important success factor for these approaches to learning is the preparation made by students before attending the classroom, which is a key component of the flipped classroom model . We also think that the collaborative working environment at the seminars, was imperative for the learning. Although the flipped classroom model give no directions with respect to learning activities, there is evidence that support the use of collaborative learning activities . However, less is known with respect to the design of the learning activities. Guided by the literature on team-based learning, we chose to keep groups stable, through all the seminars . We also hoped this positively would influence affective dimensions of learning, such as commitment to peers, being recognized and feeling safe, were acknowledge . Results from the survey show that the choice of stable groups were supported by an overwhelming majority of the students.
In the survey, about two thirds of the students reported that self-perceived learning outcomes of the flipped classroom approach was superior to previous conventional teaching in the programme. These results are in line with a systematic review in medical education which concluded that the flipped classroom is a promising teaching approach to increase learners’ motivation and engagement .
Physiotherapy education should reflect present and future demands of the health care. Due to the global rising numbers of individuals with a range of disorders that largely cause disability rather than mortality, patient education strategies are increasingly emphasized, within the context of rehabilitation [14, 27, 28]. While physiotherapy education has traditionally focused on physical activity, exercises and manual skills, future education will need to expand learning with respect to communication, critical thinking and collaboration, within a clinical setting. The flipped classroom model represent an opportunity to implement higher-order learning skills in the teaching. Nevertheless, yet there is only rudimentary evidence that blended learning has the potential to improve clinical competencies among health students .
Lessons learned and future developments
One of the strengths of this teaching approach is that it offers students a well-planned, flexible and coherent working process. The survey responses indicate that although some students enjoyed the flexibility and autonomy of the preparatory work, about half would prefer firmer structure in the seminars (Table 3). In retrospect, we think that this preference can be explained by the fact that the students’ previous experience in higher education is strongly associated with fact-based courses like anatomy, biomechanics and physiology. Asking students to shift into a new learning paradigm, when their previous learning strategies have been successful, may be a challenge for some. This is also supported by responses from the survey, were almost half of students reported that they preferred more structured classroom activities. Few studies have investigated the optimal degree of flexibility that is associated with this type of learning .
In order to increase students’ responsibility for their own learning, the seminars for this course were non-mandatory and class-attendance was not systematically recorded. We anticipated that group-accountability would be a barrier for absence. Although instructors never observed significantly low attendance, we do not know whether some students were absent from several seminars, or whether students who did not attend seminars performed poorly in the course-exam. In retrospect, we think that group-accountability alone not necessarily ensure class attendance. There were some indications in the survey responses that all groups did not work optimally. Our aim for future courses is to keep the learning activities non-mandatory. Instead, learning activities can be structured differently. For example, an assessed element at the end of group-work, which contributed to the final exam, could have been implemented. Another step would be to have students anonymously assessing other group-members’ contributions.
Findings in a study on the flipped classroom showed that there was a tendency among students to regard class attendance as optional, as there was a perception that complete learning could be achieved by viewing video lectures alone . The present approach The development of the learning activities were informed by social constructivism, which emphasizes the importance of the learner being actively involved in the learning process . Furthermore, the course-design was inspired by theories of constructive alignment. The basic premise of constructive alignment is that the curriculum is designed so that the learning activities and assessment tasks are aligned in order to support students to attain the goals intended for the course .
Without doubt, the in-classroom learning activities in the present study offered students too little variation. “Long and exhausting seminars” was the most common complaint from survey respondents. Due to this, we would like to increase variation in the feedback sessions for future courses. Example of activities that could have added variation are facilitator-led discussions and poster-presentations. We also think that there is some potential for implementing digital, interactive, learning activities and social-media platforms in the learning activities, which may facilitate remote interaction . Furthermore, research from the fields of human memory and recall has claimed that learning is better achieved when spaced out over time, in smaller chunks. In support of this, another solution could be to break the session up into different periods of the day, or even extend it over a period of a week .
It has been advocated that the role of the educator in the flipped classroom should be active, rather than passive . As could be expected, there are indications that educators who have previous experiences with active learning, more easily adapt to teaching in the flipped classroom . In the present teaching approach, educators had little previous experience, nor received any training. There is some indications from the survey responses, that students would have preferred increased availability of educators during the group work. However, responses also indicate that students appreciated autonomous discussion with their peers, with the option to contact educators, if necessary. In retrospect, we think training of the educators before the teaching approach would have helped the educators to find an optimal level of activity. However, at the time the design of the intervention took place, much effort was devoted to the technical issues concerning the production of video lectures.
As has already been mentioned, this study had some limitations with respect to the interpretation of the improved learning outcomes. The study design did not control for external factors that may have affected students’ performance relative to previous cohorts. It is also worth considering that a well-planned, conventional learning environment, may also lead to the kinds of improvements in learning outcomes that were observed during this study. Nevertheless, we would argue that an important success-factor lies in the combined effect of the preparatory work and the well-organised, collaborative learning activities.