By Andrew Crim, CHCP, Executive Director, and Dena Silva, MS, CHCP, Assistant Director, Educational Programs, University of North Texas Health Science Center
Editor's Note: This article is being published to compliment the December 2016 article by Brian S. McGowan, Ph.D., FACEhp. These projects were conducted independently but seem to draw nearly identical conclusions. As such, if you are interested in a deeper dive into lessons learned about implementing a flipped classroom in support of your continuing education, you may want to revisit this earlier article: http://almanac.acehp.org/p/bl/ar/blogaid=95.
During my senior year in high school, Mrs. Busbee would end her English class with a directive such as, “Be sure to read Act II of Hamlet before you come to class tomorrow and turn in the worksheet I just passed out. We’ll be discussing what you understood and what you didn’t based on what you wrote on your worksheets.”
And there went the evening.
Mrs. Busbee, who ironically went on to have a brief career in CME, was flipping the classroom long before flipping was cool. She assigned work to be completed before class, didn’t cover the material when class convened, and built on the assigned material through discussion and reinforcing work. She also collected data — those infernal worksheets she used to structure future lessons.
What Is a Flipped Classroom?
A flipped classroom is a blended and sequential learning activity where the learner engages in pre-work before participating in the live component1,4,5. Its use has gained considerable interest due to the advances of technology and because it seems to improve the effectiveness of and satisfaction with the associated intervention2-5,8.
An oft-overlooked component of the pre-work is that it should generate data about the content, experience or the learner that the presenter then uses to focus or refine the live component, which is reserved for deeper learning and application6. The data also serve as a learner feedback opportunity, a critical component in knowledge attainment and competence building7. In Mrs. Busbee’s class, reading sections from the book was pre-work, and the worksheets were the data. These days, when shooting video is as easy as making a phone call, a book assigned as pre-work is almost passé. In a continuing education setting, pre-work and data collection can take many forms (including books), but that pre-work must be appropriate to the activity’s objectives2,3,6.
During the Alliance for Continuing Education in Health Professions’ 2017 Annual Conference, UNT Health Science Center presented results from two attempts at planning CME using the flipped classroom approach. Each case was described, and results were discussed as a series of promising practices for educational designers and planners considering the format. Both cases were educationally well-designed. However, one resulted in 10 percent of 41 learners completing the pre-work, while the other resulted in 100 percent of 129 learners completing the pre-work.
The obvious question was, why the stark difference?
The answer is communication.
Communicating with Learners
The second activity was planned to over-communicate to participants. Communication about the “required” pre-work was conveyed in all of the following ways:
- On the conference website
- In the conference registration confirmation email
- Weekly emails to registrants
- Printed cards distributed on-site
- Printed page in handout materials
- Multiple announcements by the conference chair
- Participants were reminded upon sign-in
- Participants were reminded at close of day one
Support and Removing Barriers
The day prior to the flipped classroom activity, laptops were provided on-site to eliminate access barriers, and technical support was provided for accessing the pre-work activities. Participants were able to print the work they completed, and faculty were provided with updated information before the conference adjourned to prepare for the following morning’s session.
The flipped components of each activity differed greatly. In the first activity, participants were asked to complete an online differential diagnosis exercise and conduct five guided chart reviews pre/post activity. In the second activity, participants were asked to watch a brief video, read an article and complete a worksheet on a practice-based issue. Each was complex, required the use of critical thinking and generated data for faculty to use to guide the live activity component. And in each instance, it was observed that the information gained transitioned into application, rather than remaining just factual knowledge — something that is also noted in the literature2.
The primary difference between the two activities that could relate to the difference in engagement and completion is the amount and quality of communication that was directed at completing the pre-work. The first case included only basic information presented on the brochure and website. The second case’s success was built on the lesson learned from the first’s missteps: Plan to communicate about pre-work early and at every opportunity!
Designing a Flipped Classroom Activity
Additional items to consider when considering the format include:
- Is access to learners before the activity likely, and will they engage?
- Is the topic appropriate for flipping? What will be gained or potentially lost?
- Is the faculty presenter on-board and flexible enough, and will they use data collected and reinforce pre-work learning?
- How will the activity be designed to use the learner’s momentum?1,3,4,6,8
Mrs. Busbee’s lessons for flipping classrooms (she called it homework) have endured. Her lessons engaged, everyone knew to complete them before class, and she used what you wrote to make her lessons better. In the age of on-demand video, web surveys and PDFs, pre-work can take on many forms. With good educational design and even better implementation that includes communication, a flipped classroom can be successful.
In the end, the following tips can make your next (or first) flipped classroom attempt more successful and meaningful to the learner:
- The pre-work should be engaging and have purpose
- Don’t cover the same material in class that was covered at home – reinforce, instead
- Collect and use data.
- Be smart about the use of technology
- Plan it well, execute well, and over-communicate.
- Mayer, R. and Sims, V. For Whom is a Picture Worth a Thousand Words? Extensions of a Dual-Coding Theory of Multimedia Learning. Journal of Educational Psychology: Volume 86/Number 3/1994.
- DeRuisseau LR. The flipped classroom allows for more class time devoted to critical thinking. Adv Physiol Educ. 2016 Dec 1;40(4):522-528.
- Stephenson CR, Wang AT, Szostek JH, Bonnes SL, Ratelle JT, Mahapatra S, Mandrekar JN, Beckman TJ, Wittich CM. Flipping the Continuing Medical Education Classroom: Validating a Measure of Attendees' Perceptions. J Contin Educ Health Prof. 2016 Fall;36(4):256-262.
- Tucker, B. The Flipped Classroom. Education Next: Winter 2012.
- Turco MG, Baron RB. Observations on the 2016 World Congress on Continuing Professional Development: Advancing Learning and Care in the Health Professions. J Contin Educ Health Prof. 2016 Summer;36 Suppl 1:S4-7.
- McGowan B. Lessons Learned from Three Years Flipping Education. The Almanac: Volume 38/Number 12/December 2016.
- McFadden P.,Crim Comparison of the Effectiveness of Interactive Didactic Lecture Versus Online Simulation-Based CME Programs Directed at Improving the Diagnostic Capabilities of Primary Care Practitioners. J Contin Educ Health Prof. 2016 Winter;36(1):32-7.
- Bonnes SL, Ratelle JT, Halvorsen AJ, et al. Flipping the Quality Improvement Classroom in Residency Education. Acad Med. 2017 Jan;92(1):101-107.