A Comparison of Instructional Methods for an Undergraduate Nursing Health Assessment Course

With the emphasis on the ability of nursing students to apply knowledge learned, new classroom designs are being implemented to ensure student success. Traditional teaching modalities consisted of lecture and regurgitation of knowledge. Today, faculty are implementing a flipped classroom design as a pedagogical tool to enhance learning through increased faculty and student engagement (Paterson, 2017; Smith, 2017; Rotellar and Cain, 2016). Flipped designs have also been shown to promote higher-order thought processes and reasoning skills in English as a second language students (Kim, Park, Jang, and Nam, 2017). Some studies have shown no difference in student grades or level of student satisfaction with flipped classroom design vs traditional lecture based design but suggest that intensity of the course has a factor (Whillier and Lystad, 2015). Students are often resistant to change from traditional methods of instruction and sometimes find individual learning of content difficult without the face to face instructor contact (Telford and Senior, 2017). An additional method to integrate technology use in a health assessment course is the use of virtual patient technology which provides a comprehensive learning experience in a safe environment and engages students to develop their assessment and documentation skills. The combination of flipped classroom design with virtual patient experience has been shown to allow for a personalized learning experience that promoted higher-level learning in pharmacy students in a required therapeutics class (Lichvar, Hedges, Benedict, and Donihi, 2016).

This study compared outcomes of three different teaching modalities in an undergraduate health assessment course. The modalities were as follows: traditional lecture in a traditional classroom setting (traditional section); flipped class in a traditional classroom setting (flipped section); and flipped class in a fully technology integrated classroom (flipped and integrated section). Course content was identical across the three sections. In the traditional section, students completed preparatory readings followed by lectures in class and then completed a virtual patient module assignments at home. In the flipped section, students completed preparatory reading and viewed content-based podcasts prior to class. In the classroom, faculty reviewed key lecture elements and students completed the virtual patient module assignments individually during class time. The flipped and integrated section used the flipped delivery method as described. In a technology integrated classroom, students worked collaboratively in groups to complete the virtual patient module assignments together with the support of course faculty. At the completion of the semester, comparisons were made between mean grades on each assignment and examination. Grading of the virtual patient module assignments was completed by lab instructors associated with the course. Interrater reliability was ensured with training during orientation to this course prior to the start of the semester. Examinations were graded via Pars Score® technology and completed by the course instructor of record. Standard student course evaluations, which are de-identified in their report to course faculty, were compared to determine if there is difference between the three sections.

This study used a convenience sample as the students were already enrolled in the respective sections of this required foundational course. Teaching modality and room assignments were determined after the student enrollment period was completed. Following institutional review board approval, informed consent was obtained from students wishing to participate by having their grades included in data analysis. Students who did not consent to participate were excluded from the study. Consent was obtained by a co-investigator who did not have any teaching or grading responsibilities in the course. Further, data was collected by this co-investigator to maintain participant anonymity to course faculty. Participation or nonparticipation in this study in no way impacted their course grades or content delivery. Because end of semester standard course evaluations are reported as aggregate data, there was no way to include or exclude student data and therefore all aggregate data was examined.

A total of 95 students participated in this study. Data from both the de-identified student database and course evaluations were analyzed statistically using ANOVA and Kruskal-Wallis comparison testing. Data analysis revealed significantly better outcomes on 10 of the 12 virtual patient modules in the flipped and integrated classroom section compared to the two other teaching modalities (p < .05). Student performance across groups on course examinations did not differ except for one unit examination favoring the flipped and integrated model. Of the summative evaluations, no significant differences were found between groups for the final head to toe demonstration, final examination, and overall student grades; those in the flipped and integrated model scored significantly higher on the comprehensive virtual patient module (p < .05). Qualitative comments from student evaluations were analyzed for common themes.

In conclusion, the use of a flipped classroom design with an integrated model using a virtual patient supported student learning. It improved the scores on virtual patient modules, which provided the students with a safe platform to practice their assessment, documentation, and critical thinking skills. While most of the summative evaluations showed no significant difference, the comprehensive module did show significant difference, which demonstrates the students’ ability to organize, perform, and document their complete history and physical exam. Limitations of this study included the small sample size and the fact that the students were not allowed to self-select in which section they would participate. Further study is recommended.