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The New Nursing Classroom

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For the first few minutes, the Managing Acute and Chronic Health Problems class looks pretty much like any other. Forty-five students sit behind long curved tables in the amphitheater-style classroom in the Pearson Building, while the professor, Alison Edie stands in the front of the class, going over some announcements.

But before long, you notice something a little different. Edie doesn't give a lecture, and although she has invited two guest faculty members -- Ann Mosher and Les Harmon -- to lead parts of the two-hour session, neither of them delivers anything remotely like a lecture either.

To be precise, neither of them delivers a lecture during the class. In fact, the students have all seen a lecture by each of them -- but online, before class. They've also taken a quiz testing their understanding of the concepts presented in those recorded lectures -- but again, they did that and turned it in before class, too, not after it.

Welcome to the "flipped" classroom.

Edie is one of several professors in the School of Nursing experimenting with the flipped classroom model, which also is being used, in various incarnations, by dozens of professors throughout the wider university.

In a flipped classroom, rather than lecturing to students in class and then testing them, the instructor gives them the same information by way of online lecture or readings or some combination, prior to class time. Often they take an online quiz, also prior to class. Then, in the classroom, the students do activities designed to help them put into practice the concepts they learned before they arrived.

In this particular session, Mosher and Harmon presented a series of case studies, with symptoms and family histories, and the students, working in small groups, had to determine what questions to ask, come up with the most likely diagnoses, and formulate treatment plans.

"What we do in class is what really gets them ready to do it out there, in their clinical work," Edie says. "You need some core concepts, definitely. You have to have a strong foundation of knowledge. But how do they get that content? Does it have to be me standing in front them with a Powerpoint and telling them? If I spend two hours in class doing that, we don't have time for any of those activities you saw, the activities that require them to do the work of reasoning their way to answers."


Active Learning

Flipping isn't really a new concept; individual instructors in various disciplines have used variations of it for years. What is relatively new is identifying it as a specific educational model based on some basic principles, and using it in areas that have traditionally relied far more heavily on the classic lecture method.

"Some people have been doing it all along," Edie says. "In a lot of liberal arts classes, students read the material first and then come to class and discuss it; you don't necessarily have professors who stand in front of the class and lecture about it. But what is unique, maybe, is using it in the hard science courses, where students have long felt they have to be verbally lectured to in order to get the content."

At Duke, where flipping is one of a number of innovative educational approaches, much of the impetus came from a series of workshops and programs conducted last year by the Center for Instructional Technology. Many of the professors who have embraced the concept combine it with another fast-growing educational practice known as Team-Based Learning, which emphasizes students collaborating in groups to solve problems.

Proponents say the new approach benefits students by giving them a more active role in their own learning. Under the lecture model, a professor might describe how he or she solved a particular problem, Edie says. The flipped approach, by contrast, requires students to solve the problems themselves. Rather than being passive recipients of information, they come into class prepared -- they hope -- to do their own critical thinking.

"I'm trying to help them develop the reasoning process so they can think, 'OK, how am I going to figure this out? What are my questions, what are my resources?'" she says. "Because that's the thought process you have to have when you get into the clinic."

The flipped model allows faculty to play a more engaged role, too.

"This puts students at the center of learning, rather than faculty," says Sharon Hawks, who began using the flipped model in the fall of 2012. "I don't use class time lecturing. I use it to be a guide and a resource, to answer questions, to help them learn to make their own judgments. That's the true value of faculty. So they're getting the best of me. We're learning together. They're teaching each other."

Hawks said her experience thus far has been that the flipped model opens up new avenues of understanding for both students and teacher. The pre-class quizzes, for example, reveal where gaps in understanding lie, and those gaps can be addressed immediately.

"It's important for students to know what they don't know," she says. "This way I can give them immediate feedback on that, and we can work it out. It encourages discussion, and a much higher level of discussion. It's fun, and I think we're all learning more."  

Critics and Converts

Flipping a classroom is not easy. It requires a substantial investment of work by both faculty and students ahead of time.

"It takes a tremendous amount of time, preparation, and energy," Edie says. "It hasn't decreased my workload at all. And it really requires students to do the preparatory work. They can't slide by."

Edie didn't announce on the first day of her Managing Acute and Chronic Health Problems class that she was flipping it; she didn't want the students to feel like guinea pigs. She simply spelled out how things were going to work and told the students how she expected the unusual format to help them learn the process of clinical reasoning.

They did not all buy into the idea, at least not at first.

"I was one of the biggest critics," says NP student Ryan Ress. "This was something I'd never been exposed to, and yes, there was a little anxiety. But I actually really enjoy it. It helps that we can get the information in a formal lecture at home, and then we come in here and piece it together."

The flipped classroom is indeed a different way of teaching and learning, and it's not necessarily well suited to all subjects and all classes. Edie acknowledges that some students still aren't thrilled with it. But she believes it will help them when they begin their clinical work.

"They're nervous, because they're getting ready to go out and see a patient, listen to their story and try to decide what's wrong and how to treat it," Edie says. "That's when they want the comfort of a classroom that says, 'OK, I'm going to tell you everything you need to know. Write it down, and you will know what to do.' And it just doesn't work that way. That's not the reality."

Even those students who have had some difficulty adjusting to the flipped model say they've found it a valuable learning tool. FNP student Neha Desai said adjusting to her first flipped classroom was a significant challenge, especially considering her experience under the classical lecture model growing up in India.

"I like it," Desai says. "I don't love it. And I think the reason I don't love it is because it's so new to me. I've had most of my education in India, where students were expected to listen and never speak. To go from that to this, where I'm thinking, ‘Wait, you're not going to talk at all? I'm going to do the talking?' was uncomfortable at first. But I do think this way is more practical. It's a lot more work, but you're thinking more. Of course things make sense when someone is saying them. But it's when you say it yourself that it really clicks in."

That is precisely the point, Hawks says. She said student responses to a post-course evaluation after her first flipped class in the fall 2012 semester indicated that her students had learned at least as much as they would have in a traditional classroom environment. Moreover, they appreciated learning to reason their way to solutions themselves, which may be the most important lesson of all. In the operating room, there is no lecturer to give students the correct answer.

"Several of them said, 'I had to teach myself,'" Hawks says. "I loved that answer. Because that is what adult learning is all about."