A comparison between the impacts of lecturing and flipped classrooms in virtual learning on triage nurses’ knowledge and professional capability: an experimental study

As one of the most sensitive areas in hospitals, the emergency department provides patients with immediate medical care and is an integral part of healthcare systems [1]. Overcrowding in the emergency department is a serious issue in all healthcare systems across the world, including Iran [2]. In the 1950s in the United States, triage was suggested as a solution to the problem of overcrowding in emergency departments for the first time [3] Triage is prioritizing patients for receiving care based on the severity of their injuries or illness and giving the best treatment to the largest number of patients in the shortest possible time [4]. The effectiveness of triage depends on the knowledge and skill of the emergency department personnel, including the nurses. Nurses are the main performers of triage in emergency departments and play a primary role in prioritizing the needs of patients whose condition is critical [5]. Triage nurses’ key part in prioritizing the needs of patients who are in life-threatening conditions underscores the importance of evaluating their professional capabilities [6]. Professional capability is a broad concept and varies according to individuals’ field of practice, characteristics, positions, and perspectives [7]. A study by Bijani et al. [8] defines professional capability in triage nurses as possessing not only clinical competence and psychological capabilities, but also commitment to the profession. In other words, professional capability in triage nurses is comprised of clinical competence, psychological empowerment, and professional commitment [8].

In view of the great significance of education in developing professional behaviors, it is essential that nurses’ professional capabilities be enhanced via specialized training. The main goal of nurse education is training capable nurses equipped with sufficient knowledge and skill to give care [9]. In a study by O’Connell [10], the nursing students believed that nurse education should stress development of professional capabilities. Among the different approaches to educating learners, traditional lecturing is the most commonly-used method in universities [11]. The disadvantages of lecturing include one-way transfer of information, the lengthiness of lectures, and learners’ inability to retain information absorbed from lectures for long periods [12, 13]. As with other majors, many nursing educational programs employ lecturing. In this method, learners’ personal capacities are not properly addressed, the role of learners is not significant, and learning is superficial. To overcome these shortcomings, educators have begun to use participatory and active methods of learning [14]. At the beginning of the twenty-first century, researchers found a huge gap between nursing education and nursing practice, leading to calls for a fundamental transformation of nursing education [15]. To that end, Benner and MacKinnon et al. proposed changes in the education system, such as moving away from teaching decontextualized knowledge, better integration of active learning in the classroom. New and innovative instructional strategies must be integrated within nursing education to achieve these goals [15, 16]. Application of modern learning approaches is an effective way to improve triage nurses’ professional capabilities. One of these relatively new approaches is flipped classrooms, whose strength concerns the manner of providing information [17]. The structure of flipped classrooms is based on fundamental changes in the lecture-based method and is a transition toward student-centered learning [12]. According to a study by Dadgari et al., flipped classrooms are helpful in preparing nursing students for self-directed learning and should be used alongside traditional methods of learning [18]. A study by Tan et al. [19] showed that use of flipped classrooms resulted in better knowledge, skills, perception, self-learning, critical thinking, and problem-solving skills in nursing students [20]. According to a study by Herbosa, et al. [21] showed that the use implementation of the flipped classroom in nursing education increases performance and is satisfactorily evaluated by both students and faculty. However, more studies are needed that meet methodological quality standards to consolidate the evidence [19].

As one of the most important parts of every hospital, emergency departments are consistently faced with new challenges and changes in protocols and methods of treatments. Accordingly, it is essential that triage nurses’ knowledge and professional capabilities should be evaluated so that their weaknesses and educational needs can be identified and appropriate measures can be taken to help their professional development and enhance the quality of care provided by them. Triage nurses require continuing education and training, and modern innovative learning methods, including flipped classrooms can contribute to enhancement of nurses’ professional capabilities. Most of the available research on flipped classrooms has targeted nursing students, and the impact of this method of education on nurses, especially triage nurses in emergency departments, has not been studied, creating a gap in research in this area. Also, the most common method of educating nurses in clinical environments in Iran is lecturing, and modern methods of learning, including flipped classrooms, are rarely used, which can be attributed to instructors’ unfamiliarity with modern learning approaches. In view of the spread of COVID-19 and nurses’ heavy workload, especially emergency nurses, virtual learning can prove a proper approach to educating caregivers. The present study was conducted to compare the impact of lecturing to flipped classrooms in virtual learning on the knowledge and professional capabilities of triage nurses in the emergency departments of the state hospitals of Yazd province in southern Iran.

In total, 74 triage nurses participated in the study: 40 (54%) of the nurses were male and 63 (85%) had a bachelor’s degree. The average age of the participants in the flipped classroom and lecturing groups were 33.15 ± 4.361 and 33.12 ± 5.401 years respectively and there was not a significant difference between the means of the two groups’ ages. Independent t-test and chi-square test shows there was no significant difference in demographic variables among the flipped classroom and lecturing groups (Table 1).

The results of the independent t-test showed that there were no statistically significant differences triage knowledge mean scores between the two study groups in the pretest stage. However, after the intervention, the triage knowledge mean score of the nurses in the flipped classroom was higher than that of the nurses who were educated via lecturing, and the difference was statistically significant (p = 0.001). Moreover, measured one month after the completion of the intervention, the difference in means of the triage knowledge between the two groups was significant (p = 0.066) (Tables 2 and 3).

The results of the study showed that the difference between the pretest and posttest professional capability mean scores of the two groups was not statistically significant. However, measured one month after the intervention, the professional capability mean score of the nurses who were educated using the flipped classroom method (140.27 ± 11.744) was higher than that of the nurses who were virtually educated via lecturing (132.84 ± 10.817), and the difference in means of the professional capability scores was statistically significant (p = 0.006) (Tables 4 and 5). Moreover, the results of the test question item analysis report in two groups showed that the difficulty and discrimination index of the triage knowledge questions test it has been at an acceptable level (Table 6).

The present study was conducted to compare the impact of lecturing to flipped classrooms in virtual learning on the knowledge and professional capability of triage nurses in the emergency departments of the state hospitals of Yazd province in south-western Iran. The findings of the study showed that, after the education intervention, the triage knowledge mean score of the flipped classroom group was higher than that of the lecturing group. The results of a U.S. study by Fatima et al. [24] showed that flipped classrooms are an effective method to increase learner participation and encourage in-depth and active learning, which is consistent with the findings of the study [24]. However, another study conducted in the U.S. investigated the impact of different learning methods on ophthalmology interns’ ability to cope with the challenges in their training and concluded that there was no significant difference between lecturing and flipped classrooms in affecting the learners’ final grades [25]. The discrepancy between these findings may be due to the great importance of grades to students; therefore, the students in both groups tried their best to absorb the educational content. In flipped classrooms, students learn materials more deeply and feel a greater sense of responsibility for their learning. Video lectures allow for more flexibility in learning and give learners the chance to review previous sessions. Another reason for better learning in flipped classrooms is the fact that it allows learners to learn at their own pace: some learners need to listen to a lecture or read a text several times before they absorb it, while others learn what there is to learn the first time.

In the present study, there was not a statistically significant difference between the pretest and posttest knowledge mean scores of the flipped classroom methods and lecturing. However, measured one month after the education intervention, the triage knowledge mean score of the flipped classrooms was significantly higher than that of the lecturing. The results showed that both the lecturing and flipped classroom methods transferred knowledge to the learners, but education via flipped classrooms resulted in longer retention of knowledge by the learners. One of the shortcomings of lecturing was the learners’ failure to retain the knowledge transferred to them for long periods, which was consistent with the results of a study by Sadeghi et al. In their study, Sadeghi et al. found that lectures resulted in one-way transfer of information, took a long time to present, and did not guarantee long-term knowledge retention: the learners forgot 80% of the material presented to them in 8 weeks [26]. A study in Iran compared the impact of learning via lecturing to a combination of virtual learning and lecturing on college students’ level of knowledge and found that the blended approach resulted in higher levels of knowledge and greater satisfaction in the students [27]. Similarly, several other studies reported better outcomes for blended and learner-centered methods of learning than the conventional method of lecturing [28, 29]. Comparing the effects of the three approaches of online learning, face-to-face learning, and blended learning on medical students, Bahadorani et al. found that blended learning resulted in higher knowledge and skill mean scores on the part of the students than the other methods [30]. At the same time, a few other studies reported that blended methods of learning and lecturing were equally effective, which is not consistent with the findings of the present study [31, 32]. This discrepancy may be due to the fact that in the aforementioned studies, the subjects were tested a short time after their education; therefore, the difference between the blended learning group and lecturing group was not significant. The results of the present study showed that, in the long term, flipped classrooms result in better retention of knowledge by the learners. Longer knowledge retention in virtual learning, including flipped classrooms, can be attributed to the active and student-centered nature of this approach. In addition, learners vary in their learning potential: some learners need to review a lesson several times before they can commit it to memory, a condition available in flipped classrooms, which explains the greater efficacy of virtual learning, especially flipped classrooms [33]. Similarly, a study by Lelean & Edwards [34] showed that the implementing the flipped classroom, which included improved understanding and retention of knowledge. This was mainly due to students being able to watch the pre-class videos until they understood the content, and before applying this new knowledge to case studies and activities in class [34].

Comparing the impact of flipped classrooms to that of lecturing on nursing students’ knowledge of medical equipment, Mirdehghan et al. [33] found an increase in the mean scores of both groups of students, but the difference between the pretest and posttest knowledge mean scores of the students in flipped classrooms was greater. Thus, instructors at nursing schools are recommended to use flipped classrooms to educate students in using medical equipment [33]. Similarly, a study by AL-Mugheed and Bayraktar [35] showed that the venous thromboembolism (DVT) knowledge mean score of the nursing students in flipped classrooms was higher than that of the students who were educated via lecturing. Also, most of the students in flipped classrooms reported that learning in flipped classrooms increased their motivation for learning, improved their comprehension of the course content, and enhanced their communication and clinical thinking skills [35]. The findings of a study by Taskin and Bahar (2021) showed that the knowledge and skill mean scores of the nursing students for measuring vital signs were greater in flipped classrooms as compared to verbal-based traditional education [36]. On a similar note, Chaudhuri et al. (2022) found that, compared to lecturing, flipped classrooms resulted in better basic life support (BLS) knowledge and skill mean scores in medical students [37].

The findings of the present study showed that the posttest professional capability mean score of the flipped classroom group was higher than that of the lecturing group. Similarly, a study by Gopalan and Klann [38] reported that the students who took their psychology course in flipped classrooms felt significantly more prepared for their tests than the students who were educated via the conventional approach. In a meta-analysis conducted by Oliver et al. 2020 [39], a blend of learning models in flipped classrooms for nursing students were reviewed. The results showed that effective flipped classroom models enhanced participatory learning, teamwork, and active learning and improved the students’ critical thinking and decision making skills for better patient care [40]. Another study in China evaluated the effectives of different approaches to training medical students in conducting electrocardiogram and found that flipped classrooms increased the learners’ interest in learning and improved their self-learning abilities [41]. The reasons for better learning and learner participation in flipped classrooms include the relevance of the educational content to the learners’ lives and learners’ freedom to participate in and control their learning environment in this learner-centered approach, factors which are important to adult learners according to the adult learner theory. Since emergency departments, as one of the most important units in every hospital, are constantly faced with new challenges and changes in protocols and treatments, emergency room nurses need continuous education and training. The important role of innovative approaches to learning in preparing nursing graduates and practicing nurses in all hospital units, especially the emergency room, and the findings of studies, the present study included, verifying the benefits of flipped classrooms lead the researchers to conclude that flipped classroom models are an effective method of education in nursing.

The findings of the present study showed a significant increase in the knowledge and professional capability mean scores of the triage nurses in both groups immediately after the intervention. However, measured one month after the intervention, the increase was significant only in the case of the flipped classroom group, which shows that, in the long term, flipped classrooms were more effective than lecturing in increasing triage nurses’ knowledge and professional capability. Therefore, flipped classrooms are recommended as an effective and important teaching strategy in clinical nursing education and nursing students.