Flipped classrooms in Doctor of Physical Therapy Education
Dr. Jeremy Kirschner, PT, DPT, ATC, CSCS
1. Introduction
Flipped classrooms have become more prevalent over the past decade, including higher education. For the purposes of this chapter, flipped classrooms can be defined as instructional design in which students listen to or view pre-recorded lectures, prior to face-to-face class time which is utilized to engage in active learning tasks and assignments (DeLozier et al). By allowing students to consume foundational content on their own time and at their own pace, class time is then prioritized for activities and assignments that are intended to deepen and clarify understanding. Often, instructors utilize frequent low-stakes quizzes at the beginning of class as a springboard for guidance and facilitated discussion, after which students are asked to engage in collaborative activities during class time to apply their understanding of the topic at hand.
The integration of flipped classrooms has also made its way into healthcare education; including medical schools, nursing programs, and doctor of physical therapist programs.
Despite its increasing popularity and because of its relative novelty, research and quantitative evidence supporting flipped classroom use over traditional instruction and its ability to improve student learning is lacking. Although, qualitative research indicates that learners prefer flipped classroom models to traditional models.
2. Overview of the Case
Dr. Sara Deprey decided to compare and contrast the outcomes of a flipped instruction, partially-flipped instruction, and traditional instruction in an entry-level first year course within Carroll University’s Doctor of Physical Therapy program. This was accomplished through a retrospective review spanning 3 consecutive years that describe outcomes of three teaching methods within one unit of an entry-level physical doctor of physical therapy course. Examination scores from a traditional lecture (TRAD) classroom (n = 44), a partially flipped (pFLIP) (n = 49), and a fully integrated flipped (full FLIP) classroom (n = 50) were compared in an attempt to better understand if any quantitative benefit existed in utilizing a flipped classroom approach during an introductory neurological physical therapy course. Dr. Deprey decided to take this approach as much research concerning flipped classroom implementation in physical therapy programs is qualitative in nature (Boucher et al.). While such qualitative research is helpful in consistently describing methods, principles, characteristics, and learner/instructor attitudes regarding Flipped instruction, it does not provide evidence as to whether learning is more effective than traditional classroom instruction.
3. Solutions Implemented
In order to compare and contrast learning outcomes of flipped, partially flipped, and traditional instruction in this entry-level neurological physical therapy course; pedagogical and assessment outcomes from 3 consecutive years (2012, 2013, and 2014) were retrospectively reviewed. This is because this course is offered once per cohort, with one cohort being accepted into the physical therapy program once per year.
Each cohort received traditional instruction during the first 2 weeks of the course. This introductory unit consisted of 10 hours of neurological physiology content and served as a “baseline” for each cohort.
For the subsequent units, the traditional cohort continued to receive five 2-hour in-class lectures, homework in the form of case-studies, and a 2-hour laboratory covering balance assessments.
For the partially flipped cohort, the subsequent unit received 5 pre-recorded lectures with embedded questions prompting students for content reflection and understanding. Class time was used as an opportunity for students to ask clarifying questions. This cohort also went through a 2-hour laboratory covering balance assessment.
The fully flipped cohort received the same 5 pre-recorded lectures as the partially flipped cohort to be viewed prior to class. During class, students were able to work in groups to answer instructor-prompted questions and work through scenarios that required students to apply content covered in pre-recorded lectures. In-class activities were created with the intention of allowing students to focus on answering questions in the context of critical thinking. Role-playing scenarios were also included during in-class activities. The flipped cohort also received the same 2-hour laboratory covering balance assessment.
Ultimately, all cohorts received 22 hours of face-to-face class time. For all cohorts, 10 of these hours took place in the form of traditional instruction during the first unit covering foundational neurological physiology. Each cohort also received 2 hours of laboratory time. The traditional cohort received an additional 10 hours of traditional instructor-led lectures. The partially flipped cohort received 10 hours of in-class time to review and discuss pre-recorded lecture content. The flipped cohort received 10 hours of in-class time to work in groups to address instructor-prompted questions and work through scenarios.
Of note, there was a 3rd unit in this neurological course, but this unit was taught by different instructors and thus was not included in this retrospective analysis.
4. Outcomes
The primary outcome assessed to compare traditional, partially flipped, and flipped instruction was the scores from the 2nd instructional unit exam. Change in scores from the unit 1 exam (baseline traditional instruction for all cohorts) and unit 2 exam were also compared. All exams were given at the conclusion of instructional units, prior to beginning the next unit. Exams consisted of multiple choice and short-answer formatted questions. These questions were considered “comprehension” and “application” level questions based on Bloom’s taxonomy.
In order to account for demographic differences in the three cohorts, ANOVA was utilized regarding age, sex, ACT scores, and GRE scores. The only demographic difference discovered was that the flipped cohort was an average of 1 year younger compared to the other two cohorts.
The fully flipped cohort had the lowest baseline exam 1 scores. However, they also demonstrated the highest exam 2 scores. The partially flipped cohort had the lowest exam 2 scores compared to the fully flipped cohort. The traditional cohort demonstrated no statistical difference between either flipped or partially flipped cohorts on exam 2. Students receiving instruction in a full FLIP classroom demonstrated the greatest improvements from examination 1 to examination 2. The pFLIP cohort demonstrated statistically significant lower scores compared to the fully FLIP cohort on examination 2.
5. Implications
While Dr. Deprey’s retrospective study indicates that the fully flipped cohort saw the most improvement on exam scores from unit 1 to unit 2, this does not take into account that this could be due to the fact that this cohort also scored lowest on the first exam. Would the cohort that scored the lowest initially not have the most opportunity to improve the most?
Also, this study lacks the ability to determine or predict long-term outcomes of flipped instruction integration. The ultimate purpose of healthcare education, including doctor of physical therapy programs, are to create safe and competent entry-level clinicians. As Chen et al indicates in A Systematic Review of the Effectiveness of Flipped Classrooms in Medical Education;
“the effects of the FC on learning are inconsistent, with some purported benefits and some reports of negligible improvement over traditional teaching methods. Third, students like the FC teaching method. Overall, the FC seems a promising teaching approach in medical education, particularly when the intent is to increase students’ motivation, task value and engagement. However, most of the controlled studies focused on learners’ perceptions of the intervention and changes in their knowledge and skills, whereas limited outcomes were reported on the higher level of Kirkpatrick’s classification (i.e. changes in behaviour, professional practice and patient outcome).”
So while Deprey’s retrospective study did show significant improvement when students transitioned from traditional to flipped instruction within a single course, it does not show how this approach did or could play out in terms of the student’s ability to pass a national board test, interact with patients, and treat them safely. To this point, it would remiss to not mention that allopathic medical programs have also implemented flipped instructional models with relative success compared to traditional models (Hew et al). While other healthcare education programs have implemented a flipped approach to varying degrees, research is lacking in terms of how flipped classroom instructional models impact healthcare provider licensing exam pass rates and subsequent ability to provide.
The TRAD class received in-class lectures with homework, whereas the pFLIP cohort received in-class questions and discussion of content, while the full FLIP cohort received intentional in-class work. A full FLIP classroom requires active participation by students, and in doing so, it simultaneously provides an enhanced opportunity to apply new content to contextualize new information with prior knowledge to solve problems. This opportunity to apply content along with the availability of the instructor to provide feedback in real time may have led to greater understanding of the course material, which could explain the differences in test scores previously mentioned. This may coincide with Deprey’s suggestion that the fully flipped cohort demonstrated greater improvement from test 1 to test 2 than the partially flipped cohort due to the structured, deliberate questions students had to answer in class. Structured activities/questions can foster deeper understanding and comprehension, while the partially flipped cohort utilized class time as an open format question & answer session. While qualitative in nature, Wittich et al suggests that residency program directors who implement flipped classroom models tend to view the interactive classroom component more favorably/beneficial than the assigned pre-class lectures/activities. This may be explained by findings similar to Deprey’s, or it could be due to instructor preference.
Deprey’s study accounted for differences in instructor preference and teaching technique, as the same instructor was utilized for both units in all three cohorts. Further studies could examine the extent of which instructor strengths and preferences work best with specific learning activities and outcomes, although the design of such a study could be challenging.
Overall, Deprey’s study along with emerging research indicates that flipped classroom integration can prove to be more effective in terms of helping students achieve desired learning outcomes in didactic healthcare coursework. Future research should examine the potential benefit (or lack thereof) of implementing a flipped classroom approach into skills and laboratory-based courses. Future research should also examine the longitudinal effect on learning over an extended period of time.
Much of the research mentioned specifically defines flipped instruction that requires students to complete assignments in class, in person. Given the current state of the global pandemic, many DPT programs have shifted to a hybrid format of instruction (Gagnon et al). Does flipped instruction have a place in hybrid or fully virtual learning formats? I believe that time will soon tell, as programs and students alike are learning to navigate the ever-changing virtual and blended learning landscape.
Ultimately, emerging current research indicates that flipped classroom instruction consisting of pre-recorded lectures combined with active, structured, and engaging learning tasks during class time helps to foster learning in didactic physical therapy and healthcare education courses.
References
DeLozier, S. J., & Rhodes, M. G. (2017). Flipped classrooms: a review of key ideas and recommendations for practice. Educational psychology review, 29(1), 141-151.
Deprey, Sara M. PT, DPT, MS, GCS Outcomes of Flipped Classroom Instruction in an Entry-Level Physical Therapy Course, Journal of Physical Therapy Education: September 2018 – Volume 32 – Issue 3 – p 289-294 doi: 10.1097/JTE.0000000000000035
Boucher, Brenda, PT, PhD, CHT, OCS, FAAOMPT; Robertson, Eric, PT, DPT, OCS, FAAOMPT; Wainner, Rob, PT, PhD, OCS, ECS, FAAOMPT; Sanders, Barbara, PT, PhD, SCS, FAPTA “Flipping” Texas State University’s Physical Therapist Musculoskeletal Curriculum: Implementation of a Hybrid Learning Model, Journal of Physical Therapy Education: October 2013 – Volume 27 – Issue 3 – p 72-77
Chen, F., Lui, A. M., & Martinelli, S. M. (2017). A systematic review of the effectiveness of flipped classrooms in medical education. Medical education, 51(6), 585-597.
Wittich, C. M., Agrawal, A., Wang, A. T., Halvorsen, A. J., Mandrekar, J. N., Chaudhry, S., … & Beckman, T. J. (2018). Flipped classrooms in graduate medical education: a national survey of residency program directors. Academic Medicine, 93(3), 471-477.
Gagnon K, Young B, Bachman T, Longbottom T, Severin R, Walker MJ. Doctor of Physical Therapy Education in a Hybrid Learning Environment: Reimagining the Possibilities and Navigating a “New Normal”. Phys Ther. 2020;100(8):1268-1277. doi:10.1093/ptj/pzaa096
Lake D. A. (2001). Student performance and perceptions of a lecture-based course compared with the same course utilizing group discussion. Physical therapy, 81(3), 896–902.
Hew, K. F., & Lo, C. K. (2018). Flipped classroom improves student learning in health professions education: a meta-analysis. BMC medical education, 18(1), 38.