Effectiveness of flipped classrooms in nursing education:Systematic review and meta-analysis

Background: The flipped classroom has generated considerable interest in nursing education in the last few years, especially in higher education in China. However, research to date has been insufficient to confirm the effectiveness of the flipped classroom approach. Since most of the Chinese studies are published in Chinese journals, they may not be easily accessible to international researchers. Therefore,this meta-analysis aimed to review the effectiveness of a flipped classroom in nursing education both in English and Chinese databases.Objective: The aim of the present study was to identify the robust available evidence about the effectiveness of flipped classrooms in nursing education through a systematic review and meta-analysis.Methods: A systematic search of English databases, including PubMed, EMBASE, Science Director,CINAHL and Google Scholar, and Chinese databases, including Chinese National Knowledge Infrastructure(CNKI), WanFang Data, VIP Information and Chinese Biomedical Literature(CMB), were conducted to identify peer-reviewed studies that met the inclusion criteria. Two reviewers independently performed study identification with Endnote X7 software and used Excel to extract data. The risk of bias in the included studies was assessed with Cochrane Collaboration’s risk of bias tool, and a meta-analysis was conducted using RevMan 5.3 software following the guidelines proposed by PRISMA reporting standards with the protocol register No. CRD42016041826.Results: A total of 29 studies were included in systematic review. There was a significant postintervention improvement in academic performance both in knowledge with a pooled random-effects standardized mean difference of 1.13 and skills with a pooled random-effects standardized mean difference(SMD) of 1.68. Students’ self-learning abilities were also improved with a pooled random-effects SMD of 1.51 compared with traditional lecture. In the subgroup analysis, we found that the effect sizes had high fidelity in terms of nursing degrees and research settings. There was a high rating of flipped classroom pedagogy from teaching evaluations, study satisfaction, study attitude and improvement in critical thinking and problem-solving skills.Conclusions: These results indicated that a flipped classroom might help nursing students improve in knowledge, skills, attitudes, self-learning, study satisfaction, critical thinking and problem-solving skills.We recommend adopting this approach for nursing education reform. There is a call for robust empirical research and unification of appraisal standards for further support of the effectiveness of the flipped classroom. Furthermore, a meta-regression analysis is also recommended to explore the sources of heterogeneity in included studies.