Nursing students’ experiences and perceptions regarding in-class flipped classroom: a mixed-methods study

Abstract

Background

In medical education, flipped classroom, providing innovative ideas for teaching reform, has been actively promoted. However, it requires completing preparatory work before the classroom, with workload burden, time constraints, and lack of familiarity being the most common challenges associated with the pre-class activity. Moreover, pre-class activities inevitably impose multiple burdens and challenges on nursing students, potentially leading to fatigue and hindering their ability to cope effectively, thus impeding the achievement of the intended learning outcomes. Implementing an in-class flipped classroom approach could help alleviate these challenges. This study aimed to deepen understanding of nursing students’ experiences and perceptions in the in-class flipped classroom settings, offering valuable insights for the reforming of nursing professional courses.

Methods

This study employed a mixed-methods study. The quantitative phase collected 107 nursing students’ learning satisfaction with the in-class flipped classroom via questionnaires. The data were analyzed employing SPSS 25.0. In the qualitative phase, semi-structured interviews incorporating four focus group discussions were conducted with 57 nursing students. The Colaizzi seven-step analysis method was employed to analyze the interview data.

Results

The quantitative results showed that the top three ratings contributing to learning satisfaction in the in-class flipped classroom were mastering knowledge effectively, creating a good classroom atmosphere, and improving communication and collaboration skills. The median score for all items was no less than 4/5. The qualitative results revealed five themes: progressive learning experience, teaching efficiency and effectiveness, developing abilities, impact on academic and occupational emotions, and needing to be improved. Finally, the integrated results validated the accuracy and rationality of the data.

Conclusion

The in-class flipped classroom, an innovative teaching strategy, enhanced teaching effectiveness and efficiency. This approach is well-suited for the reform of teaching methods in nursing practice courses.

Introduction

First conceptualized in American educational settings, the flipped classroom model subverts conventional didactic pedagogy by cultivating higher-order cognitive competencies through structured engagement in application, analysis, and synthesis activities [1]. It is student-centered, and focuses on the individual needs and expressions of students, while teachers play the role of instructor of learning activities and the designer of classroom activities. Researches [2, 3] indicate that the flipped classroom is more effective than traditional methods in promoting learning and enhancing teaching quality. The flipped classroom has been extensively implemented in nursing courses and enhanced students’ engagement and competency [4, 5].

Also, the flipped classroom, introducing innovative teaching concepts, has been actively promoted in China. However, with the deepening of teaching practice, several challenges have been identified. A systematic review [6] has indicated that flipped classroom increased workload and lower efficiency in Chinese medical education compared with traditional lectures. Moreover, some students also reported insufficient motivation, self-discipline, and self-directed learning skills as challenges of flipped classroom [7,8,9]. Therefore, the flipped classroom, including pre-class activities, in-class activities, and post-class activities, may not be suitable for the majority of nursing students [10]. Specifically, it demands completing preparatory work before the classroom. The most common challenges include workload, time constraints, and lack of familiarity with pre-class activities [6]. Moreover, the nursing profession involves numerous courses and a heavy learning workload. Correspondingly, pre-class activities inevitably bring multiple burdens and challenges to nursing students, leading to fatigue and hindering their ability to cope effectively and achieve the intended learning outcomes. In light of the fluctuating emergence of new cases and variants, nurses are now required to exhibit enhanced levels of competence and motivation. Therefore, nursing schools bear the responsibility of nurturing a pool of competent nurses through a carefully crafted curriculum.

As mentioned above, the flipped classroom positively influences students’ competence across various skills, while also enhancing their interest in learning [4, 5]. In light of this, how can the flipped classroom be adapted and effectively implemented within the context of Chinese culture? The flipped classroom implementation requires careful consideration of adaptable design options [11]. This is due to the unique and diverse learning styles of individual learners in different cultures. Thus, teaching and learning strategies for the flipped classroom should be carefully designed and tailored to the proficiency and learning preferences of students [11]. The flipped classroom originated in the American educational philosophy of individual education [1]. In terms of learning methods, this model emphasizes inquiry learning and self-directed learning. Notably, in China, the educational philosophy of general education is adopted. Consistent with the educational philosophy, the instructional model is teacher-centered. The dominant pedagogical paradigm in education remains entrenched in behaviorist learning theory, where instructors function as knowledge transmitters through didactic lectures, while learners are systematically positioned as passive recipients. Moreover, from elementary school to high school graduation, exam-oriented education is the mainstream [12]. The learning content is mainly determined by examinations such as the college entrance examination. Prolonged passive learning has led to decreased motivation, lack of interest, and deficiencies in skills such as self-directed learning, critical thinking, and teamwork, all of which are inconsistent with the requirements for the successful development of classic flipped classroom and constrain effective implementation of flipped classroom [9, 12, 13]. Therefore, the Chinese approach to implementing the flipped classroom model should incorporate innovative localization strategies considering the cultural distinctions between China and the United States [14].

Nursing is practical and applied in nature. The Chinese national standards for nursing teaching quality stress the cultivation of nursing students’ practical ability [15]. Nursing practice teaching, an essential component in bridging the gap between theoretical training and clinical practice, aims not only at providing education in skills, but also at comprehensively applying knowledge and cultivating competence [15, 16]. The Community of Inquiry (COI) theory, which is well-suited for applied subjects, articulates the behaviors and processes necessary to foster knowledge construction by cultivating teaching, social, and cognitive presence [17, 18]. Teaching presence involves designing and facilitating instruction suitable for the learning environment, while social presence relates to the interaction level between students and instructors in supportive settings. Cognitive presence pertains to students’ ability to develop knowledge and skills through critical thinking, creativity, and communication [18]. Thus, successful implementation of the flipped classroom requires establishing appropriate teaching presence, fostering social presence, and achieving cognitive presence [19]. Situated learning theory (SLT) emphasizes learning knowledge in authentic contexts of its application, which is facilitated through engaging in authentic activities [20, 21]. In situated learning, by providing complex and unstructured practical tasks, learners learn to recall relevant information, reconstruct knowledge, and flexibly apply them to the presented situation [21].

Therefore, the in-class flipped classroom appears to meet the demand for enhancing teaching effectiveness and efficiency in nursing practice teaching. In the in-class flipped classroom, students are required to engage in self-directed learning during the initial segment of the class, while the final segment is primarily dedicated to internalizing knowledge [14, 22]. Unlike the traditional flipped classroom approach, the in-class flipped model relocates self-directed pre-class learning activities from outside to within the classroom setting.

The Nursing Practice curriculum is designed to cultivate not only technical proficiency but also emphasize competency development, fostering higher-order cognitive processes that encompass application, analysis, and synthesis of knowledge [16]. In this study, we implemented the in-class flipped classroom model in pediatric nursing practice teaching. As the in-class flipped classroom aims to foster an active learning environment and enhance abilities, evaluating the experience becomes a crucial aspect of outcome assessment. This study employed a mixed-methods design to gain a deep understanding of nursing students’ experiences and perceptions within the in-class flipped learning paradigm, offering insights for teaching reform.

Materials and methods

Study design

This study adopted a sequential exploratory mixed-methods design, which first involved a quantitative study followed by a qualitative study.

Instructional procedures

According to Merrill’s first principle of instruction [23], we designed the instructional model. The principles are problem-centered and engage students in a learning cycle comprising four distinct phases: activation of prior experience, demonstration of skills, application of skills, and integration of these skills into real-world activities. Additionally, the implementation of this model should also consider four instructional environmental factors: guidance, motivation, cooperation, and interaction.

In the current study, the instructional procedures of the in-class flipped classroom comprised seven steps during a 160-minute skills lab course. Initially, students were grouped within each experimental class (14–16 students). Based on the number of students, each experimental class was divided into four groups prior to the first session, with each group consisting of 3 to 4 students. Each group had 1 leader. Secondly, the instructors distributed instructional videos and reading materials (PPT, case, and others) to students via Rain Classroom ten minutes 10 min prior to scheduled class sessions. Rain Classroom is a popular online platform that facilitates seamless connectivity between students and instructors through smartphones or computers [24]. Thirdly, nursing students acquired foundational knowledge through instructional videos and reading materials. Specifically, nursing students within each group engaged in self-directed and interactive team-based learning, while instructors observed and provided guidance (approximately 60 min). During this step, they were encouraged to seek immediate clarification from the instructors regarding any uncertainties. Fourthly, instructors delivered targeted live demonstrations in the lab, focusing specifically on students’ identified challenges or high-complexity skills in the third step, rather than performing exhaustive procedural repetitions (approximately 20 min). This phase prioritized efficiency by avoiding redundant demonstrations and allocating more time to hands-on practice and personalized feedback. Fifthly, students within each group revisited their problem areas for additional practice, with the instructors providing guidance (approximately 30 min). Sixthly, students engaged in scenario simulations through interactive team-based learning and received evaluations from peers in other groups and instructors. Meanwhile, instructors guided reflection, which enabled nursing students to transition from mechanical imitation to clinical competence. This transition aligns with Patricia Benner’s From Novice to Expert framework, where guided reflection bridges the gap between procedural repetition and situated clinical judgment [25]. Lastly, the instructors supplied pertinent questions and supplementary study materials via Rain Classroom to prompt timely review by students. Concurrently, the instructors addressed questions online. Following the session, each student was tasked with composing an experiment report.

In this study, the in-class flipped classroom model was implemented across four pediatric.

nursing skill modules: (1) milk preparation, feeding, and daily care of newborns, (2) pediatric scalp.

intravenous infusion, (3) neonatal incubator procedures and phototherapy, and (4) neonatal resuscitation.

Participants and procedures

Nursing students from the grade 2019 at Wannan Medical College, who had completed all pediatric nursing skill modules through the in-class flipped classroom approach, were selected to participate in this study. There were 357 students distributed among 4 classes (classes 1 to 4), with each class being subdivided into six experimental classes (experimental classes 1 to 6). The quantitative phase involved 107 nursing students, while the qualitative phase included 57 participants. Prior to data collection and formal interview, all participants were informed of the study’s purpose, significance, and strict confidentiality principles, how their data would be utilized, and their rights. Informed consent was obtained from all participants.

Quantitative phase

The quantitative research collected nursing students’ learning satisfaction with the in-class flipped classroom via questionnaires. According to the criterion suggested by Kendall (to ensure a sufficient sample size, 10 to 20-fold the number of items and expanded at least 10%) [26], a sample size of no less than 99 was computed since the items of the Learning Satisfaction Questionnaire is 9. The random number table method and stratified random sampling were employed to select the participants. An independent research assistant, who was blinded to both the study objectives and the participants’ identities, executed the randomization protocol. In Step 1, the participants were stratified by class, encompassing the four classes numbered from 1 to 4. In Step 2, two experimental classes were randomly selected from each class. In Step 3, all students within each experimental class (14–16 students) were chosen through cluster sampling. The inclusion criteria comprised: (1) enrollment as a full-time undergraduate nursing student and (2) provision of informed consent for study participation. The exclusion criteria included individuals who were absent from any of the in-class flipped classroom activities. Finally, 112 questionnaires were received, of which 107 (95.54%) were qualified questionnaires.

Qualitative phase

In the qualitative research, participants were selected by the independent research assistant who had previously recruited the quantitative research samples. Specifically, in each class, one experimental class involved in the quantitative study was randomly selected. A focus group was formed by all students in each experimental class. There were 4 focus groups with 57 nursing students participating in the current study, in accordance with previous research which suggests four focus group discussions can reach information saturation [27]. The inclusion and exclusion criteria were consistent with those employed in the quantitative study.

Data collection

Quantitative phase

Instrument

In the quantitative phase, the Learning Satisfaction Questionnaire was designed by the authors based on prior researches [18, 28,29,30]. The questionnaire was validated by a panel of experts comprising one nursing PhD, two nursing masters, and two psychology PhDs. All experts held intermediate or senior professional titles and had more than five years of experience in teaching and research. The questionnaire contained 9 items. The response options ranged from 1 (strongly disagree) to 5 (strongly agree), with total scores ranging from 9 to 45. The higher scores indicated higher learning satisfaction. The content validity index (CVI) evaluates how well an instrument covers all relevant parts of the construct it aims to measure [31]. The item CVI (I-CVI) of nine items ranged from 0.800 to 1.000 and the average I-CVI for all individual items (S-CVI_Ave) was 0.933. CVI is rated as good when both I-CVI and S-CVI_Ave are not less than 0.78 and 0.90, respectively [31]. In this study, both the I-CVI and S-CVI_Ave exceeded these thresholds, demonstrating satisfactory content validity. This result signifies the appropriateness and agreement of the content being measured. The Cronbach’s α coefficient for the questionnaire was 0.914, which indicated the Learning Satisfaction Questionnaire had excellent homogeneity [32]. This questionnaire can be viewed in the supplementary file 1.

Procedure

The Learning Satisfaction Questionnaire was distributed via Questionnaire Star at the end of the course. Finally, 112 questionnaires were received, of which 107 (95.54%) were qualified questionnaires.

Qualitative phase

Interview outline

As for the qualitative study, an interview guide was prepared to understand the learning experience from students’ perspectives. The interview guide was initially developed based on previous studies [33,34,35] and expert consultation. Subsequently, the interview guide underwent iterative refinement through cognitive interviewing with a purposive sample of four nursing students, ultimately yielding a finalized interview guide. The finalized interview guide included the following questions: (1) How did you engage with the in-class flipped classroom during the pediatric nursing skills lab courses? (2) What difficulties and challenges did you face during the learning process, and how did you overcome them? (3) Please share your experiences during the learning process. (4) What are your thoughts on the in-class flipped classroom instructional model implemented in the pediatric nursing skills lab courses? (5) What feedback and suggestions would you like to provide?

Procedure

The interviews followed a face-to-face semi-structured approach. The interviews were conducted in a quiet conference room within the lab. Each focus group was allotted 60–80 min. The interview sessions were administered by two experienced qualitative researchers unaffiliated with the instructional team to ensure methodological rigor. Utilizing a semi-structured interview protocol, the principal researcher facilitated dialogic interactions while the other systematically documented observational notes and managed procedural logistics. The interview was audio recorded.

Data analysis

The questionnaire responses were analyzed to calculate the mean, standard deviation (SD), and median (interquartile range). Statistical analysis was performed using SPSS 25.0.

Interview recordings were transcribed into text within 24 h of each interview. The Colaizzi seven-step analysis method was applied [36, 37]. Three experienced researchers meticulously and iteratively analyzed the interview data and regularly conducted case analysis seminars. Initially, the interview recordings were meticulously reviewed multiple times to identify meaningful statements and derive significant findings. Subsequently, related topics were grouped, coded, and elaborated upon. In case of disagreement, analysis results were returned to the interviewees for verification, incorporating their feedback to finalize the themes.

Confidentiality

Firstly, as mentioned above, all participants were informed of the strict confidentiality principles and signed informed consent prior to data collection and formal interviews. Secondly, encryption was employed to safeguard interview recordings and transcriptions during storage and data transfer, thereby mitigating the risks of unauthorized access. Thirdly, only researchers were granted access privileges, contingent upon their completion of mandatory confidentiality training and acknowledgment of data security responsibilities. Fourthly, when recording and transcribing the interviews, confidentiality was assured by using a number instead of a real name.

Ethical consideration

Approval to conduct the research was granted by the Ethics Committee of the School of Nursing at Wannan Medical College (20220003) in accordance with the principles outlined in the Declaration of Helsinki.

Results

Participants’ characteristics

The participants’ ages ranged from 19 to 23. Most participants were female, resided in rural areas, and.

were not student leaders (Table 1).

Table 1 Characteristics of the participants

Quantitative results

In terms of learning satisfaction in the in-class flipped classroom, the top three rated aspects were “helping me master knowledge effectively” (4.47; SD = 0.66), “creating a good classroom atmosphere” (4.40; SD = 0.71), and “improving my communication and collaboration skills” (4.39; SD = 0.68). The median score for all items was no less than 4/5 (Table 2).

Table 2 Learning satisfaction with the in-class flipped classroom (n = 107)

Qualitative results

Five themes emerged: (1) progressive learning experience, (2) teaching efficiency and effectiveness, (3) developing abilities, (4) impact on academic and occupational emotions, and (5) needing to be improved (Fig. 1).

Fig. 1

Extracted themes and subthemes

Theme 1: Progressive learning experience

Feeling confused

Most nursing students felt confused and uncertain during the initial stage when the instructor introduced the in-class flipped classroom model.

Initially, I was unsure of what to do due to the implementation of the learning-first, teaching-later model, which contrasted with our previous learning approach. (FG2)

When I started practicing without the instructor providing detailed explanations for each step, I felt somewhat overwhelmed. (FG4)

Exploring

Guided by instructors and stimulated through curriculum-driven initiatives, the nursing students progressively engaged in exploratory learning processes, demonstrating sustained problem identification capabilities during their investigative endeavors.

I had questions about each step of the skills lab session (pediatric scalp intravenous infusion). For example, how to choose the puncture direction? how to restrain children? Initially, we applied the adult intravenous infusion techniques learned in the fundamental nursing experimental course to pediatric scalp intravenous infusion. However, notable differences exist between the two, including variations in injection angles, fixation methods, and communication approaches with children and their parents. (FG1)

In the context of neonatal resuscitation, I encountered several queries. For example, what were the recommended frequencies for chest compression and positive pressure ventilation? what criteria were used to guide these interventions? can these procedures be performed following the protocols for adult CPR? (FG2)

Solving problems

Through iterative cycles of self-directed learning coupled with triadic interactions (peer-mentor-learner), participants developed nascent clinical reasoning abilities to address authentic patient care challenges within simulated learning environments.

Gradually, we tackled each issue one by one. I found the process remarkably impressive. Throughout the process, I noticed a decrease in my initial sense of being overwhelmed. When faced with challenges beyond our immediate resolution during discussions, we can promptly seek assistance from the instructors. I felt enlightened as the instructors guided us through problem-solving. (FG4)

Self-directed learning enhanced our ability to identify issues. Subsequently, my team and I engaged in timely face-to-face discussions. Ultimately, the instructors promptly guided us in resolving unresolved queries. Adopting an inquiry-driven orientation during lecture engagement engenders enhanced cognitive engagement and promotes deeper schema encoding of didactic content. (FG2)

In our skills lab courses, the instructors observed and guided us, correcting our deficiencies and improving our skills and clinical thinking. (FG1)

Theme 2: Teaching efficiency and effectiveness

The majority of nursing students believed that the teaching approach addresses the issue of limited time for self-operational practice. They independently explored, practiced, identified issues, and sought timely guidance from peers and instructors, thereby enhancing both the efficiency and effectiveness of learning.

While watching the video, the pace can be regulated, fast-forwarding for comprehension, rewinding for clarification, and pausing for reflection or note-taking. Furthermore, I can seek assistance from both the instructor and my peers when faced with challenges. Thus, I can efficiently utilize the limited time to address the challenges. (FG1)

I greatly appreciate this instructional approach. I dedicated most of the time to exploring and practicing, which enhanced comprehension and retention. (FG4)

In the skills lab courses, we encountered challenges. However, identifying challenges and actively addressing them through focused engagement with instructor explanations significantly enhanced knowledge integration and retention. (FG2)

Theme 3: Developing abilities

Self-directed learning

In nursing education, self-directed learning capacity has been empirically demonstrated to correlate with enhanced academic performance outcomes [38]. During our interviews, the majority of nursing students expressed that the in-class flipped classroom approach was beneficial for fostering self-directed learning capacity.

Engaging in active cognitive processing during learning activities, rather than passively absorbing instructor-delivered content, systematically developed critical self-directed learning capacity. (FG3)

This instructional approach facilitates active engagement from all individuals, allowing them to fulfill their roles and transitioning the learning paradigm from passive reception to proactive knowledge construction. Of course, the learning process also faced challenges. However, all the issues were addressed one by one, highlighting the significance of each step within this approach. (FG1)

Teamwork skills

Group discussions facilitated students’ personal growth through increasing peer interactions, systematically developing communication and cooperation skills [39]. Deliberate peer-to-peer engagement not only enhanced skill awareness but also provided insights for areas of improvement in learning [40]. This contributed to the establishment of a learning community and a sense of belonging, enhancing social presence [19]. Moreover, peer learning enhanced teamwork and professional skills essential for effective medical care [41].

Our team members collaborated and learned from each other, which enhanced our teamwork skills. We engaged in discussions to address problems. For instance, such as the proper technique for scalp intravenous infusion, which direction should the needle enter? (FG4)

During the skills lab courses, group members identified issues that may go unnoticed by individuals. The students within the same group served as a mirror, reflecting weaknesses and aiding in correction. (FG1)

Collaboration is essential for effective learning and patient care. This approach fostered emotional communication among students and promoted interpersonal harmony. (FG2)

Clinical thinking ability

Nursing students must cultivate clinical thinking competencies to systematically analyze patient data, formulate evidence-based interventions, and execute clinical judgments aligned with dynamic healthcare contexts [15]. This developmental process enables the integration of theoretical knowledge with practical decision-making essential for delivering individualized care.

In neonatal resuscitation, I have learned the importance of adapting neonatal resuscitation knowledge to diverse scenarios, understanding that a one-size-fits-all approach is not suitable. During a simulation, I experienced a sense of immersion as I responded to the ECG monitor alarm and observed decreasing blood pressure and blood oxygen saturation. Initially confused, I quickly composed myself, felt a surge of nervousness, and promptly called for assistance. As we conducted the resuscitation, the “newborn” coughed, prompting us to prepare for suctioning. Witnessing the gradual improvement in the “newborn’s” heart rate and oxygen saturation, and the color returning to the face brought a sense of relief. (FG1)

This instructional approach enhances our acquisition of professional knowledge and skills and fosters our adaptability and flexibility in diverse scenarios, which are essential for our future work. (FG2)

Humanistic care ability

Nursing humanistic care ability represents nurses’ translation of humanistic literacy into clinical practice, enabling them to conscientiously and creatively serve patients [42]. This compassionate care lies at the heart of nursing [43]. Cultivating patient-centered humanistic care ability in nursing students, who represent the next generation of clinical professionals, is essential for advancing high-quality healthcare delivery. This teaching model facilitated the development of benevolence among nursing students through hands-on practice.

During a neonatal resuscitation scenario, I experienced intense anxiety as I realized the fragile life of the small “baby” in my hands while performing cardiopulmonary resuscitation. Despite feeling numbness in my hands from the chest compression, I persevered, giving my all to save the “baby”. (FG2)

Engaged in a simulation of neonatal resuscitation, I felt deeply nervous and immersed in the scenario. Regrettably, our efforts to rescue the “baby” were unsuccessful, leaving us profoundly saddened. (FG4)

I learned to talk with the child’s parents before any nursing procedures to get their support and understanding. It’s important to always think from the patient’s point of view and practice more to improve my skills. (FG1)

Theme 4: Impact on academic and occupational emotions

Learning interest and enthusiasm

Seminar participation can enhance nursing students’ engagement in learning by encouraging them to join discussions [44]. The in-class flipped classroom fosters learning autonomy among nursing students, transforming them from passive observers to active participants through group activities, peer assessment, and reflection [45]. In this study, the nursing students identified structured peer discourse as a catalyst for cultivating dynamic educational climates, stimulating sustained academic engagement and heightening cognitive investment in knowledge acquisition.

This teaching approach facilitates the identification of students’ weaknesses, stimulates self-directed study and peer discussions, and promotes active participation and expression of opinions. The approach enlivens classroom learning and makes it engaging and dynamic. (FG1)

We actively participated in discussions and exploration, creating a highly conducive learning environment. (FG2)

The active exchange of ideas contributed to a positive learning atmosphere. Compared to traditional classrooms, I felt more relaxed and content. (FG4)

Despite initial confusion, I gradually acclimated to and appreciated this teaching methodology. (FG3)

Academic self-efficacy

The nursing students progressively tackled challenges during their exploration, leading to a continuous enhancement of their academic self-efficacy.

Personal practice was essential for identifying weaknesses and making a lasting impression. Despite its initial complexity, mastering this method of learning has allowed me to delve deeper into my potential. (FG1)

Our journey from confusion to sudden enlightenment during the learning process provided a valuable and enriching educational experience. (FG3)

Professional identity

Nursing students who possess a strong sense of professional identity are more inclined to successfully finish their nursing education and transition into qualified nurses with a strong commitment to professional ethics [46]. Consequently, nurse educators are tasked with promoting the development of professional identity among students. The in-class flipped classroom can facilitate the development of professional identity among nursing students.

The sense of accomplishment we felt upon “saving” the ‘child’, even though it was just a model, prompted contemplation on the potential impact of saving real lives in the future. (FG1)

These learning encounters have instilled in me a sense of anticipation for my forthcoming pediatric internship. (FG2)

Theme 5: Needing to be improved

Some interviewees highlighted concerns and offered suggestions regarding group formation, teaching pace, evaluation methods, and more. These identified shortcomings and recommendations present an opportunity for us to explore and implement innovative strategies more suitable for the in-class flipped classroom environment.

The current grouping methodology fails to adequately address the synergistic interaction patterns that are essential for effective team collaboration. (FG4)

For students with poor foundational knowledge, the teaching pace was so fast that they struggled to keep up with the teaching pace. (FG2)

Due to my limited experience, I found it challenging to grasp the key concepts, leading to potential gaps in my knowledge. (FG4)

The unfamiliarity with the skill practice procedures May prolong the duration of independent learning. (FG3)

I suggest that instructors provide more comprehensive evaluations and guidance to enhance our comprehension and retention of the material. (FG1)

During the self-directed study phase, the students lacking in self-discipline may divert their focus towards activities unrelated to their studies. (FG1)

Data integration

Quantitative and qualitative data were merged by comparing and contrasting the results. The qualitative findings were generally corroborated by the quantitative data. The amalgamated data offered insights into how nursing students’ satisfaction could influence their perceptions of learning (Table 3).

Table 3 Joint display of nursing students’ learning perceptions

Discussion

Enhancing the quality of education stands as a primary focus for educators. Consequently, we tailored the in-class flipped classroom model to better suit the specific needs of nursing students. This study aimed to deepen understanding of nursing students’ experiences and perceptions in the in-class flipped classroom settings, offering valuable insights for the reforming of nursing professional courses. The survey and interviews yielded complementary outcomes, indicating that the in-class flipped classroom approach enhanced teaching effectiveness and efficiency, aligning with the ongoing reforms in nursing skills lab courses.

The in-class flipped classroom encourages students to actively construct knowledge, enhancing their abilities and fostering positive emotions

The extent of students’ active engagement in academic tasks significantly influences their learning outcomes, cognitive development, and educational quality [38, 47]. The in-class flipped classroom model is grounded in learning theories that emphasize the construction of cognitive structures, with a comprehensive assessment of the learning environment [14]. This approach completes the entire flipped classroom teaching process within the classroom, allowing students to engage in independent learning while instructors provide on-site guidance and supervision during the independent learning stage [22]. At its core, the approach follows the principles of the flipped classroom model, prioritizing learning before teaching and basing instruction on learning outcomes. Instructors create learning situations through cases and videos, stimulate learning interest and motivation, organize collaborative learning (student-student and instructor-student learning communities), and guide students to actively construct knowledge. In this situation, nursing students constantly find problems and conduct meaningful construction through their exploration and communication with the learning community [39]. Furthermore, role-play, an experiential method that offers nursing students a secure and realistic learning environment integrating content, emotions, and experiences, spark their enthusiasm for classroom learning and enhanced their core competencies [48, 49]. Hence, the in-class flipped classroom not only offers nursing students independent learning opportunities but also nurtures their higher-order thinking skills and positive attitudes.

The in-class flipped classroom takes into account teaching efficiency and effectiveness, aligning with the ongoing reform of the nursing practice curriculum

Currently, prevalent teaching methodologies like Problem-Based Learning, the flipped classroom, and blended teaching, which mandate students to acquire essential skills and clinical scenarios prior to classes [50,51,52,53], pose challenges due to the extensive number of nursing courses within the nursing profession and the rigorous pre-class learning demands of nursing practice courses [16, 54]. Primarily, Chinese nursing students are required to undertake a substantial number of courses, leading to a significant learning burden. These encompass three primary categories (public basic courses, professional basic courses, and specialized courses), encompassing over 2,000 school-based classes and a minimum of 40 weeks of clinical practice [15]. At our institution, specialized skills lab courses for the 4-year undergraduate nursing program are scheduled for the fifth and sixth semesters. Meanwhile, nursing students need to learn multiple professional compulsory courses such as internal medical nursing and others, as well as professional elective courses and minor courses. Secondly, nursing skills lab courses serve dual purposes: not only providing hands-on practice for specific clinical procedures, but also requiring mastery of relevant theoretical knowledge that demand substantial pre-class preparation time. Thirdly, nursing students demonstrate three critical competency gaps: (1) insufficient self-regulated learning capabilities, (2) deficiencies in time management discipline, and (3) underdeveloped interpersonal communication and team collaboration skills [16, 54]. Therefore, pre-class learning inevitably imposes a significant burden and challenge on nursing students, leading to fatigue and hindering their ability to cope effectively and achieve the intended outcomes. Fourthly, compared to theoretical courses, the material prerequisites (environment, equipment, etc.) necessary for pre-class learning in nursing skills lab courses were more demanding. Therefore, pre-class learning inevitably requires significant human and material resources. However, in the in-class flipped classroom, nursing students can conduct independent exploration and collaboration with the assistance of instructors, which does not take nursing students’ spare time and provides them with time and space for independent learning. This approach enhances teaching effectiveness and efficiency, aligning with the objectives of the nursing practice curriculum reform.

It is essential to consider the stressors and requirements of nursing students and cultivate their intrinsic motivation in the in-class flipped classroom

Timely guidance is essential to enhance nursing students’ confidence in their learning. The instructional guidance and support provided by instructors positively influence students’ engagement in the learning process [8]. Merrill’s first principle of instruction [23] points out the teaching purpose should focus on solving problems and teaching should be composed of a repeated four-stage cycle and four instructional environment factors. During the shift from passive pedagogy to self-directed learning, students may experience a challenging period of adjustment [16]. Hence, educators should offer support and guidance to nursing students, instilling belief in their capabilities to tackle learning tasks, especially when initially introduced to the in-class flipped classroom or lacking confidence [16, 55]. For example, to alleviate nursing students’ apprehension towards challenges and boost their confidence, our instructors assisted nursing students in recognizing their existing strengths in intravenous infusion and drawing upon prior experiences during the scalp intravenous infusion. Furthermore, to address students’ anxieties, they were encouraged to enhance their exploration skills without striving for perfection, with peers and instructors serving as valuable resources. Instructors should guide students to think about the problems encountered in the process of self-directed learning. Crucially, instructors must possess extensive professional expertise and contingency ability.

Task-driven learning is needed to facilitate nursing students’ active engagement in learning and experiential learning. Instructor’s course preparation positively affects students’ learning [8]. Nursing is a highly practical subject requiring students to acquire both theoretical knowledge and practical skills. This necessitates nursing students to possess strong learning motivation, effective study habits, and a persistent learning attitude. Nevertheless, nursing students often exhibit low levels of learning motivation, which requires enhancement in their initiative and the development of innovative thinking. The in-class flipped classroom utilizes task-driven learning to enhance cognitive adaptation and foster innovation among individuals, enabling nursing students to develop problem-solving skills and enhance their exploratory abilities [56]. This approach effectively enables students to engage in learning through practical application. For instance, we established specific scenarios using the SimMan Baby comprehensive simulation model, with dynamically changing conditions mimicking sick children. Correspondingly, nursing students were tasked with responding to the evolving conditions of the ‘sick children’ and observing the corresponding reactions to treatment and care. This approach aimed to enhance students’ interest in learning, ignite their enthusiasm in learning, and transition them from passive recipients to active inquirers.

Effective instructional design tailored to the learning context is essential for enhancing nursing students’ engagement in learning and enthusiasm for education. Prior knowledge from previous courses significantly influences student achievement [57]. Witherby et al.’s research [58] has validated that prior knowledge within specific domains positively influenced the acquisition of new knowledge within the same domains. This relationship was mediated by students’ curiosity judgments, suggesting that curiosity may be associated with attention mechanisms that enhance encoding efficiency during feedback. Hence, it is imperative to implement an instructional design that aligns with the learning context. (1) In skills lab courses where nursing students possess a foundational understanding, such as scalp intravenous infusion, instructors can bridge new and prior knowledge by incorporating relevant cases. (2) In skills lab courses where nursing students lack prior knowledge, such as neonatal incubator procedures, instructors can initially explain the key and difficulties using videos or other measures, followed by student-led exploration. This approach enhances students’ receptivity and improves learning efficiency and effectiveness. (3) Skills lab courses that involve several areas of knowledge, such as comprehensive nursing skills lab courses, require nursing students to possess a corresponding foundation. In instances where students exhibit inadequate foundational knowledge and learning capabilities, instructors can provide preparatory materials before class. (4) When forming groups, it is beneficial to create a mix of strong and weak members. Previous studies [41, 59] have shown that students excel in learning when they assume the role of peer instructors to support weaker group members, enhancing not only the weaker students’ understanding but also fostering the development of stronger students’ competencies in areas such as professional skills, teamwork, leadership, and lifelong learning. Furthermore, instructors should pay more attention to disadvantaged students in the classroom. (5) In the in-class flipped classroom setting, activities such as video viewing, case analysis, and role-playing demand additional time and effort compared to traditional classroom methods, posing a challenge within the constraints of limited class time. Therefore, it is advisable to refine videos and cases to ensure they are appropriately challenging but not overly complex in the in-class flipped classroom. (6) Implementing scientific evaluation methods can motivate nursing students to engage actively in learning [15, 60]. So, except for the final skills examination, a comprehensive evaluation incorporating a variety of assessment methods, targets, and subjects is essential to promote diversity in evaluation practices.

Limitations and strengths

Three constraints warrant careful interpretation. Firstly, this study was conducted at a nursing school in China, which may limit its generalizability to other contexts. Secondly, the in-class flipped classroom approach was implemented within the pediatric nursing skills courses. When applied in other courses, appropriate adjustments may need to be made following the specific characteristics and requirements of the course, such as modifications to the time allocation of the instructional procedures. Thirdly, this study investigated the effectiveness and efficiency of in-class flipped classrooms exclusively from the student’s perspective. Future research should validate these findings through teacher-centered investigations and the relationship between educator satisfaction levels and their counterparts among students.

Notwithstanding these limitations, the in-class flipped classroom provides a new and strategic approach for nursing education, enhancing its adaptability to contemporary healthcare demands. Firstly, the in-class flipped classroom strategically eliminates mandatory pre-class preparation requirements through its integrated learning design, thereby effectively alleviating students’ academic workload and enabling more efficient utilization of time and resources. Secondly, the in-class flipped classroom was designed based on the characteristics of Chinese students and the specific requirements of the nursing profession and curriculum. This innovative approach encourages students to actively construct knowledge and cultivates their core competencies, aligning with ongoing reforms in higher education. Thirdly, the present study utilized a mixed-methods approach to comprehensively explore the research problem, thereby enhancing the robustness and depth of the analysis.

Conclusion

To better suit the specific needs of nursing students, we tailored the in-class flipped classroom model in the skills lab courses. The implementation of the in-class flipped classroom model enhanced nursing students’ learning autonomy while effectively utilizing instructor guidance. It effectively tapped into the learning potential of nursing students, increased their motivation, and encouraged the adoption of deep-learning strategies. Furthermore, it encouraged nursing students to actively construct knowledge, improved their skills, and fostered positive emotions, thereby enhancing their core competencies while fostering effective learning habits, aligning with the ongoing reforms in the nursing curriculum. Consequently, this operational efficiency combined with enhanced learning outcomes suggests strong potential for extending to other subjects, particularly in competency-based nursing curricula requiring integration of theoretical knowledge with practical skill acquisition.