Accepted Manuscript

Comparing the effects of traditional lecture and flipped classroom

on nursing STUDENTS' critical thinking disposition: A quasi-
experimental study

Shadi Dehghanzadeh, Fateme Jafaraghaie

PII: S0260-6917(18)30694-4
DOI: doi:10.1016/j.nedt.2018.09.027
Reference: YNEDT 3981
To appear in: Nurse Education Today
Received date: 31 March 2018
Revised date: 24 August 2018
Accepted date: 25 September 2018

Please cite this article as: Shadi Dehghanzadeh, Fateme Jafaraghaie , Comparing the
effects of traditional lecture and flipped classroom on nursing STUDENTS' critical
thinking disposition: A quasi-experimental study. Ynedt (2018), doi:10.1016/
j.nedt.2018.09.027

This is a PDF file of an unedited manuscript that has been accepted for publication. As
a service to our customers we are providing this early version of the manuscript. The
manuscript will undergo copyediting, typesetting, and review of the resulting proof before
it is published in its final form. Please note that during the production process errors may
be discovered which could affect the content, and all legal disclaimers that apply to the
journal pertain.
 ACCEPTED MANUSCRIPT

Title page

COMPARING THE EFFECTS OF TRADITIONAL LECTURE AND FLIPPED CLASSROOM

ON NURSING STUDENTS’ CRITICAL THINKING DISPOSITION: A QUASI-
EXPERIMENTAL STUDY

Shadi Dehghanzadeh, Fateme Jafaraghaie

1- Shadi Dehghanzadeh, Department of Nursing, College of Nursing and Midwifery, Rasht

branch, Islamic Azad University, Rasht, Iran.

T
IP
Email: shadidehghan90@gmail.com

CR
2- Fateme Jafaraghaie, Social determinants of health research center, Guilan University of
Medical Sciences, Rasht, Iran.

Email: fja_a80@yahoo.com

US
Corresponding author:
AN
Shadi Dehghanzadeh

Islamic azad University, Rasht branch

M

Postal Code: 4147654919

ED

Rasht, Iran

Mobile: (+98)9111310566
PT

Fax: (+98 13)33447060

Email: shadidehghan90@gmail.com
CE
AC

Study Design: SD, FJ.

Data Collection: SD.
Data Analysis: SD, FJ.
Manuscript Writing: SD, FJ.

Ackowledgment

The current study was supported by Rasht Islamic Azad University grant (no. 1179508260009).
We express our sincere gratitude to all of the participants for their valuable collaboration.
 ACCEPTED MANUSCRIPT

Comparing the effects of traditional lecture and flipped classroom on nursing students’ critical
thinking disposition: a quasi-experimental study

ABSTRACT

T
Background: One of the most principal key aims of nursing education is to promote nursing students’

IP
and nurses’ critical thinking. Therefore, nursing education needs to develop an appropriate curriculum
and use effective instructional strategies for critical thinking promotion. Flipped classroom is a teaching

CR
method which substitutes individual learning for group learning in a dynamic, interactive environment
where the teacher guides students to understand and use concepts.

US
Objectives: The present study aimed to compare the effects of traditional lecture and flipped classroom
on Iranian nursing students’ critical thinking disposition.
AN
Methods: This nonequivalent control group pretest-posttest quasi-experimental study was done in 2016
on 85 second-year bachelor’s nursing students who had signed up for the Musculoskeletal Medical-
Surgical Nursing theoretical training course. Because of their large number, students had been divided at
M

the beginning of the first semester of their four-year program into two 42- and 43-student groups and
attended separate theoretical training classes. These two classes were randomly allocated to either a
ED

traditional lecture or a flipped classroom group. The instructional strategies in these groups were the
traditional lecture and the flipped class strategies, respectively. A demographic questionnaire and
Ricketts’ Critical Thinking Disposition Inventory were used for data collection.
PT

Results: After the intervention, the mean scores of critical thinking disposition and its engagement
domain in the flipped class group were significantly higher than the traditional lecture group (p<0.0001).
CE

Conclusions: This study shows the positive effects of flipped classroom on nursing students’ critical
thinking disposition. It is recommended that future studies assess the effects of flipped classroom on
AC

other nursing education outcomes.

Keywords: Thinking, Critical; Active learning; Lectures; Students, Nursing; Education, Nursing
 ACCEPTED MANUSCRIPT

INTRODUCTION

Critical thinking is one of the essential skills which prepare nursing students for clinical practice (Kaya et
al., 2017), because critical thinking enables them to effectively manage patients’ problems, make best
clinical decisions, have closer control over critical clinical conditions, and provide safe and quality care
(Kaddoura et al., 2017). The National League for Nursing Commission for Nursing Education
Accreditation expects nursing graduates to have competence in critical thinking (Romeo, 2010).

Critical thinking has two main components, namely critical thinking skills and critical thinking disposition

T
(CTD). The skills component refers to the cognitive processes of thinking while the disposition
component refers to personal desire and internal motivation for critical thinking (Zhang and Lambert,

IP
2008). There is a significant positive correlation between CTD and critical thinking skills (Profetto-
McGrath, 2003).

CR
Nurses with critical thinking skills have abilities such as information seeking, data analysis, decision
making, and reflection (Von Colln-Appling and Giuliano, 2017). Critical thinking is also a key predictor of

US
academic achievement (O'Hare and McGuinness, 2009). Contrarily, poor critical thinking ability has
different negative outcomes for Iranian nurses such as stagnancy in clinical settings, inability to solve
patients’ problems, and poor clinical reasoning (Hajrezayi et al., 2015). Studies in Iran showed limited
AN
critical thinking ability among nursing students, no significant differences among the students of
different educational grades in terms of their critical thinking skills and CTD, and no significant
correlation between students’ grade point average (GPA) and their CTD (Mousazadeh et al., 2016;
M

Poodineh Moghadam et al., 2015).

ED

One of the major challenges in nursing education is to develop a nursing curriculum and effective
instructional strategies which improve students’ critical thinking skills (Simpson and courtney, 2002).
The most effective instructional strategies for the improvement of critical thinking skills are small group
PT

activities, question-and-answer, role performance, discussion and negotiation, case studies or clinical
scenarios, written documents, concept mapping, learning cycle, and blended learning; however, these
strategies are not routinely used in academic settings due to short amount of time for each course,
CE

which is mostly devoted to teachers’ lectures (Chan, 2013; Von Colln-Appling and Giuliano, 2017).

Two key requirements for critical thinking promotion among nursing students are students’ active
AC

involvement in teaching-learning process and teachers’ ability to facilitate students’ critical thinking and
logical reasoning. In other words, teachers should act as facilitators to students’ critical thinking and
logical reasoning instead of simple information suppliers (Nelson, 2017). These requirements can be
satisfied through active learning strategies, which facilitate cognitive processes and thereby, promote
critical thinking.

Flipped classroom (FC) is one of the modern active learning strategies. Bergmann and Sams, two
chemistry teachers, started to flip learning for the first time in 2007 and called their technique FC
(McDonald and Smith, 2013). Now, blended learning and FC are interchangeably used, even though
blended learning is a broader term to refer to the use of different types of technology for the promotion
of active learning. FC is a more specific instructional framework and a subset of blended learning. In FC,
 ACCEPTED MANUSCRIPT

learners use different technologies to learn educational materials before attending the class and then,
they practice and use the learned materials in classroom under the guidance of their teachers (Graham
and Burke, 2014).

FC is based on the self-regulated and socio-constructivist theories of learning. The self-regulated

learning theory considers the learner as an active participant in the process of learning while the socio-
constructivist theory puts greatly values the role of classroom discussions and interactions in promoting
higher-order cognitive skills (Sun et al., 2018; Palinscar, 1998). FC divides education into two phases. In
the first phase, students achieve an understanding about the intended concepts and in the second

T
phase, they learn to use and evaluate the learned concepts in new situations (Jensen et al., 2015). This

IP
student-centered method helps students use learned knowledge in practice and thereby, prepares them
for responding to the challenges of healthcare settings (Betihavas et al., 2016). In FC, teacher’s lectures

CR
are provided to students in videos and are watched by students before classroom. Moreover, they are
required to study educational materials before attending the class. Therefore, the valuable time of the
class is spent on active learning activities, problem solving, evidence-based learning, group discussion,

US
and knowledge application, analysis, and synthesis (McLaughlin et al., 2014). In this instructional
strategy, each student learns concepts at his/her own learning speed, plays and pauses lecture videos
based on personal preferences, and watches them for preferred number of times. Moreover, FC
AN
provides nursing students and nurses with the opportunity to learn materials in the preferred time and
place and hence, it is a flexible instructional strategy (McDonald and Smith, 2013).
M

LITERATURE
ED

A systematic review showed that active and learner-centered strategies are needed to promote critical
thinking skills. FC is one of these strategies (Carvalho et al., 2017). Previous studies reported the
PT

potential effects of FC on critical thinking. For instance, FC was used in a study to teach the principles of
pharmacology to bachelor’s nursing students. Results showed that from the perspective of the students,
FC was effective in promoting their critical thinking (Hanson, 2016). Other studies reported that FC has
CE

potentials for promoting nursing students’ clinical decision making (Mudd and Silbert-Flagg, 2016),
satisfaction, and academic performance (Jafaraghaie et al., 2017; Mikkelsen, 2015), increasing their
marks, fostering their collaborative learning and teamwork, encouraging their active engagement in
AC

learning, and improving their critical thinking (Njie-Carr et al., 2017). However, there is no clear
empirical evidence regarding the effectiveness of FC in improving learning outcomes such CTD. Our
literature search showed that most studies in the area of FC had been done using the blended learning
method. For instance, a study in Iran showed that blended learning improved nursing students’ critical
thinking skills (Hajrezayi et al., 2015). Given the lack of empirical evidence in this area, the present study
was carried out to compare the effects of traditional lecture (TL) and FC on nursing students CTD in Iran,
as well as the relationship of their last-semester GPA with CTD and its domains. The practical aim of the
study was to improve nursing students’ and graduates’ critical thinking and thereby, improve their
ability to fulfill patients’ needs.
 ACCEPTED MANUSCRIPT

METHODS

Design

This quasi-experimental study was done in 2016 using a nonequivalent control group pretest-posttest
design.

T
IP
Setting and participants

CR
This study was conducted in the Nursing and Midwifery Faculty of the Rasht branch of Islamic Azad
University, Rasht, Iran. At the time of the study, 450 nursing and midwifery students were studying in

US
the faculty. Baccalaureate nursing program in Iran takes four years. During the first three years, nursing
students receive both theoretical and clinical trainings, while in the fourth year, they exclusively attend
clinical settings for their internship course.
AN
All 85 second-year nursing students who had signed up for the Musculoskeletal Medical-Surgical Nursing
theoretical training course were recruited to the study through the census method. Because of their
M

large number, these students had been divided at the beginning of the first semester of their four-year
program into two 42- and 43-student groups and attended separate theoretical training classes. These
two classes were randomly allocated to either a TL or a FC group through coin flipping. In order to make
ED

any changes in the primary outcome attributable to the study intervention, the clinical training course of
Musculoskeletal Medical-Surgical Nursing in both groups was postponed to the next semester, i.e. after
PT

the completion of the theoretical training course. Inclusion criteria were signing up for the
Musculoskeletal Medical-Surgical Nursing theoretical training course and no previous experience of FC-
based learning. Students were excluded if they partially answered study questionnaires or had more
CE

than one absence from the course sessions.

AC

Intervention

Study intervention was teaching the Musculoskeletal Medical-Surgical Nursing theoretical training
course to the students in the TL and FC groups using TL and FC, respectively. The course was run for
both groups in 120-minute once-a-week sessions for eight successive weeks. The instructor of both
groups was the same but the weekday and the classroom were different. Moreover, students in both
groups were referred to the same textbook and were provided with the same course syllabus. At the
beginning of the intervention, the overall and the daily syllabuses were provided to students in both
groups. Accordingly, the instructor recorded the lecture of each session and then, provided the recorded
sound files together with PowerPoint presentation slides and short video clips related to the content of
 ACCEPTED MANUSCRIPT

each session to an electronic education specialist and asked him to develop an electronic content for
each session using the Articulate storyline software. Then, she gave students in the FC group a DVD
which contained seven electronic contents as well as the course syllabus one week before the first
session. The electronic contents ranged in length from 21 to 52 minutes (Table 1). Students were
required to watch the content of each session and study the related materials from the textbook before
attending the session. It is noteworthy that the first session for the FC group was held using the TL
method and was on the anatomy, physiology, and assessment of the musculoskeletal system. FC
sessions were held in a suitable classroom with adequate space for small group discussions and
information exchange among groups. At the beginning of each session, students had a quiz with 3–5

T
questions. After that, their teacher divided them to small 3–5 student groups and provided them with

IP
clinical scenarios in the area of care delivery to patients with musculoskeletal disorders. Thereafter, they
held group discussions about the answers to the questions of the quiz and also the questions related to

CR
clinical scenarios under the supervision and guidance of their teacher. In each session, students in the FC
group were randomly allocated to new small groups in order to improve their teamwork and
communication skills.

US
AN
Data collection

A demographic questionnaire and Ricketts’ Critical Thinking Disposition Inventory were used for data
collection. The questionnaire included items on students’ age, gender, marital status, employment
M

status, and their last-semester GPA. In the Iranian educational system, the highest possible GPA is 20,
while scores ten and lower are considered as fail score. The inventory contains 33 items on innate
ED

attitudes regarding critical thinking and measures CTD in three specific dispositions, namely
engagement, maturity, and innovativeness on a Likert-type scale (Khandaghi et al., 2011). Engagement
refers to learner’s predisposition to seek opportunities for reasoning, to predict situations which need
PT

reasoning, and to confide in one’s own reasoning ability. Maturity deals with the learner’s predisposition
to get aware of the complexity of real problems, to take into account others’ viewpoints, and to be
CE

aware of one’s own and others’ biases and predispositions. Innovativeness is learner’s predisposition to
be mentally curious and truth-seeking (Ricketts, 2003). The items of the inventory were scored on a
Likert-type scale with five points, ranging from 1 (“Completely disagree”) to 5 (“Completely agree”).
AC

Thus, the total score of the inventory could range from 33 to 165, where higher scores represented
greater CTD (Mousazadeh et al., 2016). In Ricketts’ study, a panel of academic experts evaluated and
confirmed the face and the content validity of the questionnaire. Moreover, the Cronbach’s alpha values
of the inventory and its engagement, maturity, and innovativeness domains were 0.86, 0.89, 0.75, and
0.79, respectively (Ricketts, 2003). We used the Persian version of the inventory which was culturally
and linguistically adapted by Pakmehr et al., who reported that the Cronbach’s alpha values of the
inventory and its three domains were 0.68, 0.72, 0.76, and 0.64, respectively (Pakmehr et al., 2013). This
inventory has previously been used in Iran for CTD assessment among medical, nursing, and midwifery
students (Ajam, 2015; Rezaeian et al., 2015). For reliability assessment in the present study, thirty
nursing students, randomly selected from the study setting, completed the inventory. The Cronbach’s
alpha values were then calculated for the inventory and its three domains, which were equal to 0.81,
 ACCEPTED MANUSCRIPT

0.86, 0.57, and 0.75, respectively. Data on students’ CTD were collected in the first session and after the
last session of the intervention. Besides, at posttest, students in the FC group were requested to answer
two open-ended questions about FC advantages and disadvantages.

Data analysis

The collected data were analyzed using the SPSS software (v. 18.0) and via the descriptive statistics
measures (including frequency distribution, mean, and standard deviation) and statistical methods

T
(including paired-sample t, independent-sample t, and Chi-square tests as well as the multivariate

IP
analysis of variance). Normality assessment was conducted via the Kolmogorov-Smirnov test, the results
of which were insignificant (P > 0.05) and the null hypothesis of normality was accepted. Thus,

CR
parametric methods were used for data analysis. The level of significance was set at less than 0.05.
Students’ answers to the two above-mentioned open-ended questions were also analyzed through
categorization.

US
AN
Ethical consideration

The proposal of this study was approved by the Ethics Committee of Rash Islamic Azad University, Rasht,
Iran, with the code of IR.IAU.RASHT.REC.1395.8. After random allocation, the teacher of the groups
M

provided students in the FC group with information about FC and obtained two groups’ informed
consents. The FC program was approved by the Educational Administration of Rash Islamic Azad
ED

University. Moreover, electronic contents were assessed and approved by the Medical-Surgical Nursing
department of the University.
PT

RESULTS
CE

The number of eligible students was 85 and none of them were excluded from the study. The age mean
of students was 19.87(1.35). Most students were female (83.5%), single (90.6%), and unemployed
AC

(95.3%), and lived with their families (68.2%). Their last-semester GPA was 15.44(1.46). The
independent-sample t, the Chi-square, and Fisher’s exact tests showed that the groups did not differ
significantly from each other with respect to students’ age, last-semester GPA, marital status,
employment status, and living status (P < 0.05) (Table 2).

The results of the independent-sample t test showed that before the intervention, there were no
significant differences between the groups in terms of the mean scores of CTD and its engagement,
maturity, and innovativeness domains. Moreover, the paired-sample t test showed that these mean
scores did not significantly change in the TL group during the study (P > 0.05). Similarly, the mean scores
of the maturity and the innovativeness domains of CTD did not significantly change in the FC group
during the study (P > 0.05). However, the mean scores of overall CTD and its engagement domain
 ACCEPTED MANUSCRIPT

significantly increased in the FC group (P < 0.05). Accordingly, the independent-sample t test indicated
that after the intervention, the mean scores of overall CTD and its engagement domain in the FC group
were significantly greater than the control group (P < 0.0001) (Table 3).

The results of Pearson’s correlation analysis illustrated that before the intervention, GPA in the FC group
was significantly correlated with the maturity domain of CTD (r = 0.41; P = 0.005), while GPA in the
control group was significantly correlated with the engagement domain of CTD (r = 0.24; P = 0.01).

The multivariate analysis of variance was used to evaluate the effects of instructional strategy (TL and

T
FC) and last-semester GPA on CTD and its domains. The Wilks’ Lambda test showed that the effect of
instructional strategy was statistically significant (Wilks’ Lambda value = 0.507; F = 18.20; P < 0.0001),

IP
while the effect of last-semester GPA was not statistically significant (Wilks’ Lambda value = 0.852; F
=1.55; P =0.142). The results of the tests of between-subjects effects illustrated that the type of

CR
instructional strategy had significant relationship with the mean scores of overall CTD (F = 14.53; P <
0.0001) and its engagement domain (F = 65.57; P < 0.0001). In other words, the mean scores of overall
CTD and its engagement domain in the FC group were significantly greater than the TL group. However,

US
the interaction effect of instructional strategy and last-semester GPA on overall CTD and its domains
was not statistically significant.
AN
Our data collection tool also included two open-ended questions, one on the advantages and the other
on the disadvantages of FC. All students answered the first question, while only 72.1% of them
answered the second. Students’ comments on the advantages of FC were categorized into seven
M

categories, namely “attending classroom with prior preparation”, “better learning and retention”,
“student-centered learning”, “teamwork promotion”, “the ability to watch videos at preferred time and
ED

place”, “getting familiar with modern instructional strategies”, and “understanding how to use
knowledge in practice”. One student noted, “This method facilitates memorization. By watching the
contents before the class and practicing them in the class I feel that I can remember them more clearly”.
PT

Another student said, “One sees this method more as learning rather than studying”.

On the other hand, students’ comments on the disadvantages of FC were grouped in the following four
CE

categories: “time-consuming pre-class activities”, “lengthiness of the recorded lectures”, “late delivery
of electronic contents to students”, and “inadequate time for teacher’s lecture in the class”. One
student stated, “I had to both watch the electronic contents and study the book. This took me a great
AC

deal of time. We would have more time and would be able to watch electronic contents more carefully if
the teacher had given us the DVDs three weeks before the course onset”.

DISCUSSION

Study findings showed significant increases in the mean scores of overall CTD and its engagement
domain in the FC group. These findings imply the effectiveness of FC in promoting students’ CTD and
thereby, critical thinking skills. Previous studies also reported that FC was associated with positive
outcomes. For instance, a study showed that team-based learning through FC significantly improved
 ACCEPTED MANUSCRIPT

sociology students’ creative and critical thinking skills (Huggins and Stamatel, 2015). Studies on nursing
students also indicated the positive effects of FC on learning processes and outcomes (Critz and Knight,
2013; Holman and Hanson, 2016; Missildine et al., 2013). The significant increases in the mean scores of
overall CTD and its engagement domain after using FC in the present study can be attributed to the facts
that FC combines active student-centered self-directed learning and the principles of the constructivist
paradigm, uses different educational technologies, and facilitates teacher-student face-to-face
relationships (McDonald and Smith, 2013). Student-centeredness and flexibility of FC can help promote
critical thinking as a requirement for nursing practice (Betihavas et al., 2016). Moreover, FC provides
learners with the opportunities to use their knowledge in practice and to actively involve in participatory

T
activities and group discussions (McDonald and Smith, 2013). However, in traditional instructional

IP
strategies, such as TL, learners make little attempt for fulfilling their educational needs (Gholami et al.,
2016).

CR
We asked our participants to actively participate in purposeful classroom activities such as the analysis
of clinical scenarios. The use of clinical scenarios facilitates active learning and improves students’

US
problem-solving, critical reasoning, and analysis skills (Popil, 2011). During classroom activities, our
participants not only communicated with their teacher, but also participated in group discussions
together with their classmates and exchanged information with each other. Peer learning or learning
AN
together is a significant factor behind the promotion of learning and critical thinking (Pålsson et al.,
2017).
M

The findings of the present study showed no significant increase in the mean scores of overall CTD and
its domains in the TL group. In line with these findings, another study showed that TL cannot promote
students’ critical thinking (Gholami et al., 2016). Therefore, there are many criticism on TL (Hong and Yu,
ED

2017). Through TL, teachers provide students with a huge amount of information in a short amount of
time without the ability to effectively communicate with them; thus, they usually face challenges in
PT

creating a supportive classroom environment for critical thinking promotion (Mandernach, 2006).
Moreover, TL provides students with limited opportunity, if any, to actively engage in group discussions,
classroom activities, and data analysis, and to use the learned knowledge in practice. Yet, TL is the most
CE

common instructional strategy in nursing education system in Iran.

The interaction effect of instructional strategy and last-semester GPA was not statistically significant,
AC

while those students in the FC group which had higher GPA were expected to have greater CTD.
Previous studies in Iran also reported no significant relationship between nursing students’ GPA and
their CTD (Mousazadeh et al., 2016, Ranjbar and Esmailee, 2006). This finding may be due to the
predominance of traditional student evaluation procedures in Iranian universities which greatly value
memorization instead of critical thinking.

Our participants noted that FC has advantages such as better learning and retention as well as student-
centered learning. Similarly, students who had participated in a previous study reported that listening to
recorded lectures before each class, practical classroom activities, and using the learned concepts in
clinical situations were effective in promoting their learning and deep thinking (Hanson, 2016). Students
 ACCEPTED MANUSCRIPT

in another study who had experienced FC considered it as a learner-centered strategy which promotes
student-teacher interaction and students’ learning (Holman and Hanson, 2016).

As reported by our participants, one of the disadvantages of FC was limited amount of time for teacher’s
lecture in classroom. It is noteworthy that TL was the dominant instructional strategy in the study
setting and students were accustomed to it. Students in an earlier study also considered recorded
lectures as complementary not alternative to face-to-face lecture (Johnston et al., 2013). Generally,
students become confused and uncertain when they are taught using blended learning strategies
(Jokinen and Mikkonen, 2013), because both students and teachers are more satisfied with teacher-

T
centered strategies which do not actively involve students in the process of learning (O’Flaherty and

IP
phillips, 2015). Another disadvantage of FC in the present study was that pre-class activities were time-
consuming. Similarly, students in an earlier study reported that watching lecture videos and getting

CR
ready for classroom activities were time-consuming (Post et al., 2015). Students in another study who
had experienced FC reported that watching recorded lectures and studying for quizzes were time-
consuming and classroom activities were time-wasting (Holman and Hanson, 2016). The length of

US
electronic contents in the present study was 21–52 minutes. After the study, we decided to shorten two
52-minutes videos. Lengthy lectures can be boring and tiring for students. Of course, our participants
could stop and re-play each video at any preferred time. Videos which are produced for FC should be as
AN
short as possible (with a length of 10–200 minutes) in order to prevent students’ poor concentration
(Smith and McDonald, 2013). Of course, some other studies reported that lengthier videos in one or
even two hours can be used for FC (Boucher et al., 2013; Wong et al., 2014).
M

One of the strengths of the study was new grouping of students at each session in order to foster
teamwork and relationships among them. Collaborative activities and teamwork are among the
ED

methods for improving critical thinking because they provide students with the opportunity to discuss
with each other, give feedback to each other, and thereby, obtain better understanding about complex
PT

situations (Wiggs, 2011). The use of FC in this study was associated with different problems and
challenges such as the need for electronic technicians, the high costs of producing electronic contents,
the need for a competent and experienced teacher for the management of FC, and the high number of
CE

students in each class. Another limitation we faced in this study was the lack of an effective learning
management system in the study setting which required us to provide electronic contents to students
using DVDs. Accordingly, we could not monitor the number of times the students watched each content.
AC

Moreover, CTD assessment was done using a general questionnaire. Replicating the study using nursing-
specific CTD questionnaires may produce different findings. Besides, although all requirements of
statistical tests were fulfilled and all study variables had normal distribution, random sampling was not
possible due to the small population of the study. In addition, the study was conducted on a small
sample of students, in a single medical-surgical nursing course, and in a single academic setting; thus,
findings may have limited generalizability. Of course, we attempted to strengthen the study through
using a quasi-experimental design with a control group.
 ACCEPTED MANUSCRIPT

CONCLUSIONS

This study suggests that while TL has no significant effects on CTD, FC promotes nursing students’ CTD.
FC actively involves students in learning activities both before and during classes. Of course, FC does not
affect the maturity and the innovativeness domains of CTD. Teachers can enhance the effectiveness of
FC by providing electronic contents to students at least 2–3 weeks before the course onset. Further
studies are needed to produce more credible results.

T
IP
CR
US
AN
M
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT

REFERENCES

Ajam, A., 2015. The Role of Self-Directed Learning Readiness and Critical Thinking Disposition in
Students’ Interaction in Blended Learning Environment. Iranian Journal of Medical Education 15, 215-
226. (In Persian).

Betihavas, V., Bridgman, H., Kornhaber, R., Cross, M., 2016. The evidence for ‘flipping out’: a systematic
review of the flipped classroom in nursing education. Nurse Education Today 38, 15-21.

T
https://doi.org/10.1016/j.nedt.2015.12.010.

IP
CR
Boucher, B., Robertson, E., Wainner, R., Sanders, B., 2013. “Flipping” Texas State University’s physical
therapist musculoskeletal curriculum: implementation of a hybrid learning model. Journal of Physical
Therapy Education 27(3), 72-77. Http://doi.org/

US
10.1097/00001416-201307000-00010. AN
Carvalho, D.P.S.R.P., Azevedo, I.C., Cruz, G.K.P., Mafra, G.A.C., Rego, A.L.C., Vitor, A.F., et al., 2017.
M

Strategies used for the promotion of critical thinking in nursing undergraduate education: A systematic
review. Nurse Education Today 57, 106-9. http:// doi.org/10.1016/j.nedt.2016.11.007.
ED

Chan, Z.C.Y., 2013., A systematic review of critical thinking in nursing education. Nurse Education Today
33(3), 236-240. https://doi.org/10.1016/j.nedt.2013.01.007..
PT

Critz, C.M., Knight, D., 2013. Using the flipped classroom in graduate nursing education. Nurse educator
CE

38(5), 210-213. http://doi.org/ 10.1097/NNE. 0b013e3 182a 0e56a.

AC

Gholami, M., Moghadam, P.K., Mohammadipoor, F., Tarahi, M.J., Sak, M., Toulabi, T,. et al., 2016.
Comparing the effects of problem-based learning and the traditional lecture method on critical thinking
skills and metacognitive awareness in nursing students in a critical care nursing course. Nurse education
today 45, 16-21. https://doi.org/ 10.1016/j.nedt.2016.06.007.

Graham, K., Burke, K., 2014. Students’ perceptions on a blended and flipped classroom. International
Journal of Process Education 6(1), 21-26.
 ACCEPTED MANUSCRIPT

Hajrezayi, B., Shahalizade, M., Zeynali, M., Badali, M., 2015. Effectiveness of blended learning on critical
thinking skills of nursing students. Journal of Nursing Education 4(1), 49-59. (In Persian).

Hanson, J., 2016. Surveying the experiences and perceptions of undergraduate nursing students of a
flipped classroom approach to increase understanding of drug science and its application to clinical
practice. Nurse education in practice 16(1), 79-85. https://doi.org/10.1016/j.nepr.2015.09.001.

T
IP
Holman, R., Hanson, A.D., 2016. Flipped Classroom Versus Traditional Lecture: Comparing Teaching
Models in Undergraduate Nursing Courses. Nursing Education Perspectives 37(6), 320-322.

CR
http://doi.org/ 10.1097/01.NEP.0000000000000075.

US
Hong, S., Yu, P., 2017. Comparison of the effectiveness of two styles of case-based learning
implemented in lectures for developing nursing students’ critical thinking ability: A randomized
controlled trial. International journal of nursing studies 68, 16-24.
AN
http://dx.doi.org/doi:10.1016/j.ijnurstu.2016.12.008.
M

Huggins, C.M., Stamatel, J. P., 2015. An exploratory study comparing the effectiveness of lecturing
versus team-based learning. Teaching sociology 43(3), 227-235. http://doi.org/
ED

10.1177/0092055X15581929.
PT

Jafaraghaie, F., Dehghanzadeh, S., Khordadi-Astane, H., 2017. Nursing students’ experience in a flipped
classroom method. Research in Medical Education 9(1)27-36.
CE
AC

Jensen, J. L., Kummer, T. A., Godoy, P.D.d.M., 2015. Improvements from a Flipped Classroom May Simply
Be the Fruits of Active Learning. CBE-Life Sciences Education 14(1), 1-12. http://doi.org/10.1187/ cbe.
14-08-0129.

Johnston, A.N.B., Massa, H., Burne, T.H.J., 2013. Digital lecture recording: A cautionary tale. Nurse
education in practice 13(1), 40-47. https://doi.org/10.1016/ j.nepr.2012.07.004.

Jokinen, P., Mikkonen, I., 2013. Teachers' experiences of teaching in a blended learning environment.
Nurse education in practice 13(6), 524-528. https://doi.org/10. 1016/j.nepr.2013.03.014.
 ACCEPTED MANUSCRIPT

Kaddoura, M.A., Van Dyke, O., Yang, Q., 2017. Correlation Between Critical Thinking Skills and National
Council Licensure Examination for Registered Nurses Success in Accelerated Bachelor Nursing Students.
Teaching and Learning in Nursing 12(1), 3-7. https://doi.org/10.1016/j.teln.2016.08.004.

Kaya, H., Şenyuva, E., Bodur, G. 2017. Developing critical thinking disposition and emotional intelligence
of nursing students: a longtitudinal research. Nurse Education Today 48, 72-7.

T
http://doi.org/10.1016/j.nedt.2016.09.011.

IP
CR
Khandaghi, M.A., Pakmehr, H., Amiri, E., 2011. The status of college students’ critical thinking disposition
in humanities. Procedia-Social and Behavioral Sciences 15, 1866-1869.
https://doi.org/10.1016/j.sbspro.2011.04.017.

US
AN
Mandernach, B.J., 2006. Thinking critically about critical thinking: Integrating online tools to promote
critical thinking. Insight: A collection of faculty scholarship 1, 41-50.
M

McDonald, K., Smith, C.M., 2013. The flipped classroom for professional development: part I. Benefits
ED

and strategies. The Journal of Continuing Education in Nursing 44(10), 437-8.

https://doi.org/10.3928/00220124-20130925-19.
PT

McLaughlin, J.E., Roth, M.T., Glatt, D.M., Gharkholonarehe, N , Davidson, CA, Griffin, L.M, et al., 2014.
CE

The flipped classroom: a course redesign to foster learning and engagement in a health professions
school. Academic Medicine 89(2), 236-243. http://doi.org/10.1097/ACM.0000000000000086.
AC

Mikkelsen, T.R., 2015. Nursing students’ experiences ,perceptions and behavior in a flipped-classroom
anatomy and physiology course. Journal of Nursing Education and Practice 5(10), 28-35.
https://doi.org/10.5430/jnep.v5n10p28.

Missildine, K., Fountain, R., Summers, L., Gosselin, K., 2013. Flipping the classroom to improve student
performance and satisfaction. Journal of Nursing Education 52(10), 597-599.
https://doi.org/10.3928/01484834-20130919-03.
 ACCEPTED MANUSCRIPT

Mousazadeh, S., Momennasab, M., Bakhtiari, T., Reisi, M., 2016. Nursing Students' Disposition toward
Critical Thinking and its Relationship with their Academic Performance. Journal of Nursing Education
5(4), 20-6. (In Persian).

Mudd ,S.S., Silbert-Flagg, J. 2016. Implementing the Flipped Classroom to Enhance Nurse Practitioner
Clinical Decision-Making in the Care of the Pediatric Asthma Patient. Nursing Education Perspectives

T
37(6):http://doi.org/352-3. 10.1097/01.NEP.00000000 00000083.

IP
CR
Nelson, A.E. 2017. Methods Faculty Use to Facilitate Nursing Students' Critical Thinking. Teaching and
Learning in Nursing 12(1), 62-66. https://doi.org/10.1016/ j.teln.2016.09.007.

US
Njie-Carr, V.P.S., Ludeman, E., Lee, M.C., Dordunoo, D., Trocky, N.M., Jenkins, L.S., 2017. An integrative
AN
review of flipped classroom teaching models in nursing education. Journal of Professional Nursing 33(2),
133-44. http://doi.org/10.1016/j.profnurs. 2016.07.001.
M

O'Flaherty, J., Phillips, C., 2015. The use of flipped classrooms in higher education: A scoping review. The
ED

Internet and Higher Education 25, 85-95. https://doi.org/ 10.1016 /j.iheduc.2015.02.002.

PT

O'Hare, L., McGuinness, C., 2009. Measuring critical thinking, intelligence, and academic performance in
psychology undergraduates. The Irish Journal of Psychology 30, 123-31.
CE

http://doi.org/10.1080/03033910.2009.10446304.
AC

Pakmehr, H., Mirdoraghi, F., Ghanaei Ghamanabad, A., Karami, M., 2013. Reliability, validity and factor
analysis of Ricketts' critical thinking disposition scale in high school. Training measurement 4(11), 33-53.
(In Persian).

Palinscar, A.s., 1998. Social constructivist perspectives on teaching and learning. Annual Review of
Psychology 49, 345-75.
 ACCEPTED MANUSCRIPT

Pålsson, Y., Mårtensson, G., Swenne, C. L., Ädel, E., Engström, M., 2017. A peer learning intervention for
nursing students in clinical practice education: A quasi-experimental study. Nurse Education Today 2017
51, 81-87. https://doi.org/10.1016/ j.nedt.2017.01.011.

Poodineh Moghadam, M., Jahantigh Haghighi, M., Shahdadi, H., Saravani, S., Shojaei Shad, F., 2015. The
impact of evidence-based education on nursing students’ critical thinking. Journal of Nursing Education
4(2), 9-17. (In Persian).

T
IP
Popil I., 2011. Promotion of critical thinking by using case studies as teaching method. Nurse education

CR
today 31(2), 204-207. https://doi.org/10.1016/j.nedt.2010. 06.002.

US
Post, J.L., Deal, B., Hermanns, M., 2015. Implementation of a flipped classroom: Nursing students’
perspectives. Journal of Nursing Education and Practice 5(6),25-30. https://doi.
org/10.5430/jnep.v5n6p25.
AN
M

Profetto-McGrath, J., 2003. The relationship of critical thinking skills and critical thinking dispositions of
baccalaureate nursing students. Journal of advanced nursing 43(6), 569-77.
https://doi.org/10.1046/j.1365-2648.2003.02755.x.
ED
PT

Ranjbar, H., Esmailee H., 2006. Critical thinking disposition among nursing and midwifery student.
Orumiye Seasonal Nursing and Midwifery Faculty Journal 4(1),11-17. (In Persian).
CE

Rezaeian, M., Zare-Bidaki, M., Bakhtar, M., Afsharmanesh, K., 2015. Comparison of the critical thinking
AC

skills among medical students in different educational levels in Rafsanjan University of Medical Sciences
in 2013. Journal of Rafsanjan University of Medical Sciences 13(8), 715-24. (In Persian).

Ricketts, J.C ., 2003.The efficacy of leadership development, critical thinking dispositions, and student
academic performance on the critical thinking skills of selected youth leaders: University of Florida.
 ACCEPTED MANUSCRIPT

Romeo, E.M., 2010. Quantitative research on critical thinking and predicting nursing students’ NCLEX-RN
performance. Journal of Nursing Education 49(7), 378-86. https://doi.org/10.3928/01484834-20100331-
05.

Simpson, E., Courtney, M., 2002. Critical thinking in nursing education: Literature review. International
journal of nursing practice 8(2), 89-98. https://doi.org/10.1046/j. 1440-172x.2002.00340.x.

T
IP
Smith, C.M., McDonald, K., 2013. The flipped classroom for professional development: Part II. Making
podcasts and videos. The Journal of Continuing Education in Nursing 44(11), 486-487.

CR
https://doi.org/10.3928/00220124-20131025-93.

US
Sun, Z., Xie, K., Anderman, L.H., 2018. The role of self-regulated learning in students' success in flipped
undergraduate math course. The Internet and Higher Education 36, 41-53.
http://doi.org/10.1016/j.iheduc.2017.09.003.
AN
M

Von Colln-Appling, C., Giuliano, D., 2017. A concept analysis of critical thinking: A guide for nurse
educators. Nurse education today 49, 106-9. https://doi.org/10.1016/j. nedt.2016.11.007.
ED

Wiggs, C.M., 2011. Collaborative testing: Assessing teamwork and critical thinking bahaviours in
PT

baccalaureate nursing students. Nurse Education Today 31, 279-82.

http://doi.org/10.1016/j.nedt.2010.10.027.
CE

Wong, T.H, Ip, E.J, Lopes, I, Rajagopalan, V., 2014. Pharmacy students’ performance and perceptions in a
flipped teaching pilot on cardiac arrhythmias. American journal of pharmaceutical education 78(10), 1-6.
AC

http;//doi.org/ 10.5688/ajpe7810185.

Zhang, H., Lambert, V., 2008. Critical thinking dispositions and learning styles of baccalaureate nursing
students from China. Nursing & health sciences 10(3), 175-181. https://doi.org/10.1111/j.1442-
2018.2008.00393.x.
 ACCEPTED MANUSCRIPT

Table 1. Electronic contents for FC

Contents Topic Length

Nursing care of patients with soft tissue injuries and bone 42

1
fractures minutes

Nursing care of patients with cast, brace, and external 35

2
fixation minutes

T
Nursing care of patients with skeletal traction and hip and 52

IP
3
knee replacement surgeries minutes

CR
Nursing care of patients with osteomyelitis, infectious
35
4 arthritis, and skeletal tuberculosis and patients who
minutes
undergo limb amputation

5
musculoskeletal tumors US
Nursing care of patients with benign and malignant 21
minutes
AN
Nursing care of patients with metabolic bone disorders 23
6
such as osteoporosis, osteomalacia, and Paget’s disease minutes
M

Nursing care of patients with rheumatic diseases such as

52
ED

7 rheumatoid arthritis, systemic lupus erythematosus,

minutes
scleroderma, gout, and osteoarthritis
PT
CE
AC
 ACCEPTED MANUSCRIPT

Table 2. Comparison of the TL and the FC groups regarding students characteristics

TL FC
Characteristics P value
N % N %
Female 36 85.7% 35 81.4%
Gender 0.59b
Male 6 14.3% 8 18.6%
Marital Single 39 92.9% 38 88.4%
0.71a

T
status Married 3 7.1% 5 11.7%
Employment Employed 1 2.4% 3 7%

IP
1.000a
status Unemployed 41 97.6% 40 93%
With family 30 71.4% 28 65.1%

CR
Personal
Living status 1 2.4% 3 7% 0.69a
home
Dormitory 11 26.2% 12 27.9%

US
Mean SD Mean SD
Age 19.98 1.15 19.77 1.52 0.47c
Last-semester GPA 15.21 1.42 15.67 1.47 0.15c
AN
a: Fisher’s exact test; b: The chi-square; c: The independent-sample t test
M
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT

Table 3. Between- and within-group comparisons regarding the mean scores of CTD and its domains

Time
CTD Before After P valueb
Group
TL 38.19(6.57) 39.26(4.11) 0.33
Engagement FC 36.19(8.45) 49.84(5.92) <0.0001
P valuea 0.22 <0.0001 ——
TL 28.83(3.87) 28.12(3.17) 0.34

T
Maturity FC 27.28(3.41) 29.12(3.26) 0.30

IP
P valuea 0.01 0.15 ——
TL 41.57(4.78) 41.12(8.12) 0.75

CR
Innovativen
FC 40.51(5.56) 42.56(5.70) 0.10
ess
P valuea 0.34 0.34 ——
108.60(11.21 108.67(10.98

US
TL 0.97
) )
Overall CTD 103.95(13.44 122.53(10.57
FC <0.0001
) )
AN
P valuea 0.06 <0.0001 ——
a: The independent-sample t test; b: The paired-sample t test
M
ED
PT
CE
AC