Interactive Learning Environments

ISSN: 1049-4820 (Print) 1744-5191 (Online) Journal homepage: http://www.tandfonline.com/loi/nile20

A situation-based flipped classroom to improving

nursing staff performance in advanced cardiac life
support training course

Bieng-Yi Chang, Ching-Yi Chang, Gwo-Haur Hwang & Fan-Ray Kuo

To cite this article: Bieng-Yi Chang, Ching-Yi Chang, Gwo-Haur Hwang & Fan-Ray Kuo (2018): A
situation-based flipped classroom to improving nursing staff performance in advanced cardiac life
support training course, Interactive Learning Environments, DOI: 10.1080/10494820.2018.1485709

To link to this article: https://doi.org/10.1080/10494820.2018.1485709

Published online: 12 Jun 2018.

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INTERACTIVE LEARNING ENVIRONMENTS
https://doi.org/10.1080/10494820.2018.1485709

A situation-based flipped classroom to improving nursing staff

performance in advanced cardiac life support training course
Bieng-Yi Changa,b, Ching-Yi Changa,c, Gwo-Haur Hwang d
and Fan-Ray Kuo e

a
Department of Nursing, Cheng Hsin General Hospital, Taipei, Taiwan; bNational Defense Medical Center, School of
Nursing, Taipei, Taiwan; cGraduate Institute of Digital Learning and Education, National Taiwan University of Science
and Technology, Taipei, Taiwan; dBachelor Program in Interdisciplinary Studies, National Yunlin University of Science
and Technology, Yunlin, Taiwan; eDepartment of Occupational Therapy, College of Medicine, National Taiwan
University, Taipei, Taiwan

ABSTRACT ARTICLE HISTORY

The Advanced Cardiac Life Support (ACLS) training aims to help nurses Received 12 January 2018
establish the basic competence of the comprehension of Accepted 4 June 2018
electrocardiograms (ECG/ EKG). However, learners usually have difficulty
KEYWORDS
memorizing the meanings of different EKG waveforms, which could Flipped classroom; advanced
represent clinical symptoms or even the feeling of dying, via traditional cardiac life support (ACLS)
instruction. Some serious problems could lead to death if the nursing training course;
staff do not make correct judgments and provide timely treatment. electrocardiogram (ECG/
Thus, this paper reports an explorative study investigating the effects of EKG); nursing course; situated
a flipped classroom approach on nursing staffs’ ACLS learning learning
achievement. A 2-week experiment was conducted to compare the
learning achievement of the nursing staff who learned with the ACLS
situation-based flipped classroom approach to those who learned with
the ACLS traditional flipped approach. The experimental results show
that the nursing staff who learned with the proposed approach had
better learning achievements, motivation, and satisfaction than those
who learned with the ACLS traditional flipped approach.

Introduction
For the sake of medical quality and patient safety, clinicians in medical institutions around the world
are required to take an Advanced Cardiac Life Support (ACLS) training course, including the programs
of basic life support, acute coronary syndrome, and electrocardiograms (EKG or ECG), to check for
signs of heart disease (Keough, Tell, Andreoni, & Tanabe, 2016; O’Neill et al., 2014; Werner, Kander,
& Axelsson, 2014). Among these programs, EKG is an especially required course for medical staff
to comprehend heart rhythms (Fuller, Scott, Hug-English, Yang, & Pasternak, 2016), heart rate,
arrhythmia (Kurka et al., 2015), atrial enlargement, ventricular hypertrophy (Morton, 2014), myocardial
hypoxia (Minami et al., 2016), and myocardial injury (Lad, Gorman, Watson, & Kennedy, 2014) from a
wave chart depicting cardiac electrical conduction activity. Medical staff must have adequate exper-
tise and skills to interpret EKG when assessing patients’ heart function (Keough et al., 2016). Basic
waveforms of EKG can be categorized into critical cardiac arrhythmias (17 rhythms included) and
cardiac arrest (4 rhythms included). Moreover, symptomatic bradycardia or tachycardia rhythms
and the diagnosis of additional heart rhythms, such as acute coronary syndrome, acute pulmonary
edema, hypotension, shock, and cerebral infarct, may lead to an abnormal heart rhythm (Kurka
et al., 2015). It is important for nursing staff to enhance their EKG interpretative ability as it may facili-
tate their clinical work of monitoring patient safety, assessing disease progression, and evaluating

CONTACT Fan-Ray Kuo revonkuo@gmail.com

© 2018 Informa UK Limited, trading as Taylor & Francis Group
2 B.-Y. CHANG ET AL.

more effective therapeutic outcomes (Hu, Kao, et al., 2016). In traditional EKG training courses, based
on the philosophy of the American Heart Association (AHA), the instructors of ACLS training are able
to guide medical learners to engage in practical exercises to grasp the best treatment in real-time
time in the clinical practice aid, and to provide patients with the best care in a timely manner in
order for them to survive (Hu, Kao, et al., 2016). Two of the authors of this study have worked in
an academic medical center for over 20 years, observing the learning difficulties and problems in
ACLS. For example, it is not easy for learners to memorize various conditions of heart rhythm or to
interpret EKG accompanying changeable conditions in the traditional EKG learning process. Blake-
man, Sarsfield, and Booker (2015) indicated that it is difficult for instructors to fully introduce the
EKG waveforms for all of the clinical situations based on the various conditions of arrhythmias. Mean-
while, it is not easy for learners to associate what they have learned with actual problems encoun-
tered without taking part in a clinical internship. Accordingly, nursing staff often encounter
difficulties interpreting EKG waveforms in clinical settings (Atwood & Wadlund, 2015). It is still chal-
lenging for learners to learn by themselves, especially when learning abstract concepts such as math-
ematics (Hwang & Lai, 2017). According to a comprehensive literature review, nurses usually have
difficulty memorizing the meanings of different EKG waveforms, which could represent clinical symp-
toms or even the feeling of dying, with traditional instruction (Kim, 2005; Atwood & Wadlund, 2015).
Thus, this paper reports an explorative study investigating the effects of the flipped classroom
approach on nursing staffs’ ACLS learning achievement.
Incorporating the flipped classroom learning approach into nursing courses and combining
situated learning strategies with digital learning systems to guide learners in reflective and
deep thinking has become a new learning approach in recent years. Consequently, this study
proposes a learning approach combining the flipped classroom with the situated learning strat-
egy in an ACLS training course, which we call the ACLS situation-based flipped classroom
approach. To examine the effectiveness of the proposed approach, the following research
issues are addressed:

(1) Does the ACLS situation-based flipped classroom approach improve nursing staffs’ learning
achievement more than the ACLS traditional flipped approach does?
(2) Does the ACLS situation-based flipped classroom approach improve nursing staffs’ learning
motivation more than the ACLS traditional flipped approach does?
(3) Does the ACLS situation-based flipped classroom approach enhance nursing staffs’ critical think-
ing in ACLS more than the ACLS traditional flipped approach does?
(4) Does the ACLS situation-based flipped classroom approach enhance nursing staffs’ learning atti-
tude toward ACLS more than the ACLS traditional flipped approach does?
(5) Does the ACLS situation-based flipped classroom approach enhance nursing staffs’ learning sat-
isfaction with ACLS more than the ACLS traditional flipped approach does?

Literature review
Flipped classrooms
Flipped classrooms offer learners an interactive and autonomous learning method (Lai & Hwang,
2016). Flipped classrooms have been promoted in K12 education by Bergmann and Sams (2012),
and have been adopted in college courses in recent years. Basically, Bergmann and Sams proposed
the concept of delivering learning materials and knowledge via online resources in a flipped manner.
Many researchers finalized the definition of a flipped classroom as
a type of blended learning mode that delivers learning content or lectures often online, outside of the classroom.
Learners are allowed to watch online lectures, collaborate in online discussions, or carry out research at home and
engage in concepts in the classroom with peers and educators. (Carrick et al., 2017; Lai & Hwang, 2016; Hwang &
Lai, 2017)
 INTERACTIVE LEARNING ENVIRONMENTS 3

The research findings of Sun, Xie, and Anderman (2018) indicate that flipped classrooms could
facilitate learners’ self-efficacy; moreover, their research also found that collaborative learning with
help strategies was highly associated with learning achievement in mathematics learning. Accord-
ingly, many studies have indicated that flipped classrooms could enhance learners’ learning achieve-
ment (Hwang & Lai, 2017; Thai, De Wever, & Valcke, 2017).
Recently, flipped classrooms have been applied in medical disciplines and have gained positive
feedback. For example, DeRuisseau (2016) indicated that flipped classrooms allow educators to
explain difficult concepts and carry out case studies because they have more class time. Urban,
Swensen, Schulkin, and Schiff (2016) incorporated a flipped classroom into a gynecologic oncology
curriculum with a weekly topic and clinical activities. The research findings showed that the medical
learners could gain better learning performance than those who learned with the ACLS traditional
flipped classroom. Furthermore, Rose et al. (2016) incorporated online videos with interpolated
questions into a flipped classroom in Pediatric Emergency Medicine (PEM), and found that the
online format integrated with face-to-face interaction was an effective learning model for core
PEM. Gillispie (2016) implemented a flipped classroom in an obstetrics and gynecology clerkship
with weekly problem-solving learning sessions and voice-over presentations of the lectures to
the clerks. The results showed that the critical thinking ability of the clerks showed better improve-
ment in scores in both the obstetrics and the gynecology portions of the Objective Structured Clini-
cal Examination than traditional classroom. See and Conry (2014) applied a flipped classroom to
Clinical Pharmacy Practice for pharmacy faculty development. Faculty anyone can watch a video,
construct their own crane, and send in a picture of it to the faculty facilitators by the deadline.
The in-class program activities included a quiz, discuss the homework, evaluation and feedback
of the cranes submitted, and a discussion on how to utilize class time for higher order complex
assignments via the flipped-classroom approach. Overall, 84% of the participants agreed that the
flipped-classroom approach could strongly increase their learning performance and motivation to
engage in the program. Das and Sarkar (2015) addressed the ability of medical learners to
perform arithmetical calculations to identify the correct volume of a drug in solution via the
flipped-classroom approach.

Situated learning
Situated learning was proposed by Brown, Collins, and Duguid in 1989 based on the Theory of
Cognitive Psychology, and emphasizes that people’s knowledge is embedded in the activity,
context, and culture in which it is learned. That is, learners are able to gain knowledge, techniques,
or skills in the real world or in a simulated environment (Dobson et al., 2001). Besides, with the
mature development of Web 2.0, a situated learning environment embedded with multimedia
(videos, photos, text) in which experts’ demonstrations are recorded in an authentic world to facili-
tate learning can also be regarded as a kind of situated learning. For instance, these videos show
how professionals use the machines in real environments. Pérez-Sanagustín, Muñoz-Merino, Alario-
Hoyos, Soldani, and Kloos (2015) pointed out that using mobile and context-based technology to
include expert performances in the situated learning environments (SLEs). A new generation of
information technology, Mobility and global access to information are two characteristics that
can be used to support SLEs, including specific complementary digital content from various
sources, such as videos from experts, in its educational dimension. Pérez-Sanagustín et al.
(2015) suggested that teachers appreciated the complementary digital content included in the
SLEs which supported multiple roles and perspectives, collaborative knowledge construction,
coaching and scaffolding, and promoted reflection and articulation. Most SLEs support outdoor
learning but they should support indoor learning. Many studies have indicated that situated learn-
ing is a meaningful approach that motivates learners to engage in learning (Prensky, 2001). For
instance, Hwang, Yang, Tsai, and Yang (2009) pointed out that the situated learning process
could allow learners to take part in high-order thinking activities, analysis, evaluation, and
4 B.-Y. CHANG ET AL.

organization of learning materials. Accordingly, situated learning enables learners to think and
learn effectively. Also, researchers have found that the situated learning approach plays an impor-
tant role in medical and nursing education, as it allows medical staff to repeatedly apply expertise
in similar clinical activities (Walrath, Immelt, Ray, Van Graafeiland, & Dennison Himmelfarb, 2015). In
such a similar clinical setting, learners try to solve medical problems usually encountered in the
clinic. This innovative learning approach is quite different from the traditional approach, in
which learners not only can repeatedly practice clinical operation and assessment, but also under-
stand the critical treatment procedures in advance. In the traditional approach, learners only
learned by a teacher and practice clinical operation in-class time. Thus, situated learning could
facilitate learners’ problem solving, critical thinking, and decision making competences (Zulkosky,
White, Price, & Pretz, 2016). Related studies have shown that situated learning combined with
mobile devices could help nursing learners to develop their heart and lung assessment skills
(Yoo & Lee, 2015), communication skills for end-of-life patient care (Sherlin & Quinn, 2016), Clinical
Decision Thinking (CDM; Woda, Gruenke, Alt-Gehrman, & Hansen, 2016), anesthesiologist nurse
training (Wunder, 2016), interprofessional communication skills between clinicians and nurses
(Yu & Kang, 2017), and so on.
Research findings show that situated learning can be integrated with the flipped classroom to
guide learners to organize domain knowledge and complete learning tasks (Hwang & Lai, 2017).
For example, Carrick et al. (2017) applied the Adobe Connect digital learning platform in a 3-day
flipped classroom which included in-class activities such as exercises and discussions. Smalley
et al. (2016) conducted a 3-day seminar on ultrasound using a flipped classroom, in which medical
learners were able to preview the teaching materials and give feedback in the classroom in order
to engage learners in actively learning and cooperating with each other, and learning to solve pro-
blems in the classroom.
Considering the abovementioned studies, few have addressed the flipped classroom combined
with the situated learning approach in first-aid training courses for ACLS. Thus, this study investigates
the effects of a flipped classroom with situated learning embedded in ACLS training scenarios, which
we call the ACLS situation-based flipped classroom, on nursing staffs’learning achievements, motiv-
ation, critical thinking, attitudes, and satisfaction.

Research design
This study investigates the effect of the proposed approach, the ACLS situation-based flipped
classroom, on nursing staffs’ ACLS learning achievement in an academic teaching hospital in
Taiwan. The ACLS program is included in the official required courses for employment in
nursing schools and hospitals, and is recognized as part of on-the-job training. This study
adopted a questionnaire survey to investigate the effectiveness of the ACLS situation-based
flipped classroom and situated-learning intervention. To evaluate the effectiveness of the pro-
posed approach, a pre-test and post-test designed experiment with equivalent groups was
employed. The aim of the experiment was to compare the learning achievement, learning motiv-
ation, learning attitude, critical thinking, and learning satisfaction of learners who learned with the
ACLS situation-based flipped classroom approach with those who learned with the traditional
ACLS approach.

Participants
A total of 60 nursing staff with an average age of 27 from an academic teaching hospital in northern
Taiwan were randomly assigned to two groups. The experimental group included 30 participants
who adopted the ACLS situation-based flipped classroom approach, while the remaining 30 who
adopted the ACLS traditional flipped approach were assigned to the control group. The two
groups are taught by the same instructor.
 INTERACTIVE LEARNING ENVIRONMENTS 5

Figure 1. Screenshot of the online ACLS Pictures showing correct CPR postures.

Measuring tools
The measuring tools adopted in the study used a 5-point Likert rating scheme and had acceptable
Cronbach’s α values, ranging from .79 to .88. The questionnaires employed included the 6-item learn-
ing motivation scale developed by Wang and Chen (2010), the 7-item learning attitude scale devel-
oped by Hwang, Yang, and Wang (2013), the 9-item learning satisfaction scale constructed by Chu,
Hwang, Tsai, and Tseng (2010), and the 6-item critical thinking disposition scale constructed by Chai,
Deng, Tsai, Koh, and Tsai (2015). The ACLS assessment items were constructed by two nursing instruc-
tors certified by the Nursing Association in Taiwan. They consist of 20 multiple-choice items related to
common EKG waveforms in the clinic, giving a perfect score of 100. The online ACLS course was
established for the flipped classroom, and learners were allowed to learn using their mobile devices.

Experimental procedure
Firstly, the two groups took the 2-day ACLS training course and completed the pre-test of prior
knowledge and the pre-questionnaires to collect the nursing staffs’ starting ability and attitudes.
In the pre-class activity, learners in the experimental group were given the ACLS textbooks and
were asked to preview the ACLS online multimedia material (combining videos, photos, and text)
to construct ACLS basic knowledge and skills in advance, as shown in Figures 1 and 2. The learners
did first-aid simulation exercises in this session, such as Rhythm Tests, Airway procedures, Cardiopul-
monary Resuscitation (CPR), Automated External Defibrillator (AED), and so on. In such a learning situ-
ation, not only could the preliminary ACLS knowledge and skills be learned, but questions for the
specific operations steps of ACLS in different situations could also be proposed in advance before
the in-class activities. Therefore, the students were able to pay more attention to the educator’s oper-
ation process to address their questions when learning ACLS.
In contrast to the experimental group, the learners in the control group were only given the ACLS
textbooks, and were not asked to preview the ACLS online multimedia. During the in-class activities,
the two groups were taught with the same learning activities and course discussion on first aid for
6 B.-Y. CHANG ET AL.

Figure 2. Screenshot of the ACLS videos: An example of Videos showing correct postures for CPR.

emergency situations. Instructors in this session conducted first-aid training for any emergency situ-
ation through dummy simulations, such as Respiratory Arrest, Post-Resuscitation Care, CPR, Acute
Coronary Syndrome (ACS)/ Acute Myocardial Infarction (AMI), Hypotension/Shock/ Pulmonary,
Edema, Megacode and so on, as well as addressing the nursing staffs’ problems in the assignments,

Figure 3. Screenshot of learners’ ACLS training during the in-class learning session.
 INTERACTIVE LEARNING ENVIRONMENTS 7

Experimental group: Control group:

Situation-based Flipped Conventional Flipped
classroom classroom

Pre-test and pre-questionnaire

100 mins
Preparatory (learning motivation etc.)
1st week
week
Introduce syllabus and learning goal 50 mins

Pre-class Learn at
activity Situation-based ACLS learning Conventional ACLS learning
hospital

2nd week In-class

activity
First-aid training for emergency situations 960 mins

Post-class Post-test and post-questionnaires 100 mins

activity (learning motivation etc.)

Figure 4. Procedure of the experiment design.

as shown in Figure 3. Learners in the two groups could propose any clinical emergency problems for
discussion in this session. After the in-class activity, the learners were all required to complete the
post-test of learning achievement and the post-questionnaires. The procedure of the experiment
is shown in Figure 4. The multimedia material mainly introduced the key points of the on-site learning
activities conducted by the teachers. The videos also presented the actual group exercises, including
Rhythm Tests, Airway procedures, CPR with AED, and Megacode. The experimental group students
were able to practice the learning tasks repeatedly in the pre-class stage, thus producing the prere-
quisite knowledge, skills, and questions in advance of the in-class stage.

Experimental results
Learning achievement
Analysis of covariance (ANCOVA) was employed by using the pre-test scores of learning achievement
as the covariate, while the post-test scores of learning achievement were the dependent variable.
After verifying that the assumption of homogeneity of regression was not violated with F = 3.57
(p > 0.05), the post-test scores of the two groups were analyzed using the ANCOVA method. As
shown in Table 1, it was found that there was a significant difference between the two groups (F
= 60.34, p < 0.001). That is, the ACLS situation-based flipped classroom approach had significantly
better effects (Mean = 89.53; SD = 5.94) on nursing staffs’ learning achievement than did the ACLS
traditional flipped classroom (Mean = 80.87; SD = 5.14). The adjusted means of the experimental
group and the control group were 89.72 and 80.68, respectively. This implies that the ACLS situ-
ation-based flipped classroom approach could enhance the nursing staffs’ learning achievement
more than the ACLS traditional flipped classroom could. Besides, the correlation coefficient (η2 =
0.514) is higher than 0.138, implying that the ACLS situation-based flipped classroom approach
has high effects on nursing staffs’ learning achievement.

Learning motivation
After verifying that the assumption of homogeneity of regression was not violated with F = 0.78
(p > 0.05), the post-test scores of the two groups were analyzed using the ANCOVA method. As
shown in Table 2, it was found that there was a significant difference between the two groups (F
= 9.44, p < 0.05). That is, the ACLS situation-based flipped classroom approach had significantly
8 B.-Y. CHANG ET AL.

Table 1. Results of ANCOVA on nursing staffs’ learning achievement.

Variance Group N Mean SD Adjusted mean Std. error. F η2
Learning achievement Experimental 30 89.53 5.94 89.72 0.82 60.34*** .514
control 30 80.87 5.14 80.68 0.82
***p < .001.

better effects (Mean = 4.31; SD = 0.41) on nursing staffs’ learning motivation than the ACLS tra-
ditional flipped classroom did (Mean = 3.82; SD = 0.73). Furthermore, the adjusted means of the
experimental group and the control group were 4.31 and 4.14, respectively. This implies that
the ACLS situation-based flipped classroom approach could enhance the nursing staffs’ learning
motivation more than the ACLS traditional flipped classroom could. Besides, the correlation
coefficient (η2 = 0.142) is higher than 0.138, implying that the ACLS situation-based flipped class-
room approach could enhance nursing staffs’ learning motivation to learn in the ACLS training
course.
The learners’ intrinsic and extrinsic motivations were also examined, with the items of intrinsic
motivation including: “In this course, I like challenging materials because I can learn new things,” “In
this course, I like the teaching materials that arouse my curiosity, even though they are difficult,” and
“If it is ok, I would like to choose courses that I want, even though the scores are not high.” The
results show that intrinsic learning motivation in the experimental group was significantly better
than that in the control group (F = 4.32, p < 0.05). The items of extrinsic motivation include:
“Getting good scores in this course can satisfy me most,” “If I can, I hope to get the highest scores in
the class for the course,” and “It is important for me to show excellent ability in front of my family,
friends, teachers or other people.” The results show that extrinsic motivation in the experimental
group was significantly better than that in the control group (F = 34.62, p < 0.01). Generally, the
ACLS situation-based flipped classroom approach could enhance the learning motivation of the
nursing staff in the experimental group.

Learning attitude
After verifying that the assumption of homogeneity of regression was not violated with F = 1.07 (p >
0.05), the post-test scores of the two groups were analyzed using the ANCOVA method. As shown in
Table 3, it was found that there was no significant difference between the two groups (F = 3.04, p >
0.01). That is, the ACLS situation-based flipped classroom approach didn’t have significantly better
effects (Mean = 4.66; SD = 0.31) on nursing staffs’ learning attitude than the ACLS traditional
flipped classroom (Mean = 4.50; SD = 0.38). Furthermore, the adjusted means of the experimental
group and the control group were 4.66 and 4.50, respectively, presenting highly positive attitude
toward the course. This implies that the ACLS situation-based flipped classroom approach could
not specifically enhance the nursing staffs’ learning attitude more than the ACLS traditional
flipped classroom could. Besides, the correlation coefficient (η2 = 0.051) is lower than 0.138, implying
that there was no difference in the learning attitude of the learners between the two groups. It can be
inferred that ACLS was a required course for nurses.

Table 2. Results of ANCOVA on nursing staffs’ learning motivation.

Variance Group N Mean SD Adjusted mean Std. error F η2
Learning motivation Experimental 30 4.31 0.41 4.31 0.09 9.44* .142
control 30 3.82 0.73 4.14 0.09
Intrinsic motivation Experimental 30 4.49 0.49 4.62 0.14 4.32* .070
control 30 4.27 0.56 4.13 0.14
Extrinsic motivation Experimental 30 4.13 0.56 4.70 0.12 34.62*** .378
control 30 4.02 0.78 3.46 0.12
***p < .001, *p < .05.
 INTERACTIVE LEARNING ENVIRONMENTS 9

Table 3. Results of ANCOVA on nursing staffs’ learning attitude.

Variance Group N Mean SD Adjusted mean Std. error F η2
Learning attitudes Experimental 30 4.66 0.31 4.66 0.06 3.04 .051
control 30 4.50 0.38 4.50 0.06

Critical thinking
After verifying that the assumption of homogeneity of regression was not violated with F = 1.46 (p >
0.05), the post-test scores of the two groups were analyzed via ANCOVA. As shown in Table 4, it was
found that there was no significant difference between the two groups (F = 1.21, p < 0.01). That is, the
ACLS situation-based flipped classroom approach did not have significant effects (Mean = 4.22; SD =
0.38) on nursing staffs’ critical thinking in comparison with the ACLS traditional flipped classroom
(Mean = 4.10; SD = 0.44). Besides, the correlation coefficient (η 2 = 0.21) is lower than 0.138, implying
that the ACLS situation-based flipped classroom approach has lower correlation with nursing staffs’
critical thinking. It can be inferred that participants are all experienced professionals who originally
had stable critical thinking ability.

Learning satisfaction
After verifying that the assumption of homogeneity of regression was not violated with F = 0.27 (p >
0.05), the post-test scores of the two groups were analyzed with ANCOVA. As shown in Table 5, it was
found that there was a significant difference between the two groups (F = 10.3, p < 0.05). That is, the
ACLS situation-based flipped classroom approach had significantly better effects (Mean = 4.68; SD =
0.32) on the nursing staffs’ learning satisfaction than the ACLS traditional flipped classroom did
(Mean = 4.36; SD = 0.41). Furthermore, the adjusted means of the experimental group and the
control group were 4.63 and 4.42, respectively. This implies that the ACLS situation-based flipped
classroom approach could enhance the nursing staffs’ learning satisfaction more than the ACLS tra-
ditional flipped classroom could. Besides, the correlation coefficient (η2 = 0.153) is higher than 0.138,
implying that the ACLS situation-based flipped classroom approach could enhance nursing staffs’
learning satisfaction when taking the ACLS training course.

Discussion and conclusions

In order to enhance nursing staffs’ in-clinic EKG interpretative ability, this study proposed an ACLS
situation-based flipped classroom method that integrated EKG scenes into the clinical learning set-
tings. The multimedia materials mainly introduced the key points of the on-site learning activities
conducted by the teacher. The students in the experimental group were able to practice the learning
tasks repeatedly by watching the ACLS multimedia (combining videos, photos, and text) in the pre-
class stage, and construct the prerequisite knowledge, operation skills, and even concrete questions
in advance of entering the in-class stage. Thus, in such a learning situation, the students in the exper-
imental group could bring more concrete nursing concepts or questions into the in-class stage, and
interact with the teacher.
On the contrary, the students in the control group who did not watch the ACLS multimedia prior
to the in-class stage could not gain concrete prior knowledge or operation skills; thus, they had less
interaction with the teacher in the in-class stage than the experimental group students did. That is,

Table 4. Results of ANCOVA on nursing staffs’ critical thinking.

Variance Group N Mean SD Adjusted mean Std. error F η2
Critical thinking Experimental 30 4.22 0.38 4.22 0.08 1.21 .021
control 30 4.10 0.44 4.10 0.08
10 B.-Y. CHANG ET AL.

Table 5. Results of ANCOVA on nursing staffs’ learning satisfaction.

Variance Group N Mean SD Adjusted mean Std. error F η2
Learning satisfaction Experimental 30 4.68 0.32 4.63 0.05 10.33* .153
control 30 4.36 0.41 4.42 0.05
*p < .05.

watching the ACLS multimedia in the pre-class stage could lead the students to understand the ACLS
learning situations, and they could focus on the on-site learning situation based on the concrete
questions that arose in the pre-class stage. Consequently, the research results show that the
nursing staff who learned with the ACLS situation-based flipped classroom method gained better
learning achievement, learning motivation, and learning satisfaction than those who learned with
the ACLS traditional flipped classroom. This result is consistent with the research findings of
Hwang and Lai (2017), who indicated that the flipped classroom approach is a well-organized learn-
ing approach that enhances nursing staffs’ learning achievement and self-efficacy via well-arranged
pre-class and in-class learning activities. This result reveals that nursing staff in the experimental
group more easily constructed concrete concepts and expertise for ACLS through a continued simu-
lated manner in the pre-class and in-class activities than those who learned in the ACLS traditional
flipped classroom. That is, learners in the experimental group were provided with ACLS multimedia
and simulation exercises in the pre-class stage. In such a learning situation, not only could the pre-
liminary knowledge and nursing skills for ACLS be constructed, but they could also come up with
questions about the specific operations for ACLS in different emergency situations in advance of
the in-class activities. Therefore, students are able to pay more attention to the educator’s specific
operations for ACLS in the class. Consequently, the proposed approach linking the flipped classroom
and situated learning could promote learners’ higher-order knowledge transition (Saunders, Green, &
Cross, 2017) and enhance their mastery of ACLS skills before entering the clinic (Aliakbari, Parvin,
Heidari, & Haghani, 2015; Bergmann & Sams, 2012). In contrast, those in the control group were
not given the multimedia material and simulation exercises in the pre-class stage, so that they
may have brought abstract concepts of ACLS knowledge and skills into the in-class stage. In such
a learning situation, it was difficult for the learners to identify their weaknesses and problems
when learning ACLS in advance.
However, neither critical thinking nor learning attitude changed significantly after the intervention
of the proposed approach in the 2-day ACLS training session. It could be inferred that the participants
in the experiment are all clinical professionals whose critical thinking and learning attitude toward
ACLS are unique and stable. Research has indicated that critical thinking and learning attitude
could only be enhanced over the long term, rather than in a short-term manner (Cavus & Uzunboylu,
2009; Hu, Jia, et al., 2016).
Flipped classrooms are a globally accepted learning approach that offers learners self-determined
learning activities outside of the classroom, and allows educators and learners to deeply discuss
learning content and problems during the in-class activities (Sergis, Sampson, & Pellicione, 2018).
Many studies have emphasized that flipped classrooms are a learner-centered approach in which
learners are able to learn extra-curricular materials and then deeply discuss what they have
learned with their peers in class (Bergmann, 2012). Moreover, this approach also facilitates learners’
participation in learning activities (Carrick et al., 2017; Lewis, Chen, & Relan, in press), and increases
their learning motivation (Sahin, Cavlazoglu, & Zeytuncu, 2015; Gilboy, Heinerichs, & Pazzaglia,
2015) and learning achievement (Hwang & Lai, 2017; Lai & Hwang, 2016) in comparison with
those taught with traditional learning approaches. Thus, as in the abovementioned studies, the pro-
posed approach of this study empirically increased the nursing staffs’ intrinsic and extrinsic learning
motivation so that they could positively take part in the learning activities.
Based on the results of the present study, we may conclude that flipped classroom learning has
been well recognized as an important research field. With the popularity of videos and eLearning
 INTERACTIVE LEARNING ENVIRONMENTS 11

technologies, it can be foreseen that more studies and applications will be conducted in the coming
years. Several suggestions for future studies on flipped classroom learning are given as follows:

(1) Critical questions, quizzes, or concepts may be covered in the multimedia materials. It is impor-
tant to give learners critical questions in the multimedia materials in the eLearning system in the
pre-class stage. These questions include both important concepts and misconceptions related to
the learning units so that the educator could consequently collect each learner’s status prior to
the in-class stage (McCallum, Schultz, Sellke, & Spartz, 2015; Roehl, Reddy, & Shannon, 2013).
Besides, educators could propose relevant questions for learners to engage in further and in-
depth discussion and applications in class.
(2) Learners’ readiness prior to the in-class stage may be tested. This test would urge learners to take
on the responsibility for their learning before entering the in-class stage, and assure them of
joining the discussion in the class. This concept originated from Michaelsen and Sweet’s
Team-based learning, in which the individual readiness assurance test (IRAT) is conducted to
enhance individual students’ engagement in and quality of learning (Michaelsen & Sweet, 2011).

The sample size of the participants in this study fits the required statistical size for inferences
(Hogg, Tanis, & Zimmerman, 2014). However, the results cannot be over-extrapolated to other
medical domains based on the research findings in the nursing domain. We therefore plan to
apply the proposed approach in other medical and nursing clinical courses. Based on the learner-cen-
tered design, the flipped classroom approach would be more meaningful with diverse learning
methods. The main contribution of this article is that the innovation flipped teaching design
course is worth promoting in other forms of education and training of nursing staff and all
medical staff in the future.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This study is supported in part by the National Science Council of the Republic of China under contract numbers MOST-
105-2511-S-011-008-MY3 and MOST 106-2511-S-011 -005 -MY3.

Notes on contributors
Ms Bieng‐Yi Chang is a MSN, RN Deputy Director, at the Department of Nursing, Cheng Hsin General Hospital, National
Defense Medical Center, School of Nursing, Instructor. Her research interests include mobile learning and Flipped‐based
classroom learning and medical education, nurse education.
Ms Ching‐Yi Chang is a MSN, RN, Supervisor at the Department of Nursing, Cheng Hsin General Hospital and a Ph.D.
student at the National Taiwan University of Science and Technology. Her research interests include mobile learning,
digital game‐based learning, flipped classroom and medical education, nurse education.
Dr Gwo‐Haur Hwang is a professor at the Bachelor Program in Interdisciplinary Studies, National Yunlin University of
Science and Technology. His research interests include mobile learning and digital game‐based learning.
Dr Fan‐Ray Kuo is an assistant researcher at the Department of Occupational Therapy, College of Medicine, National
Taiwan University. His research interests include technology‐enhance learning in medical education.

ORCID
Gwo-Haur Hwang http://orcid.org/0000-0002-3380-2283
Fan-Ray Kuo http://orcid.org/0000-0001-9311-6464
12 B.-Y. CHANG ET AL.

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