Flipped and Blended Learning: Arranging Learning Activities

Instructional Design Connecting Pre-learning and In-person Activities

Flipped learning is an approach in which content traditionally delivered in lectures is studied before class, leaving in-person time for active learning such as problem-solving and discussion. Blended learning combines online resources and in-person interactions, depending on the sequence and role of each activity. Using the understanding demonstrated during pre-learning to inform in-person activities, and linking those activities back to competency assessment, is central to instructional design.

Flipped Learning Design Starting from Competency Goals

A paper on flipped learning design for competency development integrates pre-learning, formative assessment, activities to bridge learning gaps, and instructor guidance into a single curriculum (Hurtubise et al., 2015). Drawing on the Reflex Arc Concept and the zone of proximal development, the authors explained how learners construct a mental model from prior experiences and new information. Learners then modify it through reflection and expert scaffolding. Formative assessment helps instructors understand learners’ developmental levels and guide appropriate activities. The authors proposed backward instructional design, in which learning goals are established first, followed by assessment and teaching methods. Goal setting draws on the EPAs expected upon entry into residency training and competencies such as patient care, communication, and interprofessional collaboration. The Quality Matters (QM) rubric for online and blended courses is used to check the alignment of goals and assessments, learner support, accessibility, and usability.

A design example for the ‘diabetes patient management’ EPA starts with a Year 1 medical school TBL on type 2 diabetes. Teams of 6 were formed to balance learner characteristics, and preparation materials were provided 2 weeks before the module. This was followed by an individual readiness assurance test (iRAT), a team readiness assurance test (tRAT), immediate feedback, and discussions of clinical cases within and between teams. The authors presented an expanded proposal that added interprofessional teams, practice-based learning and improvement projects, collaborative evidence development, and assessment of communication and contributions. Recorded lectures and e-learning modules helped learners acquire foundational knowledge. Wikis and concept maps supported the collaborative construction of evidence. Polling and ePortfolios enabled checks of understanding and performance.

The implementation strategy addresses preparation time and cognitive load alongside the instructor’s role and institutional support systems. The authors described methods for estimating pre-learning time and advising learners on it. Content was organized around the overall assignment and assessment schedule. Reserving preparation time within the timetable, as some schools do, was also proposed. Recommendations derived from an 8-step change process include technical support and faculty development consultations at the course level. They also include changes in course assessment systems and adjustments to faculty and staff roles across the curriculum. The proposal uses the reuse of materials across institutions and mentoring to create conditions in which instructors can focus on facilitating active learning and providing feedback.

Operation of Obstetric Emergency Learning and Immediate Post-module Knowledge Changes

A pilot study in an obstetrics and gynecology residency program restructured obstetric emergency education in a setting where clinical duties made attendance at a 1-hour weekly in-person lecture difficult (Taylor et al., 2015). The study site, the Department of Obstetrics and Gynecology at Southern Illinois University, had 15 residents and 16 faculty members. All residents participated as part of their regular curriculum. The research team identified educational needs by reviewing pre-assessments on diabetic ketoacidosis (DKA) and acute severe hypertension in pregnancy and the postpartum period, along with CREOG in-training examination scores from the past 6 years. The design drew on the Community of inquiry and the Cognitive theory of multimedia learning. Each module was designed to include a pre-quiz, self-paced multimedia learning, supplemental reading, asynchronous discussion, and a post-quiz on Moodle over 1 week. An in-person class was planned to follow. Quiz scores were analyzed using paired t-tests. Participation was observed through discussion posts and the researchers’ reflection journals.

The average score among the 14 residents who completed the DKA module rose from 48.0% ± 17.4% to 78.0% ± 11.1%, while that among the 12 who completed the acute severe hypertension module increased from 65.1% ± 12.1% to 87.9% ± 7.6%. The p-value for DKA was reported as P ≤ 0.05 in the text and as ≤.001 for the two-tailed test in the table. The value for hypertension was P ≤ 0.001. Scores increased for all completers in both modules. The COLLES, administered to the 12 residents who completed the hypertension module, consists of 6 scales (relevance, reflection, interactivity, tutor support, peer support, and interpretation) and 24 statements. Statements were rated on a 1–5 point scale; a question on preferred teaching method was added. The overall average score was 4.1467. Of the 25 statements, including the preference question, 17 had an average of 4 points or higher. Ten respondents indicated that they liked the class format. When asked whether they preferred it to traditional in-person lectures, 7 responded neutrally, and 5 found asynchronous discussions uncomfortable.

In the DKA module, there were no logins until the 3rd day. In the second module, half of the learners had completed the pre-quiz and reviewed the materials by the same point. The completion deadline and the rationale for reserving time for feedback were explained in the second module. Eleven individuals participated in discussions for each module. Of the initial posts, 2 out of 8 for DKA and 3 out of 7 for hypertension received peer replies. The final in-person class for the hypertension module could not be held because of scheduling conflicts, so questions and concepts were summarized online. The pre- and post-assessments measured changes immediately after modules that combined multiple activities at a single institution. Long-term retention and clinical application require separate assessment. The research team proposed re-evaluation and medical record reviews after at least 6 months. The proposed approach uses protected education time and available ward time rather than shifting learning to off-duty hours.

Learning Transfer Connecting Chronic Hypertension Education to Clinical Procedures

A study of education on chronic hypertension in pregnancy extended assessment to examine blended learning outcomes in outpatient care (Ghareeb et al., 2016). All 16 obstetrics and gynecology residents participated from July 17 to July 24, 2015. The existing 1-hour in-person class was redesigned to include a 10-minute introduction, a week-long online assignment, and a final 1-hour in-person discussion. The Moodle materials comprised three sections: diagnosis and initial management, reciprocal effects of chronic hypertension and pregnancy, and pregnancy and postpartum care. In response to feedback from the previous educational pilot, asynchronous discussions were replaced with posts on a public forum describing key messages from the literature and applications for future practice. The pre- and post-quizzes were revised to use short multiple-choice questions. In the final in-person class, residents reviewed outpatient medical records and jointly developed a management algorithm to standardize the first prenatal visit. In addition to quizzes, posts, and surveys, the research team conducted a retrospective medical record review 6 months after the educational intervention. The review covered March–June 2015 before the intervention and July 20, 2015–February 2016 after it.

Sixteen residents completed the pre-quiz and 14 completed the post-quiz. The average score reported in the text rose from 64.0% ± 13.9% to 77.8% ± 9.9% (P = 0.015). All 16 residents selected literature from the materials provided and posted about its key messages and clinical application. Thirteen survey respondents gave positive ratings for the module’s usefulness and applicability to practice. They identified the combination of short materials, immediate feedback, case reviews, and algorithm development as advantages. Medical records were compared for a total of 17 patients (10 pre-education and 7 post-education). The frequency of adherence to each item was analyzed using Fisher’s exact test. Electrocardiogram referrals increased from 40% to 100% (P = 0.035), and liver enzyme testing and early diabetes evaluations for patients with obesity also increased significantly (P = 0.044, P = 0.029). Provision of blood pressure monitors increased from 20% to 71.4%, with P = 0.058. Documentation of disease duration and counseling was rare, and no records of previous detailed evaluations or low-dose aspirin prescriptions were identified.

The authors linked the significant increases in these three items to their discussion and inclusion in the algorithm during the final in-person class. Because the study examined resident education at a single institution and the medical records of 17 patients, the performance changes are best interpreted in light of the specific clinical environment and the actions documented in those records. When the record review results were shared with 9 of the 16 residents, the ensuing discussion addressed the difficulty of confirming whether physical examinations had been performed when they were not documented. The residents proposed placing the algorithm in an easily accessible shared location and systematizing both care and documentation. Interruptions from clinical duties and server or connection problems during learning were also reported. Regular follow-up sessions, feedback, and supplemental learning were proposed.

Reading notes

The QM rubric can also serve as a formative checklist for reviewing instructors’ competencies in program design and implementation. Guidance on completion deadlines, time reserved for feedback, and easily accessible algorithms are educational and workplace conditions that support learner self-regulation. From the perspective of HRD learning transfer and organization development, examining instructor guidance, procedure development with peers, technical support, and protected education time together can explain more precisely how content learned in medical education is applied in the workplace. Quizzes, participation records, and medical records capture understanding, participation in activities, and documented performance, respectively.

References

• Hurtubise, L., Hall, E., Sheridan, L., & Han, H. (2015). The flipped classroom in medical education: Engaging students to build competency. Journal of Medical Education and Curricular Development, 2. https://doi.org/10.4137/JMECD.S23895
• Taylor, F. A., Nelson, E., Delfino, K., & Han, H. (2015). A blended approach to learning in an obstetrics and gynecology residency program: Proof of concept. Journal of Medical Education and Curricular Development, 2. https://doi.org/10.4137/JMECD.S32063
• Ghareeb, A., Han, H., Delfino, K., & Ajayi, F. (2016). Blended learning in obstetrics and gynecology resident education: Impact on resident clinical performance. Journal of Medical Education and Curricular Development, 3. https://doi.org/10.4137/JMECD.S40598