Evaluating Medical Student Engagement in Flipped Classrooms: Insights on Motivation and Peer Learning

Abstract

BACKGROUND

Flipped classrooms have gained popularity for their ability to improve educational outcomes by flipping traditional teaching approaches and fostering interactive learning settings. Our study aims to assess the impact of these classrooms on medical students’ motivation, critical thinking skills, and facilitation of collaborative learning.

METHODS

A quasi-experimental study was conducted to involve quantitative surveys administered to students both before and after the teaching session. A predefined questionnaire was used to assess 5 key outcomes: Motivation, Critical Thinking, Student-centered learning, Learning benefits, and Peer-Assisted Learning. Data were collected at 2 points to capture changes throughout the intervention.

RESULTS

The introduction of the flipped classroom approach led to a significant improvement in medical student performance, with average test scores rising from 13.25 ± 2.36 to 16.08 ± 1.5 (P < .05). Students’ perceptions of the flipped classroom also improved, with the impact scale score increasing from 41.91 ± 4.9 to 69.71 ± 9.72 (P < .05). There was a statistically significant difference before and after the engagement, suggesting that the flipped classroom approach successfully improved students’ motivation, engagement, collaborative learning, and critical thinking skills.

CONCLUSION

Our findings highlight the positive efficacy of flipped classrooms in creating a more interactive and supportive learning environment. The study concludes with recommendations for educators on how to implement best practices to enhance student engagement and improve learning outcomes in flipped classroom settings.

Introduction

A debate in higher education revolves around the necessity for alternative curricula to address the growing requirements for students’ retention and application of knowledge and skills postgraduation. The calls for accountability have prompted faculty to shift from being a “sage on stage” to a “guide on the side.” ¹ Two teaching styles were proposed in higher education: a sage on the stage, where a teacher transmits information through lectures, and a guide on the side, who assists and corrects students as they study topics individually or in groups. Both approaches have validity, and when faculty members fulfil both roles, their courses may evolve to suit the needs of today's learners while still meeting accountability requirements. ² In-class lectures remain the primary instructional strategy in many classrooms, as referred to as the “sage on the stage.” However, classroom lectures have been criticized for their ineffectiveness in acquiring necessary knowledge and skills. ³

Research shows that students’ attention declines after the first 10 min of class, and remember only about 20% of the material presented during lectures. ⁴ This passive learning method takes classroom time away from challenging student thinking, guiding them to solve practical problems, and encouraging direct application of material through active learning with the instructor. Despite criticism, lectures are necessary for teaching skills for later career applications. ⁵ The “guide on the side” is based on the constructivist theory of learning, which suggests that knowledge is not a product of individuals but rather a process of construction or reconstruction. ⁶ The flipped classroom combines various instructional methods, allowing faculty to be more strategic in course design and to engage students at multiple levels of Bloom's taxonomy. It has demonstrated potential to enhance active learning, critical thinking, and student engagement. While it is a well-established instructional method, it remains less widely adopted in medical education. ⁷ The flipped classroom modifies standard classroom activities and assignments, allowing students to study and watch policy-related films before class and participate in active learning tactics such as interactive discussions and case studies. ⁸ Research on flipped classrooms’ impact on student learning is limited, but indirect surveys show increased student–teacher interactions, real-time feedback, and higher engagement in allied healthcare fields such as medicine, nursing, and pharmacy. This strategy, which communicates with pupils using technology, has shown promise for improving educational results. ⁹ Pluta et al highlighted the growing adoption of collaborative learning methods, citing a rise in team competency development and digital media availability. However, persistent challenges include reliance on comparative-effectiveness research and lack of guidelines for adapting methods to specific contexts. The medical education community has struggled to consistently achieve superior outcomes using collaborative learning methods. ¹⁰

In a graduate-level nurse practitioner program, faculty predesignated a pediatric nursing course using a flipped classroom approach, including weekly out-of-class videos and preclass modules. Graduate nursing students reported satisfaction with the active learning methods. Pharmacy instructors rebuilt a basic course utilizing a flipped classroom method, replacing lectures with online videos, and using active learning tactics such as pair-and-share exercises, presentations, debates, and quizzes to help students comprehend Bloom's taxonomy. ¹⁰

A study at one university found that students in flipped classes reported more active interaction and learning from professors, resulting in a shift from large lecture-style to small-group, case-based lectures. ¹¹ Pierce and Fox have utilized a flipped classroom for a renal pharmacotherapy course module, providing video podcasts of lectures and allowing students to apply knowledge through interactive patient case scenarios. The students scored higher and showed positive attitudes toward active learning practices, highlighting the unique approach to teaching in this field. ¹²

Our study aims to demonstrate the implementation of the flipped classroom and analyze students’ reactions to it in 2 undergraduate nutrition courses. It aims to demonstrate its potential to directly impact student learning through learner-centered instruction.

Methods

A quasi-experimental study was conducted according to TREND reporting Guidelines (https://www.equator-network.org/) ¹³ in collaboration with different departments of the university from January to April 2023 after the ethical approval from the Ethical Board of the University of Lahore (IRB-UOL-FAHS/1716-II/2022). A total of 60 medical students were enrolled in the study by using a convenience sampling technique. Cochran formula is used to calculate sample size by taking the margin of error (e) 0.05, an estimated proportion of the population (p) 0.5, a population of 150, and Z (a/2) score from the Z table at 90% confidence interval which was 1.96. The final sample size, based on a limited population was calculated to be 60 participants. All participants were enrolled in accredited medical programs such as MBBS, MD, or equivalent, ensuring a focus on medical education. Participants were from different years of the medical program and were proficient in the language of instruction (eg, English), which was essential for engaging with the flipped classroom activities. Students who had previous experience with the flipped classroom method, as well as nonmedical students and individuals unwilling to participate, were excluded from the study.

The written and informed consent were taken from participants and the students were informed about the study's purpose, which involved quantitative surveys administered to students before and after the teaching session.

Teaching methods

The research methods course typically carries 2 credit hours. This course generally offers an introduction to essential aspects of medical research, including fundamental research designs, data analysis methods, and literature review techniques. It is vital for developing students’ abilities to critically assess scientific literature, interpret research findings, and apply evidence-based practices in their future medical professions.

The teaching materials for the flipped classroom were collaboratively developed by the faculty responsible for the course. This included creating the lesson plan, coursework, learning task list, clinical cases, discussion topics, group report themes, and group work assignments and compiling extensive learning resources. The offline face-to-face flipped classroom fostered collaboration, critical thinking, and skill development, including teamwork, communication, and accountability. Using a flipped classroom strategy, equipped students with lifelong learning competencies and prepared them for professional challenges. ¹⁴

This intervention utilized a flipped classroom model where students were required to engage in preparatory activities before class, such as watching prerecorded lectures, completing assigned readings, or engaging with interactive videos. These preclass activities provided foundational knowledge, enabling class time to focus on active learning strategies, including discussions, problem-solving exercises, and collaborative projects. This design shifted the traditional learning dynamic, emphasizing student responsibility for initial content acquisition and fostering deeper engagement during in-class activities. By moving away from passive in-class lectures to active, student-centered learning, this model exemplifies the defining characteristics of the flipped classroom approach. The education program was implemented over 16 weeks. The study participants attended 5 sessions. The duration of each session ranged between 30 and 45 min. At the beginning of each session researcher starts by giving a summary of the previous session and explaining “the new objective.” Different strategies were used including brainstorming, instructions, lectures, role-play, and group discussions. Students completed group work together but undertook individual tasks separately. They discussed cases and questions provided by the teacher, with a representative from each subgroup summarizing their findings while others contributed additional answers. The teacher reviewed and commented on these summaries, guiding the discussion. Individual skills were demonstrated, and controversial topics were debated.

Tools and questionnaire

The researchers developed a 16-item questionnaire based on relevant literature and previous studies to assess the students’ perceptions of the flipped classroom.^15–17 For the evaluation and impact of the flipped classroom, a predefined questionnaire was used to assess 5 key outcomes: (1) Motivation (3 questions), (2) Critical Thinking (3 questions), (3) Student-centered learning (3 questions), (4) Learning benefits (3 questions), and (5) Peer-Assisted Learning (4 questions). Before distributing the questionnaire, the researchers explained the concept of the flipped classroom to the study participants. The questionnaire employed a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree). A numerical value ranging from 1 for strongly disagree to 5 for strongly agree was used. The total score ranges from 1 to 80. The total score was calculated by summing up all categories. The highest score shows more support for a flipped classroom, and the lowest score shows insufficient support.

Postsurvey assessment

All study materials were recorded and accessible to course instructors. Teachers have engaged in communication and discussion and addressed challenging questions, while also issuing evaluation questionnaires to students. After 4-month of intervention, posttest data were collected through the same instrument. Students took a 20-question online quiz before and after the flipped classroom to gauge their understanding, with teachers providing explanations based on quiz results.

Statistical analysis

Data were collected at 2 distinct time points—before and after the survey—to assess changes resulting from the flipped classroom approach. Basic demographic information, including age, gender, and year of education, was recorded for all participants. The data were then entered and analyzed using SPSS 25.0. To evaluate the effectiveness of the flipped classroom on students’ learning outcomes, a paired sample t test was conducted to compare the mean differences in class test scores before and after the intervention. Additionally, the scores from the questionnaire assessing the impact of the flipped classroom were compared. Data were stratified according to gender and year of education. Post-stratification independent sample t test for gender-based comparison and one-way ANOVA for years of education were applied. A P-value of less than .05 was considered statistically significant.

Results

A total of 60 medical students were enrolled in the study. The study sample had a mean age of 22.72 years with a standard deviation of 2.713 years, indicating some variability in the age of the participants. The gender distribution showed that 41.7% of the participants were male (n = 25), while 58.3% were female (n = 35). In terms of year of education, participants were evenly distributed across the different years of study: 26.7% were in their first year (n = 16), 18.3% in their second year (n = 11), 13.3% in their third year (n = 8), 23.3% in their fourth year (n = 14), and 18.3% in their fifth year (n = 14) (Tables 1 and 2). The results showed that student performance improved significantly after the introduction of the flipped classroom approach. The average test score increased from 13.25 ± 2.36 before the intervention to 16.08 ± 1.5 afterward (P < .05). The student's perception of the flipped Classroom, which is reflected in the results of the impact scale, also improved significantly (P < .05). The mean score increased from 41.91 ± 4.9 before the intervention to 69.71 ± 9.72 after the intervention. These results indicated that the flipped classroom approach not only improved the students’ test scores but also positively influenced their perception of the learning method (Table 3).

Table 1.

Mean age of participants.

VARIABLES	MEAN ± SD
aAge	22.72 ± 2.713

^a Age is presented by Mean ± SD.

Table 2.

Gender and educational status of participants.

	FREQUENCY (F)	PERCENTAGES (%)
aGender
Male	25	41.7%
Female	35	58.3%
bYear of education
First year	16	26.7%
Second year	11	18.3%
Third year	8	13.3%
Fourth year	14	23.3%
Fifth year	11	18.3%

^a Gender and ^byear of education were presented by Frequency (f) and Percentages (%).

Table 3.

Comparison of pre and postintervention class test scores and impact of flipped classroom scale score.

TEST SCORE	MEAN ± SD	P VALUE
aPre and Post intervention class test scores
Preintervention	13.25 ± 2.36	<.05b
Postintervention	16.08 ± 1.5
aImpact of Flipped classroom Scale Score
Preintervention	41.91 ± 4.9	<.05b
Postintervention	69.71 ± 9.72

Abbreviation: SD, standard deviation.

^a Results from paired sample t test.

^b P value <.05, significant.

In Figure 1, the bar chart illustrates the significant impact of the flipped classroom approach on various aspects of student learning, including motivation, student-centered learning, learning benefits, peer learning, and critical thinking (Figure 1). Each of these areas showed a significant increase in mean scores from preintervention to postintervention. For example, the score for motivation increased from about 7 to 12, while the score for student-centered learning also increased from about 7 to 12. Learning benefits improved significantly from around 8 to 15, and both peer-assisted learning and critical thinking increased from 9 and 8 to 15, respectively. These increases are statistically significant (P < .05), suggesting that the flipped classroom approach successfully improved students’ motivation, engagement, collaborative learning, and critical thinking skills (Figure 1).

Figure 1.

Impact of flipped classroom on student engagement.

The stratification of the impact of the flipped classroom on student engagement scores by year of education showed interesting patterns before and after the intervention. Before the intervention, the engagement scores were relatively similar across different years, with first-year students having a mean score of 42.75 ± 3.51 and fifth-year students scoring 42.0 ± 3.3. The third-year students had the lowest mean score at 39.6 ± 2.7. The overall mean engagement score across all years was 41.9 ± 4.9, with no statistically significant differences between the years (P = .710). After the flip was implemented, there was an increase in engagement scores across all years. The second-year and fifth-year students showed the highest gains, with mean scores of 72.7 ± 9.1 and 72.636 ± 9.284, respectively. The first-year students scored 66.4 ± 9.1, and the third-year students scored 68.8 ± 11.1. Although the overall mean score increased significantly after the intervention, the differences between the years remained statistically insignificant (P = .422). This suggests that the flipped approach effectively boosted student engagement across all academic years, with similar levels of improvement regardless of the year of study (Table 4).

Table 4.

Stratification of impact of flipped classroom on student engagement scale score according to gender and year of education.

	MEAN	95% CONFIDENCE INTERVAL FOR MEAN		P VALUE
		LOWER BOUND	UPPER BOUND
Preflipped Classroom Scale Score
First year	42.75 ± 3.51	40.8786	44.6214	.710 a
Second year	41.81 ± 7.44	36.8195	46.8169
Third year	39.6 ± 2.7	37.3057	41.9443
Fourth year	42.2 ± 6.2	38.6592	45.9122
Fifth year	42.0 ± 3.3	39.7517	44.2483
Total	41.9 ± 4.9	40.6261	43.2072
Post Impact of Flipped classroom Scale Score
First year	66.4 ± 9.1	61.5616	71.3134	.422 a
Second year	72.7 ± 9.1	66.5694	78.8852
Third year	68.8 ± 11.1	59.3278	78.4222
Fourth year	69.28 ± 10.14	63.4306	75.1408
Fifth year	72.636 ± 9.284	66.3970	78.8757

^a Results from one-way ANOVA.

The analysis of the flipped Classroom's effect on student engagement by gender reveals some differences in scores before and after the intervention. Initially, male students had a slightly higher mean engagement score (42.3 ± 4.18) compared to female students (41.6 ± 5.54). After the intervention, engagement scores increased significantly for both groups, with male students’ scores rising to 72.28 ± 8.7 and female students’ scores increasing to 67.8 ± 10.08. However, the differences in engagement scores between males and females were not statistically significant, either before the intervention (P = 0.56) or after (P = .084). This indicates that the flipped approach effectively boosted engagement for both male and female students, with no significant difference in the degree of improvement between the genders (Table 5).

Table 5.

Stratification of impact of flipped classroom on student engagement scale score according to gender.

GENDER	PREINTERVENTION	POSTINTERVENTION
Male	42.3 ± 4.18	72.28 ± 8.7
Female	41.6 ± 5.54	67.8 ± 10.08
P value	.56 a	.084 a

^a P value <.05, significant.

Discussion

Over the past decade, flipped Classrooms have emerged as a popular teaching method designed to boost students’ critical thinking, active learning, and motivation. This approach replaces traditional lectures with online resources that students engage with outside of class, while in-class time focuses on collaborative problem-solving and discussion. ¹⁸ Research indicates that teachers generally receive the flipped model positively, recognizing its potential to foster student-centered learning. ¹⁹ Despite some challenges, rare literature has demonstrated its effectiveness, with students reporting higher engagement and improved academic performance. Educators have observed that the flipped enhances student participation and active learning, resulting in better educational outcomes.^20,21

In this study, it is reported that the introduction of the flipped approach led to a significant improvement in student performance, with average test scores rising from 13.25 ± 2.36 to 16.08 ± 1.5 (P < .05). Students’ perceptions of the flipped classroom also improved, with the impact scale score increasing from 41.91 ± 4.9 to 69.71 ± 9.72 (P < .05). These findings suggest that the flipped classroom approach enhanced both test scores and student satisfaction. It also indicates that the student's class performance was improved after the intervention. These findings were consistent with the previous studies have found that the flipped classroom approach creates a more interactive and engaging learning environment by moving passive lecture content outside of class and focusing on active learning during class time. This shift allows students to engage in collaborative problem-solving and discussions, leading to better preparation and a deeper understanding of the material. Consequently, students often achieve higher academic performance. The improvements in motivation, student-centered learning, and critical thinking observed in our study further support these findings, indicating that the flipped classroom effectively enhances both test scores and overall learning outcomes.^22–24 However, another study reported that the self-regulated learning strategies positively impacted the development of foreign language skills in the flipped classroom model. The group using a platform with these strategies performed significantly better in speaking, reading, writing, and grammar tests. However, there was no significant difference in listening test scores. ²⁵

In our study, participants showed significant improvements in self-directed learning abilities, problem-solving, and critical thinking skills after engaging in the flipped classroom approach. Scores for motivation, student-centered learning, learning benefits, peer-assisted learning, and critical thinking all increased notably from preintervention to postintervention. These changes indicate that the flipped classroom effectively boosted student motivation, engagement, collaboration, and critical thinking skills aligning with previous research. ²⁶ The current study demonstrates that the flipped classroom approach significantly enhanced student motivation, engagement, collaborative learning, and critical thinking skills. However, the literature supports our results and indicates that these improvements can be attributed to the flipped classroom's emphasis on active, learner-centered activities, which encourage students to take greater responsibility for their learning, solve problems independently, and develop critical thinking skills.^27,28 The current study reported significant improvements in learning benefits, peer-assisted learning, and critical thinking following the intervention. Peer-assisted learning scores improved notably, reflecting the positive impact of collaborative activities where students supported each other's understanding and learning processes. These findings align with another study that reported the flipped classroom model improved grades and increased engagement with both teachers and peers. Enhanced interactions during interactive class activities were crucial in fostering problem-solving and critical analysis skills, contributing to a more effective and enriching overall learning experience.^14,29

This study offered several advantages. Firstly, we developed a range of problem-solving tasks that required teamwork, embedding learning objectives into these activities. This approach ensured that students were more engaged and better prepared for unfamiliar discussions as they tackled new tasks actively. Secondly, many flipped Classrooms only partially flipped class hours, which often failed to fully cultivate students’ analytical and critical thinking skills. In contrast, our study implemented a more extensive flipping strategy, providing ample opportunities for students to develop these higher-order skills, leading to improved performance and engagement. Data saturation was not reached, suggesting that further data collection could reveal additional insights. The study was conducted at a single institution with a small sample size, which limits generalizability to other settings or larger populations. Furthermore, the inclusion of only MBBS and MD students restricts the applicability of the findings to other student groups. Future research with larger, multicenter samples and a broader participant base is recommended to improve generalizability and provide a deeper understanding of the flipped classroom model's effectiveness. The study does not provide a comprehensive understanding of the effectiveness of problem-solving tasks and teamwork in various educational settings, does not assess the long-term impact of the extensive flipping strategy on students’ retention and application of critical thinking skills, and may not capture the full range of skills required for analytical and critical thinking. The absence of a control/comparison group to see the impact of the flipped classroom model compared to how learning would improve in the traditional model for this content.

Conclusion

Our findings demonstrate that the flipped classroom model significantly enhances student learning outcomes. By incorporating diverse problem-solving tasks that require teamwork and active engagement, students showed notable improvements in their grades, critical thinking, and problem-solving skills. The comprehensive flipping approach we utilized facilitated greater interaction, which proved crucial for developing higher-order thinking skills. Compared to partial flipping models, our method better prepared students for complex discussions and real-world challenges. Overall, the flipped classroom approach not only fostered improved academic performance but also contributed to a more engaging and effective learning experience.

Data Availability

The datasets generated for this study are available in the attachment.