Effectiveness of flipped classrooms in Chinese baccalaureate nursing education: A meta-analysis of randomized controlled trials

Background: In recent years, the flipped classroom approach has been broadly applied to nursing courses in China. However, a systematic and quantitative assessment of the outcomes of this approach has not been conducted.

Objective: The purpose of the meta-analysis is to evaluate the effectiveness of the flipped classroom pedagogy in Chinese baccalaureate nursing education.

Design: Meta-analysis of randomized controlled studies.

Data source: All randomized controlled trials relevant to the use of flipped classrooms in Chinese nursing education were retrieved from the following databases from their date of inception through September 23, 2017: PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, the China National Knowledge Infrastructure, the Wanfang Database, and the Chinese Scientific Journals Database. Search terms including "flipp*", "inverted", "classroom", and "nurs*" were used to identify potential studies. We also manually searched the reference lists of the retrieved articles to identify potentially relevant studies.

Review methods: Two reviewers independently assessed the eligibility of each study and extracted the data. The Cochrane risk-of-bias tool was used to evaluate the quality of the studies. RevMan (Version 5.3) was used to analyze the data. Theoretical knowledge scores and skill scores (continuous data) were synthesized using the standardized mean difference (SMD) and 95% confidence interval (CI). The statistical heterogeneity of the included studies was analyzed by calculating the I² statistic and applying a chi-square test. Publication bias was assessed by funnel plots. The quality of the combined results was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system.

Results: Eleven randomized controlled trials published between 2015 and 2017 were selected. All the included studies had a moderate possibility of bias due to low methodological quality. The meta-analysis indicated that the theoretical knowledge scores and skill scores were significantly higher in the flipped classroom group than in the traditional lectures group (SMD=1.06, 95% CI: 0.70-1.41, P <0.001, and SMD=1.40, 95% CI: 0.46-2.34, P <0.001). There was no significant publication bias indicated in the primary analysis. Sensitivity analysis showed that the results of our meta-analysis were reliable. The evidence grades of the results regarding the theoretical knowledge and skill scores were low and very low, respectively.

Conclusion: Flipped classroom pedagogy is more effective than traditional lectures at improving students' theoretical knowledge and skill scores. Given the limitations of the included studies, more robust randomized controlled trials are warranted in a variety of educational settings to confirm our findings.