The effects of flipped classroom and jigsaw teaching strategies on learning, retention of course content, and satisfaction among nursing students: a quasi-experimental study | BMC Medical Education

Design and participants

A quasi-experimental, posttest design study was conducted on 111 nursing students that enrolled in the medical-surgical nursing-1 (gastroenterology) course from January 2023 to November 2024 at the School of Nursing and Midwifery affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. A census sampling method was employed for participant selection. To control for any bias arising from data contamination, this study contacted on the three distinct academic semester.

Three groups—FC and jigsaw, which were the experimental groups, and the LBT group as the control group—were assessed over a period of 10 weeks. Each group, in three academic semesters, was randomly allocated to one of three different teaching approaches—FC (n = 35), jigsaw (n = 43), or LBT (n = 34). Following this assignment, all students enrolled in their respective semesters were included in the study via census sampling [26].

The inclusion criteria included willingness to participate in the study, enrollment in the medical-surgical nursing 1 course, and having a smartphone. The exclusion criteria included missing more than one session and not participating in exams.

Instruments

The demographic data collection form contained information on age, gender and previous semester grade point average (GPA).

To assess the students’ learning and retention of the course content in the three groups, the research team developed a 20-item multiple-choice question (MCQ) test. The post-test’s total scores ranged from 0 to 20. The items were chosen from the question bank of the relevant professor, who was also the project administrator. These 20-item MCQ test had been used in previous semesters and had acceptable difficulty and discrimination indices [27].

The reliability and validity of the exam was also confirmed in the present study. The reliability of the test was determent via the Kuder‒Richardson method (KR-20). KR was 0.81, 0.88 and 0.84 for the FC, jigsaw and LBT, respectively, indicating favorable the item consistency. Moreover, to measure the content validity index (CVI), six medical-surgical nursing professors assessed the relevance of each item, using a four-point rating scale from 1 (not relevant, ) to 4 (very relevant.). The results confirmed its content validity (CVI = 0.87) [28].

To measure students’ satisfaction in the experimental groups, a self-designed 12-item questionnaire was used. This tool was developed on the basis of a literature review and the opinions of the research team. The items were based on a 5-point Likert scale (ranging from strongly agree to strongly disagree). Using this questionnaire, the average score was calculated. The quantitative content validity of the questionnaire was calculated via Content Validity Index (CVI). To measure the CVI, 10 experts assessed the relevance of each item, using a four-point rating scale from 1 (not relevant, ) to 4 (very relevant.). The CVI was 82. A CVI value 0.78 or above were considered as adequate [28]. The reliability of the scale was examined via the internal consistency method. The Cronbach’s alpha coefficient for the entire scale was 0.93, indicating the desired reliability of the tool. The students’ satisfaction questionnaire had acceptable validity and reliability (Supplemental File 1).

Ethical considerations

This study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.NUMIMG.REC.1402.097). The study’s objectives were explained to the participants, and a consent form was obtained. The participants were assured of the anonymity and confidentiality of their information. All data, including the satisfaction questionnaire and test results, were provided to the researcher in a coded format. Only the course administrator had access to the students’ names and identification numbers.

Flipped classroom design

In the FC approach, electronic educational content for each session was prepared via PowerPoint and Camtasia software and uploaded to the Learning Management System (LMS), “Navid System,” one week before the class. After the content was uploaded, a daily reminder message was sent to the participants’ mobile phones to encourage them to study it. At the start of each class, participants completed a brief pretest consisting of 5-MCQs to determine if they have studied the content. They were given five minutes to do the pretest. Subsequently, the researcher called for volunteers to clarify the correct answers. In the absence of volunteers, the researcher explained them. Then, a PowerPoint presentation with five case-based questions was displayed on the monitor, and printed scenarios were distributed among the participants. The groups had 15 min to discuss and answer the scenarios. The researcher reviewed the group responses and answered any remaining questions. In the final stage, participants were instructed to compose two questions related to the session’s topic matter and share them with a peer. After that, they got 10 min to react to and discuss each other’s questions. The session ended with a summary of the material provided by the researcher.

Jigsaw design

In the jigsaw group, the students were randomly divided into six-person home groups via a simple random method. Each group was assigned a nickname, and a leader was determined for each group. The members of each group were identified by numbers 1 to 6. The educational booklet, which was divided into six sections, was distributed in hard copies. Each section was assigned to group members in numerical order. The participants could access educational images and videos related to each topic by scanning QR codes. In this method, each participant was initially given 10 min to study the assigned content. The participants with similar content from all groups were then regrouped into new specialized groups, where each member had the same content. These groups also had 10 min to discuss, exchange ideas, and resolve any ambiguities and possible problems. At this stage, the researcher, as a supervisor, addressed the participants’ questions and provided support. Then they returned to their original home group, where the group leader managed the session. Each participant had 5 min to explain their assigned content to the other group members. Finally, the researcher provided a summary of the educational content to ensure that all the participants understood the course content comprehensively.

Control group

In the control group, the educational content was presented through the LBT method, using PowerPoint slides during the class sessions.

All three teaching methods were performed separately over four sessions. The content, resources (textbooks), instructor, and test methods were consistent across all the groups. At the end of fourth and final session, participants completed a 20-item MCQ test to evaluate learning (post-test), and then responded to a satisfaction questionnaire. Six weeks after the last session, the same MCQ was re-administered unexpectedly to measure retention of course content. However, they were assured that the test score would not affect their final grade. A summary of the study illustrates in Fig. 1.

Data analysis

Data analysis was performed using SPSS (version 20). Learning and course content retention scores were compared between groups using ANOVA, followed by Bonferroni post hoc tests for pairwise comparisons of learning scores. Age differences among the three groups were assessed using the Kruskal-Wallis test, while satisfaction scores were compared between the two groups using the Mann-Whitney U test and gender distribution across the groups was analyzed with the chi-square test. A p-value of ≤ 0.05 was considered statistically significant.