Kenwright D, Osborne E, Dai W, Grainger R

MedEdPublish
https://doi.org/10.15694/mep.2016.000080

Research article Open Access

Drivers of openness to online and flipped learning in

medical education
Diane Kenwright[1], Emma Osborne[2], Wei Dai[3], Rebecca
Grainger[4]

Corresponding author: Dr Diane Kenwright diane.kenwright@otago.ac.nz

Institution: 1. University of Otago Wellington, 2. University of Otago Wellington, 3. University of Otago
Wellington, 4. University of Otago Wellington
Categories: Medical Education (General), Research in Medical Education, Teaching and Learning

Received: 05/09/2016
Published: 09/09/2016

Abstract

One online teaching approach that has gained popularity in health science education is the ‘flipped classroom’ where
students undertake content learning prior to face-to-face class time, often via watching pre-recorded videos. This
frees up contact time for activities which stimulate higher-order thinking. While previous studies have generally
reported neutral to positive student feedback and effects on academic attainment, the quality of pre-class resources
and time required for pre-class work have been identified as potential problems with the approach. A further issue
identified in the literature is students’ openness to adopting new forms of learning.

This paper examines students’ responses to the flipped classroom in two undergraduate medical education courses, in
which students were assigned pre-work comprising a mix of short video lectures and brief online activities.
Following the unanticipated finding that students in the fourth and fifth year courses formed very different views of a
similar flipped learning intervention, this study explored:

• How do students use online pre-class resources in a flipped classroom?

• What factors influence students’ openness to using online resources in a flipped classroom?

This study used a course evaluation survey followed by focus group interviews to understand students’ use of and
attitudes towards the flipped classroom.

Many students in groups reversed or wanted to reverse the intended ‘flipped’ order of classes to use the online
material as revision aids rather than as pre-class work. Students in both groups identified that time pressure
influenced the way they used the pre-class material. The fifth year cohort held a largely positive attitude towards the
flipped classroom whereas the fourth year group held a largely negative view. Differences students’ willingness to
tolerate uncertainty, connections with clinical learning and metacognitive view of ‘learning’ itself appear to account

Page | 1
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

for this difference in outcome.

Keywords: , The flipped classroom, motivation, Learning strategies, Maturity

Introduction

Flipped learning inverts the traditional pattern of lectures delivered by experts followed by independent study after
class by moving didactic lecture content before class and using contact time with instructors for students to clarify
and apply the material they have learned before class (Abeysekera & Dawson, 2015; Kurup & Hersey, 2013; Little,
2015; O'Flaherty & Phillips, 2015). Pre-class work engages students largely in passive, lower-order thinking through
watching video lectures (Abeysekera & Dawson, 2015; Khanova, Roth, Rodgers, & McLaughlin, 2015; Kurup &
Hersey, 2013; Morgan et al., 2015; O'Flaherty & Phillips, 2015; Tune, Sturek, & Basile, 2013) but may include brief
activities such as low stakes assessment (Gilboy, Heinerichs, & Pazzaglia, 2015). Face-to-face teaching time focuses
on active learning to engage students in higher order thinking, with the guidance of teaching staff (Kurup & Hersey,
2013). Pedagogically, the flipped classroom is well-placed to realise the constructivist principles of designing
learning with a focus on engaging all students in activities that "what the student does" by actively processing and
restructuring knowledge (Austin, Sharma, Moore, & Newell, 2013), scaffolded engagement with increasingly
complex material (King, 1993) and allowing the learner to learn at their own pace (Abeysekera & Dawson, 2015).
Furthermore, good flipped classroom design combats the drop in attention that students typically experience in
lectures (Risko, Anderson, Sarwal, Engelhardt, & Kingstone, 2012; Young, Robinson, & Alberts, 2009), by using a
combination of shorter pre-class tasks (Morgan et al., 2015) and in-class activities which require a higher level of
student participation (Khanova et al., 2015; Kurup & Hersey, 2013; Moffett, 2015).

Previous experiments with the flipped classroom have shown neutral (Geist, Larimore, Rawiszer, & Al Sager, 2015;
Harrington, Vanden Bosch, Schoofs, Beel-Bates, & Anderson, 2015; Liebert, Lin, Mazer, Bereknyei, & Lau, 2016;
Morgan et al., 2015) to positive (Street, Gilliland, McNeil, & Royal, 2014; Tune et al., 2013) impact on students’
performance in assessment. In trials of a flipped classroom compared to a traditional lecture-based class student
satisfaction has been found to increase (Bhuasiri, Xaymoungkhoun, Zo, Rho, & Ciganek, 2012; Gilboy et al., 2015;
Simpson & Richards, 2015; Street et al., 2014; Tan, Brainard, & Larkin, 2015). Students responded positively to
increased availability of teaching staff for discussion-based teaching (Gilboy et al., 2015; Morgan et al., 2015) and to
having lecture material in a reusable format (MacDonald-Hill & Warren-Forward, 2015; Tan et al., 2015). However,
difficulties identified by students included increased pre-class workload (Khanova et al., 2015; Tan et al., 2015;
White et al., 2015), lack of access to guidance from teaching staff in the pre-class phase (Gilboy et al., 2015) and
variable quality of flipped classroom resources (Khanova et al., 2015). Staff also identified initial student resistance
to the change from a traditional approach to the flipped classroom (Simpson & Richards, 2015; White et al., 2015;
Youngkin, 2014).

In the context of pathology teaching, online learning can give students greater control over the way they view
specimens (Ruiz, Cook, & Levinson, 2009) and expose students to a wider range of cases than they may encounter
during clinical placements. Online resources provide a practical solution to managing increasing student numbers
and limited access to older, deteriorating pathological specimens (Giroud et al., 2012). These considerations are
especially relevant where a university is training more students in the same physical space.

Page | 2
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

Methods

Course design

A flipped classroom approach was implemented in two courses at the University of Otago, Wellington. The first was
a year-long fourth year pathology course, in which the flipped classroom was used to teach four of seven modules in
anatomic pathology. The second was a fifth year Obstetrics and Gynaecology run, where the flipped classroom was
used to teach the pathology of Obstetrics and Gynaecology concurrently with clinical placements over five weeks.

This project used the kuraCloud platform (KuraCloud Ltd, 2014) to deliver flipped pre-class work consisting of:
short video segments delivered either by the instructor (DK) or sourced from other pre-existing pathology education
videos; written summaries of conditions with links to external sites giving more information about diseases and
disease processes; and exercises (labelling slides and images, and short answer questions). Feedback on these
exercises via automated answers was integrated to overcome the lack of access to guidance in the e-learning
modules. In both courses, the same instructor (DK) oriented students to the role of the flipped classroom and
delivered the face-to-face components of the flipped teaching sessions.

Evaluation

Fourth year students completed an evaluation of the flipped classroom immediately after the final anatomic
pathology class for the semester. These data indicated students were dissatisfied and disengaged with the flipped
classroom. This was at odds with anecdotal reports from the fifth year group, who reported a high level of
satisfaction with this approach. Therefore, the study was expanded to investigate the different responses of two
cohorts of students who had received a similar form of teaching.

Quantitative survey evaluation of the flipped classroom included questions on students’ self-efficacy, taken from the
Motivated Strategies for Learning Questionnaire (Pintrich, Smith, Garcia, & McKeachie, 1993), perceived
usefulness, satisfaction with instruction and ease-of-use. These variables were measured on a seven-point Likert-
style scale. All quantitative data analysis was conducted in SPSS 22. Since survey data were ordinal variables,
nonparametric tests were used. The Mann-Whitney U test was used to compare metacognition, meta-cognitive self-
regulation, perceived usefulness of the flipped classroom, perceived ease to use of the kuraCloud and perceived
satisfaction with the interaction with the instructors between fourth and fifth year students.

The qualitative component of the survey included questions on the way students used specific components of the
pre-work, questions about students’ study routines and free text questions on students’ overall experience of the
flipped classroom.

Focus group questions were developed based on an inductive thematic analysis of the responses to this survey in
order to understand the gaps between the aims of the flipped classroom and students’ experience of it (see Results
section). The focus group interviews were audio-recorded and transcribed then analysed thematically first using open
coding, then sorting these codes into themes, beginning with the themes developed from analysing the surveys
(Braun & Clarke, 2006; Burnard, Gill, Stewart, Treasure, & Chadwick, 2008).

This paper covers the aspects of the evaluation that pertained to students’ use of the online resources and their study
habits. It excludes data from the evaluation on the face-to-face teaching component in order to focus specifically on
students’ usage of the online materials. A broader report of the complete flipped classroom trial is available in our
forthcoming paper (Kenwright et al., Forthcoming).

Page | 3
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

Participants

Eighty-one fourth year students (81/95, 85.3%) and 43 fifth year students completed the post-course evaluation
survey. The fourth year students completed the evaluation immediately following their final flipped class. The fifth
year group were subsequently invited to complete the evaluation, which for some students fell immediately after
their participation in the flipped classroom and for some students occurred some months after the completion of
their Obstetrics and Gynaecology run. Six fourth year students and four fifth year students participated in two
separated focus groups. Participants gave their informed consent to participate in the survey evaluations and focus
groups.

Results

Quantitative survey results

The fifth year students held a markedly more positive view of the flipped classroom overall, despite the design for
both courses being very similar in content type and organisation. Survey results indicated that fifth year students (M=
5.25, SD = 0.81) perceived the flipped classroom as more useful than fourth year students (M= 3.11, SD = 1.22), U=
7.363, p < 0.01. Fifth year students (M=5.37, SD = 1.06) were also more satisfied with the interaction with
instructors compared with fourth year students (M= 3.32, SD= 1.33), U = 6.47, p <0.01. Fifth year students (M =
5.85, SD = 0.74) also perceived kuraCloud as easier to use compared with fourth year students (M= 3.89, SD=
1.24), U= 7.43, p <0.01. Fifth year students (M = 4.55, SD = 1.03) reported a higher level of self-efficacy compared
with fourth year students (M= 3.9, SD = 1.17), U= 2.811, p =0.005.

Qualitative survey results

Themes arising from the open questions in the survey administered to the fourth year cohort were used to inform the
development of the focus group questions. These results are briefly summarised below.

Page | 4
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

Focus groups

Both groups identified that busy schedules limited time for study and led to a preference for a single source of
content knowledge. Both groups also found the online material useful for revision when they ‘un-flipped’ the

Page | 5
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

intended order of the course.

Areas of difference between the two groups were in the groups’ willingness to tolerate uncertainty in using a new
mode of delivery, their concept of learning and the way they perceived the integration between the flipped classroom
and their clinical learning. These factors appear to have contributed to the overall negative view of the online content
in the fourth year group and positive view in the fifth, as reflected in the whole-class evaluation surveys.

Time constraints

All students reported that having limited time meant that their study was less comprehensive than what they saw as
ideal. The students in both groups stated that they began the semester making use of a wider range of resources
(lectures, summaries, text books and kuraCloud modules) than what they continued with. In order to manage the
lack of time, students prioritised what they saw as both the most urgent and the most important course content to
study, and used resources they considered an efficient means of studying.

We’re all at the mercy of our runs. (4th year)

Stuff gets pushed to the last week and you’re like, oh this would have been good to know earlier in the run. (5th year)

Prioritising urgent material meant studying material that was likely to be relevant to clinical placement and studying
just before tests. The fourth year students found online learning time-consuming. They estimated that online
learning sessions took them more than the suggested hour to complete. The time commitment required for flipped
pre-work was a deterrent, especially when they were directed to external websites. In contrast, the 5th fifth year
students all reported that they completed the online modules in about half an hour. This suited them well because it
was easy to fit around other commitments and was a manageable length of time to maintain concentration.

Sources of information

Students in both year groups preferred to use only one source of information as their primary study resource because
of their high workload and limited study time. They wanted to study from material that was easy to navigate,
consistently organised across topics and facilitated memorisation. In their own study and when selecting reference
aids, they used resources that they had identified themselves or had recommended to them by other students.

You hear from other students and junior doctors. If it works for you go for it but there’s other resources that people use.
(5th year)

While students selected and evaluated ‘staple’ sources of information, they did not want to engage in searching and
evaluating multiple sources:

Multiple sources are distracting (4th year)

Just pick one source and stick to it because there’s so much information (5th year).

They wanted resources that were aimed at medical students, and were unwilling to use information from consumer
information sites or aimed at medical specialists because this required the student to assess what was relevant to their
level of study. They also regarded video lectures delivered by teaching staff from the programme as more
authoritative and engaging than embedded video content from other universities.

Both groups regarded information that was already summarised and structured as an ideal study resource. They were

Page | 6
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

resistant to undertaking this synthesis themselves as part of the flipped classroom tasks:

Let’s throw you all this information and you can put it together. No, that’s inefficient. (4th year)

The fourth year group saw tasks which directed them outside the kuraCloud platform as a design failure rather than
seeing the task of synthesising and evaluating different sources as a component of learning.

Why can’t we use one website if it’s that good – why do we need multiple sources. (4th year)

Otherwise it’s like you go and look at ten websites and you don’t know which one is better. (4th year)

For example, fourth year students disliked tasks that required them to look at multiple sources of information about
the prevalence of diseases because they considered this should have a straightforward answer; minor differences
between sources was confusing. Looking at multiple sources took more time than the students were willing to spend
and ran counter to the fourth year students’ view that learning and applying content knowledge should be separate
tasks. They did however indicate greater willingness to consult multiple sources where they saw value in different
perspectives, such as looking at treatment options. Although the fifth year group were not perturbed by not knowing
enough to complete the activities, they were still disinclined to spend time searching for additional information.

Un-flipping

Students in both groups universally rejected the ‘flipped’ order in their weekly study routines. Students preferred to
use the intended pre-work after face-to-face teaching as a revision tool. Fourth year students reported completing
pre-reading for class using their textbook, or using videos of their own choosing but not using the flipped resources
because they found these too time-consuming. This group articulated a willingness to use the online modules as an
optional tool for revision but resented it being a compulsory part of the course. They saw themselves as experienced,
successful learners and wanted to be trusted to continue in their established study routines:

Yes, we should choose at this stage and know how we learn. We shouldn’t have to do kuraCloud if it’s not beneficial to
us (4th year).

While this group indicated that they had found the flipped classroom unhelpful during the semester, some
participants nonetheless indicated their intention to go back and redo the online modules for exam revision.
Likewise, although the fifth year students reported far more enthusiasm for the online content, they also completed
the activities after class or later in the course for revision.

Clinical focus

Students in both groups reported that they strove to learn pathology to become better clinicians. Thinking about what
they were likely to encounter in clinical situations influenced students’ view of what was useful learning. The fourth
year group had mixed views content that was less likely to arise in a clinical setting, as evidenced in their views of
histology:

Being able to recognise it [abnormalities on a slide] off your own bat without prompting is quite important. (4th year)

Knowing what a histology section looks like is not relevant for us yet. (4th year)

Whereas not seeing pathology in clinical situations diminished its importance for the fourth year focus group, the
fifth year students saw the online material as an opportunity to fill gaps in what they were exposed to in clinical

Page | 7
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

situations. The found learning pathology "the hardest because it’s not like you’ll see it" in clinical placement (5th year
student). For these students, online learning was a good means of applied learning in pathology and for learning
about conditions that were too rare to be able to count on seeing them on the ward.

Clinical is the best but obviously we have to learn about the rare stuff, which you can’t see so either questions [online
question bank] or kuraCloud is good. (5th year)

Learning versus applying

Students in the 4th year group conceptualised learning and applying knowledge as separate activities. They described
‘learning’ as acquiring new factual knowledge, distinct from applying this knowledge in flipped classroom activities
or quizzes:

Unanimously we do not use kuraCloud to learn. We use it to apply knowledge. That’s what it should be for. (4th year)

This perceived dichotomy was incompatible with the flipped pre-work in which students were expected to attempt
problems with a short introduction to the content and guidance on where to find additional information, rather than a
comprehensive lecture. These students experienced anxiety when they were required to apply knowledge before
feeling confident of knowing the correct answer:

I found that there were lots of incidences – and I emailed to say – this is the wrong way around. You made me try and
answer this question and then you told me how to answer it. (4th year)

I cut out the histology slides where you had to annotate because I didn’t feel I had enough information to do it correctly.
(4th year)

If I’m going to learn something, I like being taught what it is and then being tested – I don’t so much like the go away
and answer it for yourself because you can have it wrong. (4th year)

In contrast, in the fifth year group, students viewed learning through a mixture of content acquisition and problem-
solving much more positively:

I find applying it, I learn it better. (5th year)

Although they found the flipped classroom problems challenging, this challenge did not provoke the anxiety that it
did for the fourth year students.

Uncertainty and ambiguity

Students’ openness to uncertainty affected their perceptions of flipped learning. The constructivist course design
pushed students to problem-solve using the content that they had just learned. The fourth year group responded very
negatively to this approach, while the fifth year group responded positively. For the fourth year students, pathology
played a special role as the most structured part of their curriculum:

path[ology] has quite clear objectives about what they expect from your learning. In everything else half the time they
don’t even tell you what you’re meant to be learning. (4th year)

When faced with the "unstructured world of fourth year" (4th year), students wanted to retain a highly predictable
approach to studying pathology. Students explained that they used their pathology notes to arrange their learning

Page | 8
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

from other areas, for example adding in notes they had made in clinical placements into their pathology notes.

In contrast, the fifth year students were more open to learning through problem solving. Although both groups
reported feeling they sometimes lacked sufficient knowledge to complete the online problems, this knowledge gap
did not provoke anxiety for the fifth year students; they were willing to use workaround strategies, such as searching
for unfamiliar terms or returning to the problem later in the course. They framed the level of uncertainty that they
experienced in the flipped classroom as comparable to other components of the run as a whole:

I feel like O&G [obstetrics and gynaecology] is quite a different run – I feel like it’s the run where I have to teach
myself the most because it’s so out of order. (5th year)

Participants accordingly expressed confidence in their ability to manage unfamiliar material that they encountered in
the flipped classroom without immediate guidance from teaching staff:

It’s not really that new. We teach ourselves a lot. (5th year)

In addition, the groups benchmarked the relative level of uncertainty they encountered in the flipped classroom
differently. The fourth year group contrasted the flipped classroom against the more structured teaching in their
previous years. On the other hand, the fifth year group compared the flipped classroom favourably against seminar-
style classes in the rest of the run presented by either other students or specialists, which were less likely to be
organised well and pitched at their level.

It depends on who is presenting. Lots of them are student presenters and they haven’t really got their head round it. You
just have to go into it again. (5th year)

They go into quite a lot of detail. Like if they’re a specialist, that’s what they’ve been doing for 30 years. That’s why
Diane [flipped classroom instructor] is quite good – she does very much what you need to know. (5th year)

Discussion

Students in both year groups either un-flipped or wanted to un-flip by using the online modules as revision exercises
to consolidate their in-class learning or to revise for assessments. This student-led adaption of the course design
supports recommendations to limit to restrict pre-class work to material that draws on lower-order thinking (Kurup
& Hersey, 2013) and with the cognitive loading principle of gradually increasing the complexity of material that
students encounter (Abeysekera & Dawson, 2015; Van Merriënboer & Sweller, 2010). This study adds support to
the recommendations in the existing literature by providing an example of the way students respond to e-learning
which exceeds these recommended restrictions. Students’ concerns about the time pre-class work took and the
quality of the online resources are consistent with qualitative findings from other flipped classroom trials (Khanova
et al., 2015; White et al., 2015).

When presented with flipped learning, both groups of students identified similar challenges and used similar
strategies to manage those challenges. What differed was their emotional response to using these strategies. A
possible explanation for this difference is where in the medical degree structure the students encountered the flipped
classroom. Students begin clinical placements in fourth year, and these students used the flipped classroom in the
first half of this year. They expressed feeling overwhelmed by the less structured nature of learning on the ward, and
looked to pathology, which was taught in the classroom, to provide them with structured learning and a point of
continuity with their earlier study. The fifth year students in the focus group completed the flipped classroom in the

Page | 9
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

second half of the year while on the Obstetrics and Gynaecology rotation. These students expressed a much greater
degree of confidence in their ability to handle learning in an unstructured environment and learning without direct
instruction. These views expressed in the focus groups concord with the higher levels of self-efficacy reported by the
fifth year students. This aligns with research that suggests students’ tolerance for uncertainty in medical education
increases throughout their course of study (Hancock, Roberts, Monrouxe, & Mattick, 2015; Nevalainen, Mantyranta,
& Pitkala, 2010). These students’ greater exposure to less structured learning environments appears to have prepared
them to adjust to the unknowns undertaking pre-work without direct guidance of teaching staff.

Abeysekera and Dawson (2015) postulate that if flipped learning increases student motivation, it does so by
increasing students’ autonomy, competence and relatedness through way they learn, self-paced learning which allows
students to master content before continuing, and greater interaction with peers and instructors. Further, they argue
the self-paced nature of the flipped classroom may reduce cognitive load. This theoretical model would seem to be a
good fit for students’ experience of the flipped classroom in this trial. Students reported that they found flipped
learning demotivating when it was compulsory, suggesting a lack of autonomy, and when pre-class activities required
them to extend rather than consolidate their knowledge, suggesting that the flipped classroom did not enhance
students’ sense of competence in this situation. Conversely, students modifying the way they used the online modules
to suit their needs may have increased their sense of autonomy and competence and lowered cognitive demand on
students and thus had a positive effect on students’ motivation.

Limitations

This small-scale initial study was limited to two undergraduate medical courses at the same institution and therefore
the generalisability of these findings may be limited. Recruitment in the fifth year group was low for the survey and
some students completed the survey some time after participating in the flipped classroom, which may have affected
their recall of their experience. The numbers of students participating in focus groups was small and self-selected
and may not be representative of the entire student body, although the views expressed by students in the focus
groups did appear to align with the survey results from their respective year groups.

Conclusion

Students in this study preferred to un-flip their use of online resources. This study supports existing literature by
confirming that if a flipped approach is used, passive learning may be more suitable for pre-work and that there is
the risk of cognitive overload in active flipped learning activities. Alternatively, this study does provide support for
utilising active online learning in pathology teaching. It indicates the potential for online learning to meet a need for
revision resources and to fill in gaps in exposing students to problems they may not encounter clinically. The finding
that students in these two groups viewed a similar approach very differently was unexpected and appears to stem
from students’ perceptions of learning in medical school and the manageability of an approach that they were not
familiar with.To better engage students with online learning, instructors may need to clearly communicate the gap
that online learning is filling and to consider how students view applied learning and managing uncertainty in
learning.

Take Home Messages

Page | 10
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

Students welcome active online learning exercises as revision aids.

Students are reluctant to engage in active learning before face-to-face teaching occurs.
Medical students are more open to using online learning when they see a clear complementary relationship
with their clinical learning.
Instructors implementing new approaches to learning should be mindful of other new challenges students are
encountering in other areas of the curriculum.

Notes On Contributors

Dr. Diane Kenwright is the Head of Department of Pathology and Molecular Medicine, University of Otago,
Wellington. She investigates student engagement with elearning.

Emma Osborne is the Student Learning Advisor of at the University of Otago Wellington. She has a Masters of
Education in adult education, with a focus on how people learn in the context of community development projects.
Emma is interested in active learning and embedding transferable academic skills into students' coursework.

Wei Dai is a research assistant of Department of Pathology and Molecular Medicine, University of Otago,
Wellington. She is currently doing her Ph.D. in Educational Psychology in Victoria University of Wellington. Her
research interest lies in the area of involvement of cognitive resources in the learning process.

Dr. Rebecca Grainger is a consultant rheumatologist. She teaches chemical pathology and is the course convenor
for the undergraduate pathology teaching programme at University of Otago Wellington.

Acknowledgements

Bibliography/References

Abeysekera, L., & Dawson, P. (2015). Motivation and cognitive load in the flipped classroom: definition, rationale
and a call for research. Higher Education Research & Development, 34, 1-14.

http://dx.doi.org/10.1080/07294360.2014.934336

Austin, R., Sharma, M., Moore, P., & Newell, D. (2013). Situated computing and virtual learning environments: E-
learning and the benefits to the students learning. Paper presented at the 2013 7th International Conference on
Complex, Intelligent, and Software Intensive Systems, CISIS 2013, Taichung.

Bhuasiri, W., Xaymoungkhoun, O., Zo, H., Rho, J. J., & Ciganek, A. P. (2012). Critical success factors for e-
learning in developing countries: A comparative analysis between ICT experts and faculty. Computers and
Education, 58, 843-855.

http://dx.doi.org/10.1016/j.compedu.2011.10.010

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3,
77-101.

Page | 11
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

http://dx.doi.org/10.1191/1478088706qp063oa

Burnard, P., Gill, P., Stewart, K., Treasure, E., & Chadwick, B. (2008). Analysing and presenting qualitative data. Br
Dent J, 204, 429-432.

http://dx.doi.org/10.1038/sj.bdj.2008.292

Geist, M. J., Larimore, D., Rawiszer, H., & Al Sager, A. W. (2015). Flipped Versus Traditional Instruction and
Achievement in a Baccalaureate Nursing Pharmacology Course. Nursing Education Perspectives, 36, 114-115.

http://dx.doi.org/10.5480/13-1292

Gilboy, M. B., Heinerichs, S., & Pazzaglia, G. (2015). Enhancing Student Engagement Using the Flipped Classroom.
Journal of Nutrition Education & Behaviour, 47, 109-114.

http://dx.doi.org/10.1016/j.jneb.2014.08.008

Giroud, J. M., Jacobs, J. P., Fricker, F. J., Spicer, D., Backer, C., Franklin, R. C. G., Anderson, R. H. (2012). Web
based "Global Virtual Museum of Congenital Cardiac Pathology". Progress in Pediatric Cardiology, 33, 91-97.

http://dx.doi.org/10.1016/j.ppedcard.2011.12.015

Hancock, J., Roberts, M., Monrouxe, L., & Mattick, K. (2015). Medical student and junior doctors' tolerance of
ambiguity: development of a new scale. Advances in Health Sciences Education, 20, 113-130.

http://dx.doi.org/10.1007/s10459-014-9510-z

Harrington, S. A., Vanden Bosch, M., Schoofs, N., Beel-Bates, C., & Anderson, K. (2015). Quantitative Outcomes
for Nursing Students in a Flipped Classroom. Nursing Education Perspectives, 36, 179-181.

http://dx.doi.org/10.5480/13-1255

Kenwright, D., Dai, W., Osborne, E., Gladman, T., Gallagher, P., & Grainger, R. (Forthcoming). "Just Tell Me
What I Need To Know To Pass The Exam! Can Active Flipped Learning Overcome Passivity? The Asia-Pacific
Scholar.

Khanova, J., Roth, M. T., Rodgers, J. E., & McLaughlin, J. E. (2015). Student experiences across multiple flipped
courses in a single curriculum. Medical Education, 49, 1038-1048.

http://dx.doi.org/10.1111/medu.12807

King, A. (1993). From Sage on the Stage to Guide on the Side. College Teaching, 41, 30-35.

http://dx.doi.org/10.1080/87567555.1993.9926781

KuraCloud Ltd. (2014). KuraCloud. Retrieved from http://www.kuracloud.com/

Kurup, V., & Hersey, D. (2013). The changing landscape of anesthesia education: is Flipped Classroom the answer?
Current Opinion in Anesthesiology, 26, 726-731.

Page | 12
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

http://dx.doi.org/10.1097/ACO.0000000000000004

Liebert, C. A., Lin, D. T., Mazer, L. M., Bereknyei, S., & Lau, J. N. (2016). Effectiveness of the Surgery Core
Clerkship Flipped Classroom: a prospective cohort trial. The American Journal of Surgery, 211, 451-457.e451.

http://dx.doi.org/10.1016/j.amjsurg.2015.10.004

Little, C. (2015). The flipped classroom in further education: literature review and case study. Research in Post-
Compulsory Education, 20, 265-279. doi:10.1080/13596748.2015.1063260

http://dx.doi.org/10.1080/13596748.2015.1063260

MacDonald-Hill, J. L., & Warren-Forward, H. M. (2015). Feasibility study into the use of online instrumentation
courses for medical radiation scientists. Radiography, 21, 282-287.

http://dx.doi.org/10.1016/j.radi.2015.02.004

Moffett, J. (2015). Twelve tips for 'flipping' the classroom. Medical Teacher, 37, 331-336.

http://dx.doi.org/10.3109/0142159X.2014.943710

Morgan, H., McLean, K., Chapman, C., Fitzgerald, J., Yousuf, A., & Hammoud, M. (2015). The flipped classroom
for medical students. Clinical Teacher, 12, 155-160.

http://dx.doi.org/10.1111/tct.12328

Nevalainen, M., Mantyranta, T., & Pitkala, K. (2010). Facing uncertainty as a medical student-A qualitative study of
their reflective learning diaries and writings on specific themes during the first clinical year. Patient Education and
Counseling, 78, 218-223.

http://dx.doi.org/10.1016/j.pec.2009.07.011

O'Flaherty, J., & Phillips, C. (2015). The use of flipped classrooms in higher education: A scoping review. Internet
& Higher Education, 25, 85-95.

http://dx.doi.org/10.1016/j.iheduc.2015.02.002

Pintrich, P. R., Smith, D. A. F., Garcia, T., & McKeachie, W. J. (1993). Reliability and predictive validity of the
motivated strategies for learning questionnaire (MSLQ). (Validity Studies). Educational and Psychological
Measurement, 53, 801.

http://dx.doi.org/10.1177/0013164493053003024

Risko, E. F., Anderson, N., Sarwal, A., Engelhardt, M., & Kingstone, A. (2012). Everyday Attention: Variation in
Mind Wandering and Memory in a Lecture. Applied Cognitive Psychology, 26, 234-242.

http://dx.doi.org/10.1002/acp.1814

Ruiz, J. G., Cook, D. A., & Levinson, A. J. (2009). Computer animations in medical education: a critical literature
review. Medical Education, 43, 838-846.

Page | 13
Kenwright D, Osborne E, Dai W, Grainger R
MedEdPublish
https://doi.org/10.15694/mep.2016.000080

http://dx.doi.org/10.1111/j.1365-2923.2009.03429.x

Simpson, V., & Richards, E. (2015). Flipping the classroom to teach population health: Increasing the relevance.
Nurse Education in Practice, 15, 162-167.

http://dx.doi.org/10.1016/j.nepr.2014.12.001

Street, S. E., Gilliland, K. O., McNeil, C., & Royal, K. (2014). The Flipped Classroom Improved Medical Student
Performance and Satisfaction in a Pre-clinical Physiology Course. Medical Science Educator, 25, 35-43.

http://dx.doi.org/10.1007/s40670-014-0092-4

Tan, E., Brainard, A., & Larkin, G. L. (2015). Acceptability of the flipped classroom approach for in-house teaching
in emergency medicine. Emergency Medicine Australasia, 27, 453-459.

http://dx.doi.org/10.1111/1742-6723.12454

Tune, J. D., Sturek, M., & Basile, D. P. (2013). Flipped classroom model improves graduate student performance in
cardiovascular, respiratory, and renal physiology. Advances in Physiology Education, 37, 316-320.

http://dx.doi.org/10.1152/advan.00091.2013

Van Merriënboer, J. J. G., & Sweller, J. (2010). Cognitive load theory in health professional education: design
principles and strategies. Medical Education, 44, 85-93.

http://dx.doi.org/10.1111/j.1365-2923.2009.03498.x

White, C., McCollum, M., Bradley, E., Roy, P., Yoon, M., Martindale, J., & Worden, M. (2015). Challenges to
Engaging Medical Students in a Flipped Classroom Model. Medical Science Educator, 25, 219-222.

http://dx.doi.org/10.1007/s40670-015-0125-7

Young, M. S., Robinson, S., & Alberts, P. (2009). Students pay attention! Combating the vigilance decrement to
improve learning during lectures. Active Learning in Higher Education, 10, 41-55.

http://dx.doi.org/10.1177/1469787408100194

Youngkin, C. A. (2014). The Flipped Classroom: Practices and Opportunities for Health Sciences Librarians.
Medical Reference Services Quarterly, 33, 367-374.

http://dx.doi.org/10.1080/02763869.2014.957073

Appendices

Declaration of Interest

The author has declared that there are no conflicts of interest.

Page | 14