learning is a learner centered strategy in which students
are exposed to the fundamentals of a concept prior to
attending the classroom session. Content is delivered via a
learning module that is presented in the form of a video,
power point, or some other type of instructional medium.
This frees up class time for deeper learning activities that
address the understanding and application of this newly
learned concept (Bergman & Sams, 2012). In this way, the
flipped learning model lends itself very well for the
scaffolding of a difficult concept, thereby providing
learning structure and precluding the learner from becoming
overwhelmed by complexities (Tawfik & Lilly, 2015).
Cardiovascular physiology, which deals with the workings of
the heart and blood vessels is conceptually difficult for
students because of its highly integrative nature. The
learner has to juggle several different disciplines such as
physics, chemistry, and biology and varying levels of
organization such as molecules, cells, tissues, organs, and
organ systems at the same time (Michael et al., 2002). Any
meaningful learning of this topic would require the learner
to think like an expert and apply these concepts to clinical
problems (Michael, 2001). For these reasons, cardiovascular
physiology can be considered to be a threshold concept.
concept is defined as a challenging concept that can be
troublesome, transformational, and integrative to the
learner (Meyer & Land, 2003). The concept is troublesome
because it is conceptually difficult, alien, or tacit (Meyer,
Land, & Baillie, 2010). A threshold concept is transformational when
it results in new ways of thinking about something or
produces a paradigm shift in thinking for the learner.
Cardiovascular physiology can be transformational for the
learner when hidden connections between lifestyle and
cardiovascular function become revealed. It is integrative
in the sense that it exposes the interrelatedness of this
concept to other disciplines (Meyer & Land, 2003).
that is in the process of mastering the threshold concept is
said be undergoing a threshold experience, which
occurs within a liminal space or learning
environment. A learner who is yet to begin engaging with
the threshold concept is said to be in a pre-liminal
state; when the learner begins to engage with the
concept, the learner is said to have entered the liminal
state; and once the learner has mastered the concept, he
or she is said to have crossed the threshold and reached a
post-liminal state. Frequently, when faced with a
threshold concept, the learner is disinclined to leave the
pre-liminal state and pretends to engage with the concept by
memorizing bits of seemingly important information without
any meaningful learning taking place. The initial challenge
for the instructor therefore would be to encourage these
students to enter the liminal state so they may begin to
truly engage with the concept. This is where the flipped
learning method can be extremely valuable. Once the student
has been exposed to the background information needed to
understand the concept outside of class, regular low stakes
quizzes on this material can help build student confidence,
interest, and motivation (Warnock, 2014) thereby urging the
student to enter the liminal state and engage deeply with
the threshold concept. Regular, low stakes, formative
assessments providing immediate feedback, have also been
shown to have a profoundly positive effect on self-regulated
learning (Sadler, 1998; Pintrich & Zusho, 2002; Nicol &
MacFarlane-Dick, 2006). When combined with thoughtful
scaffolding and frequent low stakes quizzes, flipped
learning can help to break down barriers such as lack of
confidence and a tendency to procrastinate when faced with a
challenging task, both of which prevent the learner from
entering the liminal state.
with a high level of difficulty is said to have a high
intrinsic cognitive load, which is characterized by too
many elements within the concept that must interact
continuously, requiring a great deal of mental effort. (Sweller,
1994). Intrinsic cognitive load cannot be reduced because
the nature of the information is inherently difficult. But
it can be managed or manipulated by thoughtful scaffolding
(Mayer, 2005). Students learning cardiovascular physiology
need to juggle several interacting mini-concepts drawn from
physics, chemistry, and biology before gaining conceptual
understanding. And this takes a lot of mental effort. In
order to understand the concept, students must engage in
intrinsic cognitive processing, which is limited by the
number of interacting elements that can be held in the
working memory of the learner (Mayer, 2005). Our working
memory can only hold about four units of newly acquired
information for a period of 30 seconds (Cowan, 2001).
However, these limits can be expanded infinitely when
previously learned information stored in long term memory is
retrieved (Ericsson & Kintsch, 1995) and enhances working
memory. This greatly reduces the mental effort required to
grasp a concept. Here is where the flipped learning model
makes its strongest contribution. In the non-flipped
learning model, the instructor presents all the interacting
elements embedded in a concept and the students are expected
to juggle a relatively high number of yet unfamiliar
conceptual elements in order to comprehend the information.
The intrinsic cognitive load is especially evident in this
setting and the student struggles to understand the
unfamiliar concept. The flipped learning model on the other
hand, provides the learner with the opportunity to process
new information outside of class, rehearse it, and store it
in long term memory before coming to class. Later when faced
with the same concept in class, the learner is able to
retrieve information from long term memory, thereby vastly
expanding the limits of the working memory. This kind of
pre-training helps to significantly reduce the mental effort
needed for information processing thereby successfully
managing the intrinsic cognitive load (Musallam, 2010).
When pre-training is combined with retrieval practice as in
a short quiz based on the material learned, the effect on
learning and long-term retention can be significant (Karpicke,
& Butler, 2011; Roediger & Pyc, 2012).
We know that
learning has taken place when the student is able to
transfer newly acquired conceptual knowledge to real world
examples. This involves germane load processing,
which is a kind of deep conceptual processing that alters
the very schema or mental organization of information
in the learner’s mind (DeLeeuw & Mayer, 2008). We want to
increase the level of germane load processing or germane
cognitive load in our learners. Another major strength
of the flipped classroom is that it frees up class time for
deeper learning (Bergman & Sams, 2012). Once in the liminal
space, the learner has the opportunity to deepen conceptual
understanding and expand procedural knowledge by applying
newly learned concepts to novel situations, thereby
increasing germane cognitive load.
Alternatively, it is possible to increase a different kind
of cognitive load and actually hamper a student’s learning
by including facts that are not directly relevant to the
concept that is being learned. This is called extraneous
cognitive load (Sweller, 1994) and is described as any
kind of mental processing that does not support the learning
objective. This can be avoided by evaluating instructional
content for inclusion of only the facts and background
knowledge that are relevant to the concept. This practice
is known as intentional content as opposed to the
practice of merely covering the content. Evaluating
content and streamlining it in a meaningful way is a
necessary prerequisite to ensure the success of flipped
learning (Hamdan McKnight, McKnight, & Arfstrom, 2013) or to ensure any meaningful
learning for that matter (Lujan & DiCarlo, 2005).
describe the adoption of the flipped learning method to
accomplish the following: a) to promote student
preparedness, motivation, confidence and encourage
self-regulated learning; c) to draw students into the
liminal space and encourage them to master the threshold
concepts embedded in cardiovascular physiology; d) to manage
intrinsic cognitive load, increase germane cognitive load,
and reduce extraneous cognitive load during this learning
process; e) to continually inform and shape my teaching.
the usefulness of the flipped learning approach for a period
of four consecutive semesters in a Human Anatomy &
Physiology course each with a class size of 18-24 and a
total of 90 students at Bronx Community College, a campus
belonging to the City University of New York. Here, I
report the effectiveness of the flipped learning method in
the lecture portion of the course, and for the topic of
cardiovascular physiology, in particular. As a comparison
of general student performance, I present data from four
consecutive semesters prior to the flipped learning
approach. These lecture class sizes were also between 18-24
students with a total of 92 students.
Intentional Content and Formative Assessment
step in this process was to evaluate the course content and
outline student learning outcomes for each topic based on
the philosophy of intentional content usage rather than
content coverage (Lujan & DiCarlo, 2006; Hamdan et al.,
2013). Learning outcomes were classified into three
categories – factual knowledge, conceptual knowledge, and
procedural knowledge (Anderson & Krathwohl, 2000). In this
way, it was easy to separate the factual knowledge from the
other two types and present it in a learning module to be
mastered by the students prior to attending class (see Table
Table 1. An excerpt of Student
Learning Outcomes and how they are classified.
Student Learning Outcome
the factors that affect stroke volume and explain
how each affects stroke volume
Write the full equation for cardiac output
Predict what would happen to cardiac output when
stroke volume increases (or decreases) or when heart
rate increases (or decreases)
Apply the relationship between cardiac output, heart
rate, and stroke volume to a real life situation
when a person’s cardiac output must increase during
exercise to meet the body’s increased oxygen
modules were designed in a way that it would take the
student no more than two hours to master. They were made
available in a folder titled “Help for Pre-lecture Quizzes”
and contained a total of 10 learning modules (one for each
quiz) via the Blackboard learning management system. A
weekly lecture quiz served as the primary motivator for
students to master this knowledge prior to attending a
lecture on the same topic (see Table 4 for a list of
topics). These quizzes worth 20 points each, were typically
easy and assessed mastery of fundamental knowledge, without
which the student cannot hope to achieve deeper conceptual
understanding (see Table 2).
Table 2: Examples of Questions
appearing on a Low Stakes Lecture Quiz.
I. Fill in the blanks:
There is more Na+
____________ (inside/outside) cells
There is more Ca++
____________ (inside/outside) cells
There is less K+
_____________ (inside/outside) cells
When the concentration gradient
decreases, the speed of diffusion __________
(simple diffusion/active transport/
osmosis/facilitated diffusion) is the movement
of molecules up or against their concentration
When the voltage rises above the resting
membrane potential and approaches
zero, we call it
When the voltage falls below the resting
membrane potential, we call it
When the voltage falls and moves away
from zero, we call it _______________________
When voltage gated K+ channels
open, K+ ____________
When voltage gated Ca++
channels open, Ca++ ____________
Under parasympathetic stimulation, the
SA node will make the heart beat ___________
(faster/slower) than 72 beats.
The SA node sends its signal first to the
______________ (AV bundle/Purkinje
fibers/AV node/Bundle branches).
were administered at the start of each lecture session and
so latecomers missing the first 20 minutes of class time
were not allowed to take the quiz. Students were also not
given opportunities to make up a missed quiz. However, only
the top 8 quiz grades were included in the lecture quiz
average to allow for unforeseen circumstances. Quiz grades
comprised 12% of the total grade for the course with each
individual quiz contributing 1.5% to the final course
grade. Students were repeatedly informed that they had to
score 90% or above in these quizzes in order to be able to
do well in the higher stakes lecture examination, which
includes questions that are significantly more difficult
than those that appear in the weekly quizzes (see Table 3).
The benchmark for student performance was set at 80% for the
low stakes quiz grade and 70% for the higher stakes lecture
Table 3: Examples of Questions
Appearing in High Stakes Lecture Exam.
Z is recovering from a heart attack. However, he is
back in the ICU with fluid accumulation in his
lungs. The following are the possible reasons for
his condition EXCEPT:
Right ventricular output exceeds left
The stroke volume on both sides of the heart
The left ventricle is probably damaged
Left ventricle pumps less than the right
following statements regarding the electrical
activity in a cardiac myocyte are true EXCEPT:
The slow inflow of calcium ions creates a
plateau in the action potential.
The repolarization phase of the action
potential is brought about by the inflow of
The plateau increases the absolute refractory
period of the action potential.
The depolarization phase of the action
potential is rapid and caused by the inflow of
sodium in a positive feedback cycle
factors that directly affect blood pressure are:
diet and exercise
osmotic and hydrostatic pressures
flow and peripheral resistance
peripheral resistance and blood volume
Typical “Lecture Session” in the Flipped Learning Format
period is usually about 3 hours with two ten minute breaks
included. In my flipped lecture session, these blocks of
lecture time are organized in such a way as to include a
variety of student-centered activities (Figure 1). The
quiz is always administered during the first 25 minutes,
followed by a five-minute feedback period when I review the
quiz with the students. This is followed by short
8-10-minute mini-lectures of new concepts interspersed by
periods of rehearsing of conceptual information via
interactive note-taking, explanation of worked examples
followed by problem solving either individually or in small
groups, and breakdown of clinical problem solving into
discrete steps (Figure 1). When students solve clinical
problems there is plenty of opportunity for peer to peer and
instructor to peer interaction. The latter is intended to
help students correct any misconceptions and keep them
moving in the right track. After working on the problem,
students are often invited to the board to breakdown
clinical problems into discrete steps using flow charts.
Figure 1. Major elements
within a three-hour flipped lecture session.
Formative and Summative
and summative assessments of student performance were
regularly conducted. Formative assessments were made based
on the students’ performance on weekly quizzes and in-class
problem solving exercises. Summative assessments were based
on the students’ performance on three full length lecture
examinations. Student perceptions of the flipped learning
approach were collected in the form of responses to a short
survey at the end of the first lecture examination.
Summative assessment of factual, conceptual, and procedural
knowledge of cardiovascular physiology was done using the
full length lecture examination as the assessment tool with
roughly one third of the questions devoted to assessing each
type of knowledge – factual, conceptual, and procedural.
comparison of students who were taught using the non-flipped
learning method (n = 92) versus the students that were taught
using the flipped learning method (n=90) was made.
Student performance data from a total of 8 different
sections was analyzed with four of these sections from
non-flipped learning sections that I had taught prior to the
four flipped learning sections. Analysis of student
performance data shows that the students in the flipped
learning sections did significantly better in terms of pass
rates, retention rates, and overall performance (Figure 2).
Figure 2. Comparison of overall
student performance in non-flipped vs. flipped learning
student performance in the high stakes lecture examinations
also showed that students from the flipped learning classes
performed significantly better with more number of students
scoring at least 70% on a given lecture examination (Figure
3). It is important to note that both learning modes
operated from the same set of learning outcomes with student
centered learning strategies embedded in both. The
difference was that in the flipped learning model, students
were given the opportunity for pre-training followed by
retrieval practice and more class time was devoted to
student centered learning activities.
Figure 3. Students scoring at least
a C in lecture examinations in non-flipped vs. flipped
flipped learning sections designated I, II, III, and IV
student performance in the weekly lecture quizzes shows that
at least 90% of the students scored 80% or more. There was
more variation in student performance across the four
sections (60-92%) when students scoring 90% or more on these
weekly quizzes was taken into account (Figure 4).
Figure 4. Student performance on
weekly quizzes within the flipped learning format.
all four flipped learning sections were asked how they felt
about preparing and taking weekly lecture quizzes. 100% of
the responses were resoundingly positive. Most of them
remarked that it motivated them to keep up with the lecture
material or they wouldn’t study for the lecture portion of
the course until it was time to prepare for a lecture
Flipped Section III, which had the lowest percentage of
students scoring 90% or above in the weekly quizzes for a
closer look at student participation in the flipped learning
format, performance in the in-class clinical problem solving
in cardiovascular physiology, and performance in the
factual, conceptual, and procedural knowledge questions
pertaining to cardiovascular physiology on the lecture
A look at
student participation data in the weekly quizzes gives us an
idea of student motivation to take these quizzes seriously
and show up to class on time. Students were allowed to drop
two of their lowest quiz grades or miss two quizzes due to
lateness or unavoidable absence. Student participation data
in the 10 weekly in class quizzes shows that 75% of the
students attempted at least 90% of the quizzes with 65%
attempting 9 out of 10 quizzes, 10% attempting all 10
quizzes, and the remaining 25% attempting 80% of the quizzes
Figure 5. Student Participation in
the 10 weekly quizzes within the flipped learning format.
A look at
the average quiz grades for each week gives us an idea of
student readiness or preparedness for that day’s lecture.
Student readiness is indicated by the average quiz grades
for each week, which was at or above the benchmark of 80%
Table 4. Cardiovascular Physiology
is addressed in the first four flipped learning modules.
Flipped Learning Modules that address Factual
and basic conceptual knowledge
Average Quiz Grade
Electrophysiology of the Heart
Electrophysiology of the Heart and Pressure
Hemodynamics & Capillary Exchange
Osmolarity, Viscosity & Erythropoiesis
Lymphatic Pathway and Nonspecific Defenses
Antibody mediated immunity
Physiological Pathway of Air & Breathing
Pathway of Urine Formation
Digestive Pathway and Chemical Digestion
A look at
the time allotted to various in-class activities shows that
pre-training opened up more face-to-face class time to
address deeper conceptual understanding and germane load
processing in the form of clinical problem solving. In the
non-flipped learning format, factual knowledge was presented
in class thereby limiting the time available for students to
participate in small group or individual clinical problem
solving, receive immediate feedback, and correct
misconceptions. Whereas, in the flipped learning format,
30% more class time was devoted to formative assessment and
feedback (Figure 6).
Figure 6. Percentage of class time
spent on various learning activities.
Cardiovascular physiology was taught in four lecture
sessions and the students addressed a total of 16 novel
clinical situations (Table 5). All of the clinical problems
presented to the students were preceded by a worked example,
that was used to demonstrate “how to think like a
physiologist” via a flow chart that breaks down a clinical
problem into discrete steps. More than 80% of the students
were successful in arriving at the correct answer when
addressing these clinical problems. However, there was a
tendency to obscure explanations by including elements not
directly pertinent to the problem. Even when students were
able to construct their own flow charts correctly they
stated that they did not feel confident in their ability to
do this on their own.
Table 5: Formative Assessment and
Feedback of Clinical Problem Solving in Cardiovascular
Clinical Problems Outlined
How does a Ca++ channel blocker help to
lower the heart rate?
How do Beta Blockers help to lower heart
94% of the students were able to solve the
problem with some feedback.
80% of the students were able to solve the
problem with some help.
Explain how each of the following situations
affects venous return?
Sitting for long periods
Increased Atrial Pressure
Standing Upside down
Lying down with feet raised higher than
Students were able to answer all of these
correctly except for #6. Only 50% were able to
connect high arterial pressure with lowered
How does arteriosclerosis result in high
blood pressure? How does a stent help to lower
They were all able to answer this correctly.
However, only 33% were able to complete the flow
chart without bringing in unnecessary elements
such as viscosity.
How do each of these factors affect Blood
Atrial Natriuretic Peptide
Tumor in the adrenal medulla increasing
90% of the students arrived at the correct
answers but there was a strong tendency to bring
in unrelated elements into their flow charts.
Only 10% of the students were able to make the
connection between adrenal medulla,
overproduction of epinephrine and high blood
Why does a person who has recently
suffered a heart attack sometimes suffer
100% of the students were able to answer this
correctly but were not able to construct a flow
chart by themselves.
length high stakes lecture examinations were used as
summative assessments, which assessed student outcomes for
factual, conceptual, and procedural knowledge. The first
lecture examination assessed student understanding of
cardiovascular physiology and their ability to apply this
knowledge to solve clinical problems. Results of this
assessment showed that students achieved the pre-set
benchmark of 70% for factual and procedural knowledge but
fell slightly short of the benchmark for conceptual
knowledge (Figure 7).
Figure 7. Percentage of students
answering questions correctly in the three knowledge areas.
examination also included one clinical problem solving
question in the form of a short answer. About 83% of the
students answered the question correctly overall. Among
those that answered the question correctly, 40% made one or
two mistakes by including unrelated elements in their flow
Practical implications of this study
learning approach has a direct positive impact on student
motivation, participation, preparedness, confidence, and
performance. For the instructor, the flipped learning
approach can save time that can be used for deeper
conceptual understanding and application.
Overall, the lowered withdrawal
rates, increased pass rates and increased rate of
students scoring C+ and above in the flipped learning
sections in comparison with the non-flipped learning
sections (see Figure 2) is an indication that the
flipped learning approach can have a strong influence on
student motivation to successfully complete a
challenging science course.
Even in the lowest performing
flipped learning section there was strong student
participation in the weekly quizzes (see Figure 5). When
asked if the weekly quizzes were helpful, student
response was overwhelmingly positive. They stated that
the quizzes motivated them to keep up with the lecture
material and to help prepare for lecture examinations.
The flipped learning approach combined with retrieval
practice can boost student participation.
With more than 90% of the students
scoring 80% or more on the weekly quizzes, class
preparedness was high. This also increased student
confidence and engagement during the lecture session.
In all three exams students in the
flipped learning sections did significantly better than
those in the non-flipped learning sections (see Figure
3). The flipped learning approach when combined with
retrieval practice can greatly improve student
performance in the long run.
For the instructor, flipping one
third of the lecture and following the philosophy of
intentional content can free up valuable class time for
deeper learning (see Figure 6).
Theoretical implications of this study
learning approach when applied efficiently can harness the
power of formative assessments and retrieval practice to
enhance self-regulated learning. It can lower extrinsic
cognitive load by the practice of intentional content;
manage intrinsic cognitive load by pre-training and
interactive note-taking; and raise germane cognitive load by
the use of worked examples.
Formative assessments can confer
affective, cognitive, and behavioral benefits on
students by giving them a goal to which they can aspire,
build self-esteem by learning from mistakes, boost
confidence, and positively influence study behavior by
promoting self-regulated learning (Sadler, 1998; Nicol &
MacFarlane-Dick, 2006; Black & Wiliam, 1998). I have
found that by reminding students to score 80% or above
weekly quizzes, giving them a weekly opportunity to
learn from their mistakes, feel good about their
performance, and track their own progress, it is
possible to reap the benefits of formative assessment.
This is a kind of self-assessment that is known to
enhance future performance in summative assessments such
as the full length or final examinations (McDonald &
Boud, 2003), which I have also seen from my results (see
Pre-training (Musallam, 2010) and
retrieval practice (Roediger & Butler, 2011; Roediger &
Pyc, 2012; Karpicke, 2012) can help to manage intrinsic
cognitive load. By practicing intentional content
rather than merely covering the content, it is possible
to lower extrinsic cognitive load (Lujan &DiCarlo, 2005;
DeLeeuw & Mayer, 2008). If both of these cognitive
loads are properly managed, it is possible to increase
germane cognitive load, a type of processing that allows
the student to apply conceptual knowledge to novel
situations. During the four lecture sessions on
cardiovascular physiology the students addressed a total
of 16 novel clinical situations (see Table 5) and
students were largely successful with more than 80% of
the students solving the problems correctly, thereby
demonstrating germane cognitive processing.
Meaningful learning takes time and
this journey can be troublesome. (Lujan & DiCarlo,
2006). Viewing this learning process as a threshold
experience allows us to focus on the struggle that the
students face to master difficult concepts. The flipped
learning model has helped immensely in drawing students
from the pre-liminal state to the liminal state to
engage deeply with this threshold concept in
physiology. The threshold experience reveals the
non-linear learning process in that we see students
brimming with confidence as they do well on the quizzes
and then struggle with the mastery of conceptual
understanding. Yet they demonstrate the ability to
apply this knowledge to real world situations. At the
same time, they oscillate towards a loss of confidence
in their abilities and end up including unrelated
elements in their explanations. This is a classic
characteristic of the threshold experience. The learner
attempts bold excursive journeys into the
conceptual landscape towards better understanding
interspersed with recursive journeys into areas
of confusion and loss of confidence (Cousin, 2006). An
instructor who is aware of this struggle can provide a
supportive learning environment or liminal space
that addresses these excursive and recursive journeys
(Land Cousin, Meyer, & Davies, 2005).
have found that the flipped learning model provides a highly
supportive and effective learning or liminal
environment for the student. By taking into consideration
the functioning of our working and long term memory, the
flipped learning strategy appears to be highly compatible
with the human cognitive architecture (Kirschner, Sweller, &
semesters, I will alter the design of the classroom
activities to include formative assessments to test
conceptual understanding and step up opportunities for
self-assessment both inside and out of the classroom. I
would also be interested in further exploring the
relationship between the flipped learning approach and the
development and maintenance of self-regulated learning.
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