The Effects of Flipped Classroom versus Lecture-Based Learning on Academic Performance and Perceptions of Classroom Environment among Nursing Students: A Randomized Controlled Trial

ERCT Criteria Breakdown

• Level 1 Criteria

  • C

    Class-level RCT

    • Randomisation was performed at the individual student level within a single course cohort, not at the class or school level, and no tutoring exception applies.
    • "After consent was obtained, the 58 participants were randomly assigned to the intervention group (n = 29) or the control group (n = 29)."
    • Relevant Quotes: 1) "After consent was obtained, the 58 participants were randomly assigned to the intervention group (n = 29) or the control group (n = 29). A blocked randomization sequence with randomly varying block sizes of 4 and 6 was generated by an independent statistician using the web-based service Sealed Envelope..." (p. 7-8) 2) "This study was conducted at the School of Nursing and Midwifery, Qom University of Medical Sciences, Iran... A total of 60 second-semester nursing students registered for the Adult and Older Adults Nursing 1 course and were initially assessed for eligibility." (p. 7) 3) "To minimize the risk of contamination, students in the intervention group were explicitly instructed at the outset not to share pre-class materials or related discussions with peers in the control group." (p. 8) Detailed Analysis: The unit of randomisation was the individual student. All 58 students were drawn from a single Adult and Older Adults Nursing 1 course cohort at one institution and were then individually allocated to flipped-classroom or lecture-based conditions. Criterion C requires randomisation of entire classes or schools to prevent cross-contamination between treatment and control participants. Here both arms coexisted within the same programme and semester, and the authors themselves acknowledge the contamination risk and attempt to mitigate it only by verbal instruction. The intervention is a classroom pedagogy, not one-to-one tutoring, so the personal-teaching exception does not apply. Criterion C is not met because randomisation was conducted at the individual student level within a single class, not at the class or school level.
  • E

    Exam-based Assessment

    • Academic performance was measured with a researcher-developed 20-item multiple-choice test, not a widely recognised standardised exam.
    • "The primary outcome was academic performance, measured by researcher-developed 20-item multiple-choice knowledge test."
    • Relevant Quotes: 1) "The primary outcome was academic performance, measured by researcher-developed 20-item multiple-choice knowledge test." (Abstract) 2) "The pre- and post-test questions were identical and designed by two members of the research team (not the lecturer) with several years of experience teaching the fluid and electrolytes course; the questions were based on the learning objectives (See Supplementary File 2)." (p. 13) 3) "The CUCEI was used to assess students' perceptions of the classroom environment (secondary outcome), which was developed and validated by Fraser, Treagust, and Dennis (1986)." (p. 13) Detailed Analysis: The primary academic outcome was a knowledge test built by the research team specifically for this study. Although the authors report content validity (CVI = 0.98) and reliability (KR-20 = 0.84), these are properties of a locally constructed instrument, not evidence of a standard, widely recognised, externally administered exam (e.g., a national or licensing examination). Criterion E requires a standardised exam-based assessment that is not custom-designed for the study. The CUCEI is a validated instrument but measures classroom-environment perceptions, not exam-based academic achievement. Criterion E is not met because the academic outcome relied on a researcher-developed test rather than a standardised exam.
  • T

    Term Duration

    • The intervention lasted only four weekly two-hour sessions with outcomes measured immediately at the end, far short of one academic term.
    • "According to the lesson plan, the fluid and electrolytes topic was structured into four two-hour sessions delivered over four consecutive weeks."
    • Relevant Quotes: 1) "According to the lesson plan, the fluid and electrolytes topic was structured into four two-hour sessions delivered over four consecutive weeks." (p. 9) 2) "At the end of the fourth session and upon completion of the intervention, the CUCEI and post-test were completed by the students in the two groups." (p. 14) 3) "Relatedly, our study did not assess the long-term retention of knowledge, as the design did not include a delayed post-test... The results are confined to short-term knowledge gains, as long-term retention was not assessed." (p. 22, 23) Detailed Analysis: The intervention spanned four consecutive weeks (four two-hour sessions), and the primary and secondary outcomes were measured immediately at the end of the fourth session. There was no delayed post-test or any follow-up. Criterion T requires outcomes to be measured at least one full academic term (approximately 3-4 months) after the intervention begins. A four-week window with immediate measurement falls well short of this, and the authors explicitly acknowledge the short duration and absence of long-term follow-up. Criterion T is not met because the interval from intervention start to outcome measurement was only about four weeks, far less than one term.
  • D

    Documented Control Group

    • The control group's size, demographics, baseline scores, and business-as-usual lecture condition are clearly documented.
    • "In the control group, instruction consisted of lecture-based learning delivered during class time with no required or assigned preparation beforehand."
    • Relevant Quotes: 1) "In the control group, instruction consisted of lecture-based learning delivered during class time with no required or assigned preparation beforehand." (p. 8) 2) "Table 1: Sociodemographic and educational characteristics... Lecture-based learning (n=29): Age 20.82 +/- 3.41; Male 12 (41.4); Female 17 (58.6); Single 27 (93.1); GPA 15.73 +/- 1.68." (p. 25) 3) "Table 2... Lecture-based learning (n=29): Pre test mean +/- SD 5.58 +/- 1.78; Post test mean +/- SD 12.24 +/- 2.19." (p. 25) Detailed Analysis: The control group is thoroughly documented. Its size (n = 29), demographic profile (age, sex, marital status, GPA in Table 1), and baseline and post-test knowledge scores (Table 2) are all reported, and the paper states no significant baseline differences between groups. The nature of the control condition (standard lecture-based learning with the same instructor, content, and class timing, and access to identical slides after each session) is clearly described. Criterion D is met because the control group's characteristics, size, baseline data, and condition are clearly documented.

• Level 2 Criteria

  • S

    School-level RCT

    • Randomisation occurred at the individual student level in a single institution, not at the school level.
    • "This study was conducted at the School of Nursing and Midwifery, Qom University of Medical Sciences, Iran, during the second semester of the 2019-2020 academic year."
    • Relevant Quotes: 1) "This study was conducted at the School of Nursing and Midwifery, Qom University of Medical Sciences, Iran, during the second semester of the 2019-2020 academic year." (p. 7) 2) "After consent was obtained, the 58 participants were randomly assigned to the intervention group (n = 29) or the control group (n = 29)." (p. 7) Detailed Analysis: The study was conducted at a single school and randomised individual students, not schools. Criterion S requires randomisation among schools (institutions or implementation units). With one institution and student-level allocation, no school-level randomisation exists. Criterion S is not met because randomisation was at the individual student level within one institution, not at the school level.
  • I

    Independent Conduct

    • The intervention was designed and delivered by the authors themselves, with no independent third party conducting the trial.
    • "All materials were developed by the primary instructor, who had over five years of teaching experience in fluids and electrolytes management."
    • Relevant Quotes: 1) "All materials were developed by the primary instructor, who had over five years of teaching experience in fluids and electrolytes management." (p. 10) 2) "However, all researchers involved in data collection and statistical analysis were blinded to group allocation. To ensure this, the lead investigator coded the groups as 'A' and 'B' in the dataset. The data analyst performed all analyses on this coded dataset and remained unaware of which group corresponded to the intervention until the analysis was complete." (p. 8) 3) "MSY: Conceptualization, Methodology, Investigation, Data Curation, Writing - Original Draft, Project Administration, Supervision." (p. 24) Detailed Analysis: The intervention (flipped-classroom materials and in-class design) was created by the primary instructor, who is the first author, and the trial was designed, delivered, and analysed by the author team. Although the analyst was blinded to coded group labels and neutral research assistants handled enrollment and data collection, there was no independent, third-party evaluator separate from the intervention designers conducting the study. Criterion I requires that the study be conducted independently from those who designed the intervention. Criterion I is not met because the same team that designed and delivered the intervention also conducted and analysed the trial, with no independent external evaluation.
  • Y

    Year Duration

    • The study lasted only four weeks with immediate measurement, far below the year-duration requirement; criterion T is also not met.
    • "The limitations of this study include the small sample size and the fact that only four sessions of the two-credit nursing course were delivered in flipped format."
    • Relevant Quotes: 1) "According to the lesson plan, the fluid and electrolytes topic was structured into four two-hour sessions delivered over four consecutive weeks." (p. 9) 2) "The limitations of this study include the small sample size and the fact that only four sessions of the two-credit nursing course were delivered in flipped format." (p. 21) 3) "The results are confined to short-term knowledge gains, as long-term retention was not assessed." (p. 23) Detailed Analysis: The intervention and outcome measurement together spanned roughly four weeks. Criterion Y requires tracking outcomes for at least 75% of a full academic year (roughly 9-10 months). This study is an order of magnitude short of that. In addition, because criterion T (Term Duration) is not met, criterion Y cannot be met. Criterion Y is not met because the study duration was only about four weeks, far short of an academic year, and criterion T is not met.
  • B

    Balanced Control Group

    • In-class time, instructor, content, and slides were identical across arms; the additional pre-class engagement is the integral defining feature of the flipped classroom tested against business-as-usual lecture.
    • "The instructor, classroom environment, class timing, and educational content were identical in both groups."
    • Relevant Quotes: 1) "Students assigned to the flipped classroom group attended four 2-hour sessions and were required to engage with pre-class materials made available online prior to each session." (p. 10) 2) "To ensure a valid comparison, participants in the control group attended four two-hour sessions covering the exact same learning objectives and core content as the intervention group... The instructor, classroom environment, class timing, and educational content were identical in both groups." (p. 8, 10) 3) "To maintain educational equivalence, the PowerPoint slides used in the lectures were identical in content to those provided to the flipped classroom group. Students in the control group were given access to these slides for review after each session concluded." (p. 10) 4) "These logs, collected via a simple online form, indicated that these tasks required approximately 60-80 minutes per session on average." (p. 11) 5) "Lastly, the use of the Telegram application for communication exclusively within the intervention group introduced another potential confounder, as no equivalent channel was provided for the control group." (p. 23) Detailed Analysis: Both arms received the same amount of in-class time (four two-hour sessions), the same instructor, the same learning objectives and core content, and identical PowerPoint slides (the control group receiving them after each session for review). The one resource difference is that the flipped-classroom group additionally engaged with pre-class videos and questions requiring about 60-80 minutes per session, delivered via Telegram. Applying the criterion B decision tree: extra time/engagement is present and is not negligible, so the key question is whether it is integral to the intervention being tested. The flipped classroom is defined by shifting foundational content delivery to pre-class self-study so that in-class time is freed for active application; the pre-class preparation is therefore an inseparable, defining component of the intervention, not a detachable add-on that could have been balanced without dissolving the "flipped" design. The control condition represents the business-as-usual lecture baseline against which this integral design is contrasted, and it received the same slides. Under ERCT logic, when the additional resource is integral to the intervention tested against business as usual, the criterion is met, though the extra pre-class time and the intervention-only Telegram channel are acknowledged by the authors as potential confounders. Criterion B is met because the only resource difference (pre-class engagement time) is integral to the flipped-classroom intervention being tested against a business-as-usual lecture control that received identical in-class time, instructor, content, and slides.

• Level 3 Criteria

  • R

    Reproduced

    • No independent replication of this specific trial by a different research team is reported or identified.
    • Relevant Quotes: 1) "A key strength of this study is its use of a randomized controlled trial to rigorously evaluate the flipped classroom for teaching a specific, critical topic such as fluids and electrolytes to nursing students within the Iranian context." (p. 21) 2) "no published trial has focused on the Adult and Older Adults Nursing 1 course, which includes the notoriously challenging fluids and electrolytes module." (p. 6) Detailed Analysis: Criterion R requires that this specific study be independently replicated by a different research team in a different context and published in a peer-reviewed journal. The paper positions itself as the first trial on this specific course and topic in the Iranian context. While many flipped classroom studies exist in nursing education broadly, none constitutes an independent replication of this particular fluids-and- electrolytes trial. An internet check was attempted; the web-search quota for this session was exhausted, but a WebFetch of the DOI landing page and the paper's own literature review confirm the study is presented as the first of its kind, and no independent replication of this specific trial was identified. Criterion R is not met because there is no independent replication of this specific study.
  • A

    All-subject Exams

    • Only a single fluids-and-electrolytes module was assessed with a custom test, and criterion E is not met, so all-subject exams cannot be satisfied.
    • "the fluid and electrolytes topic was structured into four two-hour sessions delivered over four consecutive weeks."
    • Relevant Quotes: 1) "The primary outcome was academic performance, measured by researcher-developed 20-item multiple-choice knowledge test." (Abstract) 2) "According to the lesson plan, the fluid and electrolytes topic was structured into four two-hour sessions delivered over four consecutive weeks." (p. 9) Detailed Analysis: The study assessed only knowledge of the fluids and electrolytes module, a single narrow topic, using a researcher-developed test. Criterion A requires measuring impact across all main subjects using standardised exam-based assessments and explicitly depends on criterion E being met. Since criterion E is not met (the outcome is a custom test) and only one topic was assessed, criterion A fails on both counts. Criterion A is not met because only one topic was assessed with a non-standardised test and criterion E is not met.
  • G

    Graduation Tracking

    • Outcomes were measured immediately after the intervention with no follow-up to graduation, and criterion Y is not met.
    • "Relatedly, our study did not assess the long-term retention of knowledge, as the design did not include a delayed post-test."
    • Relevant Quotes: 1) "At the end of the fourth session and upon completion of the intervention, the CUCEI and post-test were completed by the students in the two groups." (p. 14) 2) "Relatedly, our study did not assess the long-term retention of knowledge, as the design did not include a delayed post-test. Therefore, we cannot draw conclusions about the lasting impact of the flipped classroom on memory." (p. 22) Detailed Analysis: Measurement stopped immediately after the fourth session; there was no delayed post-test and no tracking of students to graduation. Criterion G requires following participants until graduation and depends on criterion Y being met. No subsequent follow-up publication by the same authors tracking this cohort to graduation was identified (web-search quota was exhausted, but no such tracking is referenced in the paper). Neither condition holds. Criterion G is not met because there was no follow-up beyond the immediate post-test and criterion Y is not met.
  • P

    Pre-Registered

    • The trial was retrospectively registered in December 2025, years after the 2019-2020 data collection, so it was not pre-registered.
    • "The study was retrospectively registered in the Iranian Clinical Trials Registry (IRCT) with the trial number IRCT20240610062078N2 on December 21, 2025."
    • Relevant Quotes: 1) "The study was retrospectively registered in the Iranian Clinical Trials Registry (IRCT) with the trial number IRCT20240610062078N2 on December 21, 2025." (p. 4) 2) "The study was conducted with 58 nursing students at Qom University of Medical Sciences, Iran, during the 2019-2020 academic year." (Abstract) Detailed Analysis: Criterion P requires the full protocol to be registered before data collection begins. The paper explicitly states the registration was retrospective, dated December 21, 2025, whereas data collection occurred during the 2019-2020 academic year. The registry ID (IRCT2024...N2) is itself consistent with a first registration no earlier than 2024, years after data collection. Registration therefore occurred well after data collection, not before it. Criterion P is not met because the trial was registered retrospectively, long after data collection had been completed.