The online inverted classroom model (oICM). A blueprint to adapt the inverted classroom to an online learning setting in medical and health education

This article was migrated. The article was marked as recommended. The idea of this paper is to offer a blueprint, to guide educators setting up a complete digital teaching scenario according to the latest insights of educational research. The COVID-19 pandemic forced higher education institutions all around the world to radically shift their curricula from a mix of face-to-face and remote teaching methods to a fully remote curriculum. Though challenging, this time provides opportunities to implement new educational methods and to improve the quality of digital teaching. The concept of the inverted classroom was modified to meet the special needs of the new online settings. The proposed online Inverted Classroom Model (oICM) includes the following phases: (1) pre-phase, (2) self-learning-phase, (3) synchronous online phase, (4) transfer-phase, and (5) evaluation. Recommendations and potential tools are provided for each phase. The oICM is an innovative and easy to use approach to shape digital teaching and learning processes during and after the COVID-19 pandemic. This blueprint is developed by the committee “Digitalization” of the German Association for Medical Education (GMA), mainly for educators who are familiar with the Inverted Classroom Model (ICM) or similar blended learning formats.


Introduction
During the CoVid19 pandemic, educational institutions had to quickly adapt their curricula to digital teaching.Despite the lack of resources, such as time and experts for digital teaching, the shift in education moved from traditional lectures and seminars to online learning environments.Hence, we face a state that can be best described by "Emergency Remote Teaching" (Hodges et al., 2020).This is a challenging time, but it also holds opportunities to improve the quality of digital teaching and learning if implemented appropriately.We would like to offer an approach to face the challenge of digital teaching and to implement a new way of online teaching using an existing concept and modifying it to the special needs of this time plus the time after the pandemic.Thus, we propose a blueprint for the application of the inverted classroom model (ICM) in an online setting to minimize the disadvantages of online teaching and to achieve real benefits with digital teaching methods.

The traditional Inverted Classroom Model
According to several meta-analyses, the inverted or flipped classroom method (ICM) showed positive effects regarding engagement, motivation, overall satisfaction, and learning outcomes (Chen, Lui and Martinelli, 2017;Lo, Hew and Chen, 2017;Cheng, Ritzhaupt and Antonenko, 2019;Låg and Saele, 2019;van Alten et al., 2019;Strelan, Osborn and Palmer, 2020).ICM has successfully been implemented in healthcare education (McLaughlin et al., 2014;O'Flaherty and Phillips, 2015;Tolks et al., 2016;Chen, Lui and Martinelli, 2017;Hew and Lo, 2018).The idea behind the concept of the inverted classroom is to use the face-to-face time for the more challenging part of knowledge application, instead of presenting the conceptual knowledge in a lecture in which students have to take a passive role (Lage, Platt and Treglia, 2000).The overall goal is to focus the face-to-face phase on the interactions between students and teacher and to solve problems that may arise during the knowledge application.According to Bloom's taxonomy, the ICM creates a learning environment that enables the learner to reach a higher level of cognition (Anderson et al., 2013).One of the basic ideas behind the concept is to engage the learner based on the concept of active learning (Snyder, 2003).

The online Inverted Classroom Model (oICM)
Faced with the challenges of the corona pandemic, universities had to adapt their curricula to online methods quickly.The traditional ICM proposed by Tolks et al. was adapted purposefully for the new online approach (see Figure 1) (Tolks et al., 2016).This blueprint was mainly designed for educators without prior experience with the ICM, who already use blended learning or especially the traditional ICM.However, teachers with no prior experiences can also use this blueprint but probably will require more preparation and maybe guidance.
Online teaching can be differentiated in synchronous vs. asynchronous delivery modes.In synchronous teaching learners and teachers meet at the same time with video conferencing tools.In asynchronous teaching, learning media is produced and, for example, provided via a learning management system (LMS), where learners consume content ad libitum.The advantages and disadvantages of both modes are listed in Table 1.
As mentioned before, the most important part of the oICM is to maintain learner activation.Active rather than passive learning requires the involvement of students in the learning process, resulting in a more intense learning experience that goes beyond memorization (Snyder, 2003).Active learning leads to more sustainable knowledge acquisition and promotes problem-solving skills (Chi and Wylie, 2014).Furthermore, activities and interaction create a more learnercentered environment and are based on constructivist teaching rather than a direct instructional, mainly unilateral approach (Salmon, 2013).Designing clear learning outcomes for online learning is just as important as for face-to-face environments.

Pre-phase
Before starting to teach, the learners have to be informed about the concept and process of the oICM, technical requirements, learning outcomes and expectations.It is important to offer the possibility to co-shape (e.g. a short presurvey) and to use communication channels for your learners.This can be done via your LMS or by e-mail or a short synchronous session.At this stage students should be able to explain why they want to participate.What makes the course interesting?Therefore, special attention should be paid to the learning experience from the beginning (e.g.intuitive learning tools, clear structure of the learning process).

Online Self-learning phase
As for ICM, in this asynchronous phase, it is important to provide learning material that targets the needs of your students.Students are used to learn from videos so we recommend using videos as a source for online learning (Hurtubise et al., 2013) as well as interactive tools.There are a fast variety of different methods and tools available.For some recommendations, you can look at the list of the digital tools (German) from the committee "Digitalization" of the German Association for Medical Education (GMA): tinyurl.com/ADTLLGMAThere are many ways to create learning content using videos.We would endorse three different approaches.
The easiest way to create great videos is by using screencasts.Screencast software (e.g.Screen-O-Matic, SnagIt) allows you to record your presentation together with your speech.You may also include a video of you while talking.These programs are mostly free of charge and easy to use.Be aware that the presentation does not have to be perfect from a technological and rhetorical point of view.A study by Carpenter et al. (2013) has shown, that, with imperfect presentations, learners have a higher cognitive activity and a better knowledge retention rate compared to perfect presentations.Care should be taken to ensure that presentations are not overloaded with content and complex animations, but are structured, in high-resolution and reduced to essential elements.This applies especially to online teaching.To support the learning process, a handout could be useful.You can also use existing video tools that help you create innovative learning videos with cartoons (PowToon) or draw images with a digital pencil.
Another possibility is to record the speaker with a camera.This is often used in massive open online courses (MOOCs).These learning videos were analyzed in a study by Guo, Kim and Rubin (2014) regarding the engagement rate of students.To improve learner engagement, the following recommendations can help to improve the quality of the videos:  During the online self-learning phase, quizzes engage the learners during and after the learning sessions and offer a way to assess their learning process.At the end of the self-learning phase, a final quiz should be implemented to assess the learning status of the group.If any problems or low rates in quiz occur, the teacher can address them in the upcoming online face-to-face phase.Most LMS provide tools for assessment and self-assessment.

Synchronous, online face-to-face phase
In an ICM setting the self-learning phase is followed by a face-to-face phase.One way to reduce the limitations of an online scenario such as low retention and engagement rates of students is to use synchronous online meetings.In oICM, this phase will take place online using video conferencing tools (VCTs), such as AdobeConnect, Zoom, or GoToMeeting.As in ICM, the session is moderated by the educator in real-time and in an interactive way.Depending on the number of students, this can be realized in form of interactive webinars or small group discussions making use of the small group rooms most VCTs offer.
In addition to VCTs and in order to engage the learner you can use various, easy-to-use, digital tools.Helpful tools are audience response systems (ARS) such as Kahoot!, Mentimeter, and/or Pingo or VCT integrated tools.Applying those programs, the facilitator can quiz students, create word clouds, rate questions, and use gamification approaches such as points, leaderboards, and badges (Sailer and Homner, 2019).The (o)ICM offers a good structure to implement gamification aspects within the learning scenario (Sailer and Sailer, 2020).Addressing questions with the help of ARS continuously activates participants to collaborate on the content and thus allow a more thorough reflection.While in traditional teaching sessions potentially more than half of all present participants are mentally distracted, ARS effectively counteracts this.Overall, they have a proven positive effect on learning outcomes (Nelson et al., 2012;Szpunar, Moulton and Schacter, 2013).In addition, the facilitator receives feedback from a large proportion of those present.A further benefit for the use of ARS in the oICM: Once an interactive quiz is used, learners are more likely to use the chat or audio connection for discussion.
This way, the moderator gets feedback, and it lowers the barrier for students to participate actively by talking or using the chat function.Case-based learning and problem-oriented learning can be easily facilitated by combining an onlinemeeting with collaborative online documents.For creating complex classifications, students might be asked to build a concept map (e.g.Miro, MindMap or integrated whiteboard in ZOOM).
For students not attending the online synchronous meeting, the session can be recorded and uploaded to the LMS.In this case, every participant must agree to the recording and its use.However, we recommend including some additional homework to avoid a drop-out of the regular online sessions.

Transfer phase
The transfer phase deepens the learning outcome with another asynchronous learning session, where the learner will be challenged to apply their knowledge and transfer it to other content domains or contexts.This can be achieved with small projects students have to work on collaboratively, e.g.solving problems, virtual patients, virtual labs or let students develop cases or videos themselves.

Evaluation
After the oICM, it is also important to evaluate the process and outcome of the curriculum.Especially the online face-toface phase should be critically assessed in the evaluation as it is a new approach within the ICM concept.We recommend integrating the evaluation into the online face-to-face meeting to enhance the response rate.
There already exist validated tested evaluation questionnaires for traditional teaching sessions like lectures and seminars (Perry and Smart, 2007;Schiekirka et al., 2015).However, it is possible to develop a short evaluation questionnaire for oICM based on existing instruments of traditional teaching and online teaching.In Appendix 1, we provide some examples for items structured by different aspects of teaching.

Conclusion
The oICM is based on the traditional ICM.The focus is on synchronous digital teaching, the activation of learners, and making use of VCTs and ARS.The oICM concept supports educators in transferring their previous face-to-face teaching into online teaching in a structured and meaningful way.
An advantage of the oICM concept is that after returning to face-to-face teaching nearly all the phases can be used without changes.The synchronous phase can be easily transformed into face-to-face teaching such as small group sessions or seminars including transferring the concept and content for using ARS.
Thus, with a few modifications of the existing ICM concept and with this easy-to-use approach presented here, it is possible to significantly improve digital teaching and support students in their learning process.Another positive aspect is that the oICM can be used even after the pandemic as ICM.The online learning material provided can be used during the self-learning phase for the teaching concept.The online ARS can be used during the face-to-face phase to activate the learners.Before, during and after the CoVid19 pandemic, oICM is an innovative approach to shape digital teaching and learning processes.
We hope that with this blueprint educators will be able to develop their own oICM teaching concepts, that also can be used after the pandemic and additionally build concepts that are feasible for the future.We would like to encourage all educators to invest more time in their teaching concept now and use this blueprint so that these challenging times have a positive impact on teaching.

Take Home Messages
The online Inverted Classroom Model (oICM) is an innovative and easy to use approach to shape digital teaching and learning processes during and after the CoVid19 pandemic.With a few modifications of an existing ICM concept educators can transform their face-to-face teaching activities into digital teaching.
The most important part of this concept is to maintain learner activation with synchronous digital teaching using video conferencing tools (VCRs) and audience response systems (ARS).Completely Partially Not at all n.a.

Notes On Contributors
I have used/worked with the provided online learning materials.
Completely Partially Not at all n.a.
The learning content of the provided materials was understandable.
5 Point Likert Scale for agreement n.a.
Which online activities were particularly helpful for you and why?
Free text question

Didactics and support
The learning goals that I was supposed to achieve were clarified at the beginning.
5 Point Likert Scale for agreement n.a.
The online activities in this teaching session had clear tasks and goals.
5 Point Likert Scale for agreement n.a.
During online activities the teacher supported me well.
5 Point Likert Scale for agreement n.a.
The lecturer responded well to questions and suggestions.
5 Point Likert Scale for agreement n.a.
I was encouraged to critically reflect upon the contents taught.
5 Point Likert Scale for agreement n.a.
Learning success I can give an overview of the contents of the teaching session.
5 Point Likert Scale for agreement n.a.
Measured by my previous knowledge, I learned a lot during the teaching session.
5 Point Likert Scale for agreement n.a.
Overall rating I particularly liked the following aspects of the teaching session:

Free text question
The following three aspects should be improved:

Free text question
Overall, I rate the attended teaching session with: 5 Point Scale: excellent to insufficient n.a.

Stijntje Dijk Erasmus Medical Center
This review has been migrated.The reviewer awarded 4 stars out of 5 The authors provided a helpful blueprint to medical teachers seeking to use a flipped-classroom approach in an online environment setting.In this helpful paper, they lay out steps to consider, from rationale, preparation of asynchronous learning materials, the synchronous session, a short note on transfer of knowledge, and the evaluation.The paper provides those with an interest in the topic with a collection of tips and tricks mostly regarding the preparation of learning materials.Additionally, the authors are to be congratulated on the diverse group of contributors to this paper.I have some notes in reaction to the paper, none of which require a full revision of the paper by themselves, but could be taken into account for future work / planned revisions:-The paper does not contain a section / explanation / reflection on how the blueprint came to be.Although it is a review of literature much more than empirical research, the paper may benefit from a section added to the introduction or elsewhere describing the methodology of writing the paper would be helpful.-Thepaper focusses mostly on the presentation of information (short/long videos, powerpoint vs alternatives, the use of quizzes).When thinking about the creation of learning content, a crucial part of the design of educational material is also the actual content: What type of learning objectives/topics could be more / less suited for this format?Crucially, next to what formats/platforms/tools to use, how can the facilitator assess that students prepared for the session and correctly understood the material?What happens in the transfer phase, how can a facilitator guide students to ensure that knowledge is further deepened and not lost?I would consider two approaches to these rising questions: to either specify that the blueprint specifically aims to guide choices in preparation of learning material rather than all aspects of flipped learning, or to dedicate additional attention to the assessment of learning.-Ashort note on terminology: I had difficulty finding out what "Khan-style tablet drawings" were, I assume this is a reference to the platform Khan Academy?Additionally, Powtoon is spelled as Powton.I would like to thank the authors for providing this blueprint, which can be very helpful to those seeking tools and tips to make their online teaching more engaging.
need to be addressed.•The paper says that "This blueprint is designed for teachers without any prior experience with the ICM, but also for those who already teach in a traditional ICM".I think, however, if someone has never used ICM before, then there would have to be far more training than this blueprint, and I think the authors are a little blasé about just how difficult it is for people to transition from old-style didactic teaching to any ICM process (if it were easy, everybody would be doing it).So, I think that the authors should make it clear that this would serve those who already use ICM in face-to-face teaching; those who don't would do well to team up with a person experienced with ICM, or, if they have access to decent educational support structures, then consult and be guided by those.• The "Pre-phase" and "Transfer phase" could do with some expansion and examples, especially as this paper would be mostly beneficial to novices.Smaller issues• I am presuming that the heading "3.1 Pre-phase" corresponds to the portion "Online information Phase" in Figure 1.If so, this should be made clearer (either use the same words, or refer directly to it); if not, then it should be explained.•Although the abbreviations in Figure 1 are explained later in the text, they should also be given as a key to Figure 1.This is in keeping with the standard process of expanding an abbreviation the first time it is used anywhere in the paper.I look forward to Version 2 of this paper in which these issues are addressed.
Competing Interests: No conflicts of interest were disclosed.

Table 1 .
Advantages and disadvantages of synchronous and asynchronous delivery modesVideo produced with a more personal feel could be more engaging than high-fidelity studio screencasts Khan-style tablet drawings tutorials are more engaging than Powerpoint slides Videos, in which instructors speak fast and with enthusiasm, are more engaging Students engage differently with lecture and tutorial videos A third approach is based on Open Educational Resources (OER).You can always use freely available learning content that is offered under an open-access license.Many universities offer their high-quality learning material including universities like Oxford, Harvard, Cambridge, or the Massachusetts Institute of Technology.Or you look at special databases e.g.Open Education EU to find suitable learning material.
Dr. Daniel Tolks studied public health and is a post-doc researcher at the chair for medical education at the Medical Faculty of LMU Munich and at the Centre for Applied Health Promotion at the Leuphana University Lüneburg.His research interests are technology enhanced learning, gamification and serious games for health.He is chair of the commitee "Digitalization" of the German Association for Medical Education and the German Network Gamification and Herdecke University, Germany.His research interests are digital transformation of health care, technology enhanced learning and higher education didactics.ORCID iD: https://orcid.org/0000-0001-6306-4173SebastianKuhn,MD, MME is a Orthopedics and Trauma surgery and Medical Educator.His research interest on digital transformation an artificial intelligence in healthcare and education.ORCID iD: https://orcid.org/0000-0002-8031-2973MPH is a research associate and post-doc researcher at the chair for medical education at the Medical Faculty of LMU Munich and works in the field of evaluation studies, questionnaire construction and validation, graduate studies with a focus on the scientific, professional and social skills development, and health research capacity development.Martin Fischer, MD, MME, FAMEE, is an internist, endocrinologist, and medical educator.He holds the chair for medical education and serves as the Assoc.Dean of Clinical Studies at the Medical Faculty of LMU Munich, Germany.His research interests are clinical reasoning skills, faculty and curriculum development, and technology-enhanced learning.ORCID iD: https://orcid.org/0000-0002-5299-5025ChristophBohne is a research scientist and specialist for educational technology at the Brandenburg Medical School Theodor Fontane.
Medical School, and a Master of Medical Edication in Heidelberg in 2017.ORCID iD: https://orcid.org/0000-0002-9693-3870JanP.Ehlers, DVM, MA, FTA, is a veterinarian, instructional designer and medical educator.Her holds the chair for didactics and educational research in healthcare at the medical department and serves as vice president of Witten/ Luisa Merz has a Master's degree in Sociology and works at the Center for International Health at LMU University Hospital as a coordinator of training programs and courses in the field of Global Health with a focus on e-learning and international courses.In addition to various e-learning projects, she has coordinated a blended learning master program in the field of International Occupational Safety and Health.MichaelSailer is a postdoctoral scholar at the Chair of Education and Educational Psychology at LMU Munich.He is currently conducting research about gamified learning, simulation-based learning and the use of technology in classrooms.ORCID iD: https://orcid.org/0000-0001-6831-5429IngaHege, MD, MCompSc, is an Associate Professor for Medical Education at the Medical School, University of Augsburg, Germany.ORCID iD: https://orcid.org/0000-0003-4335-5162PPTslidesets, summaries) Online (group) task Figure 1.Source: the authorsTable 1: Source: the authors Appendix 1: Source: the authors van Alten, D. C. D., Phielix, C., Janssen, J. and Kester, L. (2019)Effects of flipping the classroom on learning outcomes and satisfaction: A meta-analysis.Educational Research Review.28.Guo, P. J., Kim, J. and Rubin, R. (2014) How video production affects student engagement: an empirical study of MOOC videos.in.ACM Press, pp.41-50.McLaughlin, J. E., Roth, M. T., Glatt, D. M., Gharkholonarehe, N., et al. (2014) The flipped classroom: a course redesign to foster learning and engagement in a health professions school.Academic Medicine: Journal of the Association of American Medical Colleges.89(2), pp.236-243.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.