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The teaching problem
Fluid and electrolyte balance is a core concept that prelicensure nursing students often find hard, because it combines physiology, laboratory values and clinical judgment. In the traditional lecture described in this paper, most class time goes to explaining facts, and students have little chance to apply them. Exam results show students can define hyperkalemia but struggle to prioritize care for a patient with it. The course and its results are illustrative.
Evidence for the flipped classroom
In a flipped classroom, students learn the basic content before class, usually through pre-recorded videos, and class time is used for active learning. A meta-analysis of 28 comparative studies in health professions education, including nursing, found a significant overall effect in favor of flipped classrooms over traditional ones (standardized mean difference 0.33). The approach was more effective when instructors began each class with a quiz, and more students preferred it to traditional teaching (Hew & Lo, 2018).
Writing objectives with Bloom's revised taxonomy
The revised taxonomy has two dimensions: a cognitive process dimension (remember, understand, apply, analyze, evaluate and create) and a knowledge dimension (factual, conceptual, procedural and metacognitive knowledge; Krathwohl, 2002). Moving objectives up the cognitive process dimension matches the move from lecture to application.
| Phase | Objective: by the end, students will be able to… | Cognitive process |
|---|---|---|
| Before class | State normal ranges for sodium, potassium and calcium | Remember |
| Before class | Explain how aldosterone and antidiuretic hormone regulate fluid balance | Understand |
| In class | Calculate a patient's 24-hour intake and output and identify a fluid deficit | Apply |
| In class | Analyze a patient's labs, ECG and medications to identify the cause of hyperkalemia | Analyze |
| In class | Prioritize nursing actions for two patients with electrolyte imbalances and justify the order | Evaluate |
The lesson plan
Before class (60 minutes). Two 12-minute videos on fluid compartments and electrolyte regulation, a one-page summary table of normal values, and a 10-question online quiz with feedback.
In class (3 hours):
- Readiness quiz (15 minutes). Five questions answered individually with a polling tool, then discussed. The meta-analysis found starting class with a quiz strengthened the effect (Hew & Lo, 2018).
- Mini-review (15 minutes). The educator addresses only the concepts most students missed.
- Unfolding case study (90 minutes). In small groups, students follow a patient with heart failure who develops hypokalemia on a loop diuretic, then hyperkalemia after starting spironolactone with acute kidney injury. Each stage asks groups to interpret data and choose actions.
- Prioritization exercise (30 minutes). Groups rank the care of two patients and defend their choices to the class.
- Exit ticket (10 minutes). "The one thing I'm still unsure about is…"
Evaluation
- Learning: unit exam items written at the apply, analyze and evaluate levels, compared with the previous year's results.
- Engagement: completion of the pre-class quiz.
- Student experience: a short survey on preparation time and usefulness.
Anticipated challenges
Some students won't prepare, which weakens the in-class activities. Short, graded pre-class quizzes and making clear that class time builds on the videos encourage preparation. Faculty also need time to record videos and design cases, so the course could flip one unit at a time.
References
Hew, K. F., & Lo, C. K. (2018). Flipped classroom improves student learning in health professions education: A meta-analysis. BMC Medical Education, 18, Article 38. https://doi.org/10.1186/s12909-018-1144-z
Krathwohl, D. R. (2002). A revision of Bloom's taxonomy: An overview. Theory Into Practice, 41(4), 212–218. https://doi.org/10.1207/s15430421tip4104_2
