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Radford university.

Learning Domain: Social Work

Standard: Basic Research Methodology

Lesson 10: Sampling in Qualitative Research

Lesson 11: qualitative measurement & rigor, lesson 12: qualitative design & data gathering, lesson 1: introduction to research, lesson 2: getting started with your research project, lesson 3: critical information literacy, lesson 4: paradigm, theory, and causality, lesson 5: research questions, lesson 6: ethics, lesson 7: measurement in quantitative research, lesson 8: sampling in quantitative research, lesson 9: quantitative research designs, powerpoint slides: sowk 621.01: research i: basic research methodology.

The twelve lessons for SOWK 621.01: Research I: Basic Research Methodology as previously taught by Dr. Matthew DeCarlo at Radford University. Dr. DeCarlo and his team developed a complete package of materials that includes a textbook, ancillary materials, and a student workbook as part of a VIVA Open Course Grant.

The PowerPoint slides associated with the twelve lessons of the course, SOWK 621.01: Research I: Basic Research Methodology, as previously taught by Dr. Matthew DeCarlo at Radford University. 

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Lecture Notes on Research Methodology

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Research Methodology in Health Sciences ( Epidemiology + Statistics )

Nov 09, 2019

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Research Methodology in Health Sciences ( Epidemiology + Statistics ). Önder Ergönül, MD, MPH İlker Kayı, MD. Summer Course on Research Methodology in Medical Sciences July 10-21, 2017, Istanbul. Summer Course on Research Methodology in Medical Sciences

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• relative risk
• smallpox vaccine
• public health
• case fatality rate
• incidence rate incidence density

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ResearchMethodology in HealthSciences(Epidemiology+ Statistics) Önder Ergönül, MD, MPH İlker Kayı, MD SummerCourse on ResearchMethodology in MedicalSciences July10-21, 2017, Istanbul

SummerCourse on ResearchMethodology in MedicalSciences June 16-20, 2014, Istanbul Aims • Read a scientific manuscript • Write a scientific manuscript • Study design • P value • Effect estimates (relative risk, odds ratio, hazard ratio) • Interpretations of the study results Learning Objectives

Objectives of the talk • Emergenceanddevelopment of epidemiology • Historicalremarks • Measuringdiseaseoccurence

What is Epidemiology? “A discipline, whichexploresthecausality of thediseases” “A discipline, whichdividesthepeopleintogroups” “Epidemiology is not tomisstheforest, whilelooking at thetrees” “Epidemiology is toestablishtheassociationbetweentheexposuresandtheoutcome”

Epidemiology • Identifycausesand risk factorsfordisease • Determinetheextent of disease in thecommunity • Studynaturalhistoryandprognosis of disease • Evaluatepreventiveandtherapeuticmeasures • Providefoundationforpublicpolicy 6. Evidencebasedmedicinefordecisionmaking

EPI (on/ upon) + DOMOS (people) + OLOGY (Study) Symptoms, Progress Whywastheagentpresent in theenvironment Who, when Where, how

I keepsixhonestserving men, theytaughtmeall I knew. Theirnamesare what, why, when, how, where, who. RudyardKipling, 1865-1936

TheEvolution of Epidemiology in Modern Era • Graunt; Natural andPoliticalObservations on theBills of Mortality 1835 Farr; Mortality, life tables 1854 Snow; cholera 1950-80 BoomforEpidemiology: cohortstudies >2000 Emerginginfections, genetics, cardiology Rothman K, IJE 2007

William Farr (1807-1883) In Great Britain medical registration of deaths had been introduced in 1801 and in1838 William Farr introduced a national system of recording causes ofdeath. Once the mechanism started to work it provided a wealth of data which Farrhimself first analyzed with great skill, making full use of life table techniques (close inmost details to those in present day use) and of procedures for standardizing rates. Hewas also instrumental in building up a classification of diseases for statistical purposes, at bothnationalandinternationallevels.

1831-1832 22 000 deaths 1848-1849 52 000 deaths 1853-1854 John Snow’sstudies Thelastoutbreak: 1866 2 200 deaths

TheRevolutionarySteps in PublicHealth in recent 200 years Theuse of chlorine in thewater Snowremovedthehandle of thepump Koch Germ theory Malaria control Polio eradication 2001 1850 1882 1915 1963 1853 1885 1944 1953 1977 1796 Smallpoxvaccine is obligatory in UK Pasteur Rabiesvaccine, pasteurization Penicillin Salk poliovaccine Jenner smallpoxvaccine Smallpoxeradication

Pellagra: mal de la rosa Firstly identified among Spanish peasants by Don Gaspar Casal in 1735. 4 D: dermatitis, diarrhea, dementia, death. In 1937 it was discovered that pellagra was caused by a deficiency of the B vitamin niacin (nicotinic acid).  The body’s synthesis of this vitamin depends on the availability of the essential amino acid, tryptophan, which is found in milk, cheese, fish, meat and egg. 

TheCause of Pellegra: DietversusGerm? 1912, South Carolina, 30,000 cases of pellagra, with a case fatality rate of 40 per cent.  The disease was not confined to Southern states, however, and the US Congress asked the Surgeon General to investigate the disease.  In 1914 he appointed Joseph Goldberger (1874-1929), a medical officer in the US Public Health Service, to lead the investigation.

The Role of ObservationalStudies Goldberger believed that an infectious disease was unlikely to distinguish between inmates and employees or so systematically between rich and poor, and he favoured the hypothesis that a superior diet protected people from pellagra. He had also in mind the case of beri-beri, a disease which had recently been shown to be responsive to dietary interventions. (Vandenbroucke 2003).

Leukemia in Shoeworkers Exposed Chronically to Benzene Shoeworkers benzene leukemia Muzaffer Aksoy, Blood, 1974

Int J AntimicrobialAgents2008

TheCausalPie Model

CausalRelationbetweenIndependentanddependentvariables

Interpretation of an epidemiologicstudy Is there a validstatisticalassociation? Is theassociationlikelyto be duetochance? Is theassociationlikelyto be duetobias? Is theassociationlikelyto be duetoconfounding? Can thisvalidassociation be judged as causeandeffect? Is there a strongassociation? Is therebiologiccredibilitytothehypothesis? Is thereconsistencywithotherstudies? Is thetime sequencecompatible? Is thereevidence of a dose-responserelationship?

ComparingDiseaseOccurence • Absolutecomparisons • Risk • Risk density • Risk difference • Attributablefraction • Relativecomparisons • Relative risk • Attributable risk • Oddsratio

Ratio, Proportion, Rate

PrevalenceandIncidence Number of existingcases of a disease P= at a givenpoint of time CI = P= incidence x duration Total population Number of newcases of a diseaseduring a givenperiod of time Total population at risk CI = Cumulativeincidence

Incidence rate = incidencedensityA / time Number of newcases of a diseaseduring a givenperiod of time CI = Total person time of observation

Risk = A / N Number of subjectsdevelopingdiseaseduring a time period Risk= Risk = Incidence rate x time Risk: 0-1, probability Number of subjectsfollowedforthe time period risk time

MortalityandFatality CaseFatality Rate: Number of fatalcases Number of patients Mortality: Number of fatalcases Total population E.g. HIV have a high CFR but lowmortality in Turkey Attack rate: Number of newcases Population at risk

Relative Risk RR = = RR= incidence in exposed / incidence in nonexposed a / (a + b) Risk of exposedgroup c / (c + d) Risk of nonexposedgroup

When OR is closeto RR: Rarediseaseassumption RR= = = = OR a/ (a+b) a / b ad c/ (c+d) c / d bc

The Confidence Interval for the Effect Size

Confidence Intervals  When an estimate is presented as a single value, such as an odds ratio, we refer to it as a point estimate of the population odds ratio. When we compute a confidence interval, we form a interval estimate of the value. A confidence interval is called an interval estimate, which is a interval (lower bound , upper bound) that we can be confident covers, or straddles, the true population effect with some level of confidence. The interpretation of a 95% confidence interval for the odds ratio is (van Belle et al, 2004, p.86): The probability is 0.95, or 95%, that the interval (lower bound , upper bound) straddles the population odds ratio.

Risk Difference / Attributable Risk Therisk difference (RD) orattributable risk (AR) is a measure of associationthatprovidesinformationabouttheabsoluteeffect of theexposureortheexcess risk of disease in thoseexposedcomparedwiththosenonexposed. AR = IRe-IRo Attributablefraction = = Goodtoseetheattribution of theexposure RD Re-Ro R1 Re

Summary:Objectives of the Course Program 1.Bias 2.Confounder 3. Chance StudyDesign Data collection Epidemiology Analysis: Statisticalmethods

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A COURSE IN RESEARCH METHODOLOGY 2018.pptx

This teaching paper is an introdcution to the field of research methodology as it enables beginners (students) to understand basic things about research, research techniques , research design and research procedure. The general aim behind this teaching paper is to facilitate the task of students to tackle this complicated field with confidence and ease.It covers a lot of courses and it can be taught to different levels of students: BA, MA and even PHd students.

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Wafae Barkani

Xochitl Ortiz

The authors felt during their several years of teaching experience that students fail to understand the books written on Research Methodology because generally they are written in technical language. Since this course is not taught before the Master’s degree, the students are not familiar with its vocabulary, methodology and course contents. The authors have made an attempt to write it in very non- technical language. It has been attempted that students who try to understand the research methodology through self-learning may also find it easy. The chapters are written with that approach. Even those students who intend to attain high level of knowledge of the research methodology in social sciences will find this book very helpful in understanding the basic concepts before they read any book on research methodology. This book is useful those students who offer the Research Methodology at Post Graduation and M.Phil. Level. This book is also very useful for Ph.D. Course Work examinations.

Anil Jharotia

Research is an important activity of any nation and societies for generating the information to its developments. Robust collection of qualitative information helps in the development of the any nations. Research & Development is an important tool for acquiring new knowledge in any field of human survival. Various type of problems and questions need to use research methodology depend on the rationale of researchers. How to use the research for finding answers of any research questions/problems.

https://www.ijrrjournal.com/IJRR_Vol.6_Issue.3_March2019/Abstract_IJRR0011.html

International Journal of Research & Review (IJRR)

Research methodology is a way to systematically solve the research problem. It may be understood as a science of studying how research is done scientifically. In it we study the various steps that are generally adopted by a researcher in studying his research problem along with the logic behind them. It is necessary for the researcher to know not only the research methods/techniques but also the methodology. Researchers not only need to know how to develop certain indices or tests, how to calculate the mean, the mode, the median or the standard deviation or chi-square, how to apply particular research techniques, but they also need to know which of these methods or techniques, are relevant and which are not, and what would they mean and indicate and why. Researchers also need to understand the assumptions underlying various techniques and they need to know the criteria by which they can decide that certain techniques and procedures will be applicable to certain problems and others will not. All this means that it is necessary for the researcher to design his methodology for his problem as the same may differ from problem to problem.

Scholarly Communication and the Publish or Perish Pressures of Academia A volume in the Advances in Knowledge Acquisition, Transfer, and Management (AKATM) Book Series

Dr. Naresh A . Babariya , Alka V. Gohel

The most important of research methodology in research study it is necessary for a researcher to design a methodology for the problem chosen and systematically solves the problem. Formulation of the research problem is to decide on a broad subject area on which has thorough knowledge and second important responsibility in research is to compare findings, it is literature review plays an extremely important role. The literature review is part of the research process and makes a valuable contribution to almost every operational step. A good research design provides information concerning with the selection of the sample population treatments and controls to be imposed and research work cannot be undertaken without sampling. Collecting the data and create data structure as organizing the data, analyzing the data help of different statistical method, summarizing the analysis, and using these results for making judgments, decisions and predictions. Keywords: Research Problem, Economical Plan, Developing Ideas, Research Strategy, Sampling Design, Theoretical Procedures, Experimental Studies, Numerical Schemes, Statistical Techniques.

Hafizi Saari

Dr. Moses Gweyi

This book is the outcome of more than four decades of experience of the author in teaching and research field. Research is a creative process and the topic of research methodology is complex and varied. The basic premise for writing this book is that research methods can be taught and learnt. The emphasis is on developing a research outlook and a frame of mind for carrying out research. The book presents current methodological techniques used in interdisciplinary research along with illustrated and worked out examples. This book is well equipped with fundamentals of research and research designs. All efforts have been made to present Research, its meaning, intention and usefulness. Focussed in designing of research programme, selection of variables, collection of data and their analysis to interpret the data are discussed extensively. Statistical tools are complemented with examples, making the complicated subject like statistics simplest usable form. The importance of software, like MS Excel, SPSS, for statistical analyses is included. Written in a simple language, it covers all aspects of management of data with details of statistical tools required for analysis in a research work. Complete with a glossary of key terms and guides to further reading, this book is an essential text for anyone coming to research for the first time and is widely relevant across the disciplines of sciences. This book is designed to introduce Masters, and doctoral students to the process of conducting scientific research in the life sciences, social sciences, education, public health, and related scientific disciplines. It conforms to the core syllabus of many universities and institutes. The target audience for this book includes those are going to start research as graduate students, junior researchers, and professors teaching courses on research methods. The book entitled “A guide to Research Methodology for Beginners” is succinct and compact by design focusing only on essential concepts rather than burden students with a voluminous text on top of their assigned readings. The book is structured into the following nine chapters. Chapter-1: What is Scientific Research? Chapter-2: Literature Review Chapter-3: How to develop a Research Questions & Hypotheses Chapter-4: Research Methods and the Research Design Chapter-5: Concept of Variables, Levels and Scales of Measurements for Data collection Chapter-6: Data Analysis, Management and Presentation Chapter-7: Tips for Writing Research Report Chapter-8: Glossary Related to Research Methodology Chapter-9: References It is a comprehensive and compact source for basic concepts in research and can serve as a stand-alone text or as a supplement to research readings in any doctoral seminar or research methods class. The target audience for this book includes those are going to start research as graduate students, junior researchers, and professors teaching courses on research methods.

Yuanita Damayanti

Khamis S Moh'd

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Research Methodology Course for Postgraduate Students by National Medical Commission: A Welcome Step That Needs Complimentary Action

Ajay gajanan phatak.

Central Research Services, Bhaikaka University, Karamsad, Gujarat, India

After decades of administrative hibernation, the Medical Council of India (MCI), now National Medical Commission (NMC), started deliberating on reforms in medical education a few years back. The MCI/NMC introduced vertical corrective actions, yet there is a need for horizontal integration, and these measures require adequate guidance on implementation strategies. All postgraduate medical students must conduct a research project as a “Thesis.” This crucial opportunity to instill scientific thinking is excellent, along with patient care and clinical training. This opportunity has a long-term impact on clinical practice and research and development in medicine if implemented well. To enforce this step, the Board of Governor introduced a compulsory course in basic research methods for all postgraduate medical students, but alas, without adequate deliberations on implementation and complementary mechanisms. This critical review provides a brief history of the evolution of medicine and medical education in India and reforms in medical education. Further, it presents a balanced critique of the process, intending to brainstorm in improving the process and achieving the expected outcome from this course. Albeit many relevant issues need attention, this article will focus mainly on ways to leverage infrastructure optimally to imbibe scientific thinking in medical students of India with cursory deliberation of the relevant issues.

The Medical Council of India (MCI) governs the medical education and medical profession in India. The Board of Governors (BoG) superseded MCI from September 2018 as a transitory arrangement. A new body National Medical Commission (NMC), in September 2020, replaced MCI. The BoG made it mandatory for all postgraduate students to complete an online course in “Research Methods” through a Gazette notification (No. MCI-18 (1)/2019-Med./171700) dated December 13, 2019. [Available from: https://drive.google.com/file/d/1wFW3HPVy2GrtDbshJKwchNn2Wm5Y4829/view ].

E VOLUTION OF M EDICINE AND M EDICAL E DUCATION IN I NDIA

India is a land that witnessed one of the most ancient and flourishing civilizations in the world. It has a rich cultural as well as scientific heritage. A multitude of medical systems developed in India, including Naturopathy, Siddha, and Unani, although Ayurveda dominated the Indian medical system for eras. Ayurveda is a part of the Atharva-Veda and means “Science of Life.” It is one of the oldest medical systems that emphasize a holistic approach to health. Ayurveda developed through an organized theoretical framework supplemented with reasoning and critical thinking. Two subspecialties of Ayurveda, namely Dhanvantari and Atrey strengthened over centuries. Dhanvantari paved the way for the school of physicians, and Atrey paved the way for the school of surgeons. Charaka Samhita and Sushruta Samhita are early classical texts in these subspecialties.[ 1 ]

Sushruta considered the father of surgery, elaborated on various surgical instruments and used gourds and dead animals for low-fidelity simulation training. The education system was residential and supported by the rulers and people at large.[ 2 ] Unfortunately, foreign invasions and an unstable socio-political milieu hampered the organized education system.[ 1 ] Portuguese introduced modern medicine or allopathy to India in the 16 th century, and the East India Company established the medical departments in the then Bombay, Bengal, and Madras presidencies in 1775 catering to military and British citizens in India. In due course of time, establishing various medical colleges to train the natives in Western medicine, albeit initially, it was proposed for financial reasons. Portuguese also started a medical college in Goa in 1840. After some initial hiccups, Western and India's indigenous medical systems like Ayurveda, Unani etc. started contemplating but the later withered as they were ridiculed as inferior in knowledge and scientific rigor.[ 3 ]

R EFORMS IN M EDICAL E DUCATION

In the west, Abraham Flexner and William Osler's work undoubtedly shaped the reforms in Medical education. While Flexner was known for integrating basic sciences in the preclinical curriculum, Osler's work provided directives for clinical training.[ 4 ] While Western medical schools struggle to cope with a shortage of patients for clinical training through community settings,[ 4 ] the abundant clinical material remains untapped in India.

The healthcare system and medical education in India probably share the same path – A good head start followed by exponential decline. The early postindependence era showed a great promise in medical education, and the Government of India invited every system on board to deal with poor health indicators like low life expectancy and high maternal and child mortality. The goal was to produce family physicians to deal with most ailments at the local level. The mimicking of British Raj systems continued with little effort to make medical education contemporary and contextual until recently.

The current medical education system is not even at par with practice in Nalanda and Takshashila. The guru used to impart the knowledge and skills artfully through small group discussions diligently, and the teacher-student ratio was in line with current recommendations.[ 3 ] Until recently, the regulator's response toward reforms in medical education in India was slow, albeit with a systematic path.

As India exports many medical graduates to other countries, India's quality of medical education has global ramifications.[ 5 ] There are almost countless committee reports and other deliberations recommending urgent and drastic reforms in medical education in India.[ 5 , 6 , 7 ] Autocratic regulatory body, outdated curriculum, mushrooming of private medical colleges, a severe shortage of faculty coupled with almost nonexistent faculty development programs, selection of medical students, and poor research culture have been identified as common problems in the current medical education system in India.[ 5 , 6 , 7 ]

R ESEARCH: THE N EED FOR IT

We define research as the “spirit of inquiry.” It is almost impossible to overemphasize the importance of research (or in popular rubrics – Research and development). Research is a hallmark of any progressive civilization. The 20 th century witnessed an unprecedented transformation in science and technology. The health sector also followed the suit. The population structure that was static for millions of years changed drastically. The life expectancy increased steadily, followed by a decrease in fertility rates globally. This change is at least partially attributable to the industrial revolution along with advancements in modern medicine.[ 8 ]

Flexner may not be credited fully for the medical advances in the “post-Flexner” period. However, he stressed science and articulated the importance of science in medical education.[ 4 ] American Government established the National Institutes of Health (NIH) to promote research after the second world war, and today the budget of NIH is more than the national budget of many countries. The hegemony in research made America a true superpower in a short span. On the contrary, dependency on research and development can ruin a nation economically and politically. While many opportunities in research and development have global appeal, countries need contextual and pertinent research to tackle local issues confined to that particular country. The prevalence of head-and-neck cancers is very low in the west except probably in northern France. Hence, research on head-and-neck cancer management will not be the priority in the west. In India, the prevalence of head-and-neck cancers is almost 35%, and it is a priority research area. Undernutrition in children is yet another issue pertinent to India and neighboring countries. Thus, countries like India need to identify priority research areas and develop local evidence to guide healthcare policy.

I NDIAN S CENARIO

A scientometric analysis revealed that India's research output in medicine is abysmal.[ 9 ] Adding insult to the injury, they have consistently shown that only a handful of medical colleges produce most of the research, and further, a handful of researchers contribute a significant chunk of research.[ 6 , 10 , 11 ] Initially, research was a tool for early promotions; in 2009, after the Medical Council of India (MCI) made corrective measures, it became mandatory for faculty to propagate “publish or perish” without enough adjuncts to provide a conducive environment for research. The implementation was too quick without systematic training in research methodology for the faculty. Soon after this dictum, there was a mushrooming of predatory journals where one can publish quickly for a fee under the pretext of open access charge. As a corrective action, MCI rectified the rules from time to time regarding the type of journals and authors credited for the work, creating unnecessary chaos in academia. Finally, the National Medical Commission (NMC) arrived at an amicable solution in 2020, providing some wonderful choices to authors for selecting journals and crediting the first three and the corresponding author for the work, and this is probably the best solution to maintain checks and balances against gift authorships but allows credit to more authors.

R OLE OF T HESIS /D ISSERTATION DURING P OSTGRADUATE S TUDIES IN M EDICINE

There has been a heated debate on thesis/dissertation as a requirement in postgraduate medical education. Anantkrishnan, over 20 years back, well-articulated the objectives of the thesis.[ 12 ] Many educationists pointed to insufficient knowledge of research methods as the main barrier in conducting a good thesis.[ 13 , 14 ] The opposition is not in principle but how to conduct and facilitate.

The regulator (MCI) has taken many actions towards reforms in medical education in the last decade. The development and implementation of Medical Education Technology through basic and advanced courses and FAIMER fellowships are notable efforts to improve clinician-educator. The integration of preclinical, para-clinical, and clinical modules provided avenues to impart competency-based medical education holistically. Workshops like Attitude, Ethics and Communication Model (AETCOM) supplemented it. However, the doctor-patient ratio is skewed, with one doctor responsible for seeing 100 patients. There is very little time for research in such a scenario despite massive clinical data; hence, dedicated time should be allotted for research without hampering clinical work.

In yet another move to improve the quality of medical education and particularly postgraduate thesis, they introduced a mandatory course in biomedical research in 2019. It is a well-intended step, although quite late. National Institute of Epidemiology (NIE) conducts the course in collaboration with the Indian Council of Medical Research (ICMR). Some educators may suggest minor modifications in course contents based on their experience and preference, but overall, it is a well-designed course.

Decentralise

There are advantages of single-institution conducting the course specifically concerning standardization of delivery and assessment. However, considering the number of expected participants, it is advisable to share the task with regional institutes so that NIE, an institute of national repute, can focus on other important national goals. The course uses the digital platform to deliver the contents that also allow stalwarts from other institutions for the delivery. A national portal can easily archive lecture videos and notes by experienced faculty across India (in future across the globe as well). It will make up an excellent resource for students/faculty with the freedom to study the material at their own pace. The portal can be updated every 3 years to incorporate new knowledge.

Handholding

Imparting knowledge in research methods is necessary but not sufficient. Mentoring by experienced researcher/s is a key in shaping a future researcher. At Charutar Arogya Mandal, Karamsad, Gujarat, they established Central Research Services in April 2009. They supplemented the workshop-based model to empower the faculty in various aspects of research with handholding and mentoring that significantly improved the quality and quantity of research. It is challenging to cater to other institutions with a limited workforce. A Regional Resource Centre (RRC) can cater to all the needs of researchers across that region. However, sufficient funding must be ensured. Another advantage of these RRCs is that people trained in other domains like statistics, public health, medical sociology, advanced computing can be appointed proportionate to the need. These proposed RRCs should be autonomous and recognized competitively.

Short-term sabbaticals for postgraduate students

It is common to complain that students and faculty do not get sufficient time to think and develop the research proposal for the thesis. Many Departments of Charutar Arogya Mandal tried short-term sabbatical for faculty, and the quality of proposals improved almost instantaneously. A 1-week sabbatical in each year of residency will surely help students organize their thesis-related work in a much better way. The option could be a set time and place for research in each department during the week.

Catch them young

This probably is the most crucial intervention required in the Indian education system. As the familiar banter goes – “Rome was not built in a day”. The foundation of scientific thinking must start even before students enter medical school. The Indian education system borrowed from British Raj encourage rote learning and discourage logic, reasoning, and critical thinking. The new education policy provides some hope for positive changes in this direction right from childhood.

Digitalisation

Encouraging electronic medical records with data entry operators, involving data analysts is the way forward to capture data and aid research.

R ESEARCH IN I NDIAN M EDICAL S CHOOLS : O PPORTUNITIES AND C HALLENGES

It is heartening to note that most doctors who pursued research did it for personal interest and recognition rather than just monetary benefits.[ 15 ] The significant challenges in performing pertinent and methodical research are lack of knowledge, lack of mentor/guide, and other resources like access to journals and funding. A medical student echoed similar challenges.[ 16 ] Beyond monitory gains, research is exciting and provides a sense of fulfillment. A pool of good researchers can make the country knowledge-generating rather than knowledge importing.[ 17 ]

Interlibrary loans and consortium of libraries are uncommon in India. The motivated students lose interest quickly due to the lack of such basic amenities. The NMC should relax the current rules and encourage more online journals and consortiums purchasing the journals rather than individual institutions. In the digital era, asking for X number of print and Y number of online journals is redundant. Universities have a shared pool of journals funded by the central Government. The NMC can establish similar systems for all medical colleges in India for a nominal fee. The individual colleges can form other consortiums to add more journals to their pool as per their own perceived needs.

There are few funding options like Short Term Studentship (STS), Kishore Vaigyanik Protsahan Yojana (KVPY), but the funding options are limited, and the amount is insufficient. RRCs can serve the purpose. These measures are advocated more than a decade back[ 18 ] without much deliberations and subsequent action.

The grading of STS applications should be available in the public domain with comments from reviewers to bring transparency to the selection process. It will also allow young and mid-level faculty guides to reflect upon the challenges in the proposals and improve. Comments from the experienced reviewers rather than the final decision, communicated to the aspirant researchers is an audit of their work.

There have been few attempts to improve the quality of research conducted by medical students. They tried two primary models – A workshop-based model for imparting knowledge about research methods and mentored students' project model.[ 19 , 20 ] The only fly in the ointment is that these models measured knowledge/perceptions of students after the intervention, but not the tangible outcome.

Investigating a pertinent health problem methodically is an essential first step towards knowledge generation. It must be supplemented by converting the research into some form of scholarship. The conversion rate is lacking in developing countries.[ 21 ] The situation is not different in India.[ 22 ] Thousands of students conduct some research through thesis/STS/KVPY. The whole exercise is futile unless the learnings are not shared. In this digital world, a platform to share at least the gist of the project with contact details of the supervisor is need of the hour.

Role of medical societies; In India, almost all subspecialties established associations/societies for a long time. Some are very active in promoting research. For example, the Indian menopause society, Federation of obstetrics and gynecology societies of India, Indian Academy of Pediatrics conducts research methods and scientific writing workshops. These societies can act as a catalyst in various ways. They can provide small grants for pertinent research in their field. Some societies can collaborate to develop a national priority project and invite postgraduate students to work on these projects as a thesis. For example, Pediatrics, Community Medicine and Psychiatry can develop a project to investigate screen time use and models to minimize it across India.

The students will work on pertinent national issues, and they will learn the finer nuances of research, teamwork, communication by working under the guidance of stalwarts.

Inter-sectoral collaboration may appear utopian in India, where compartmentalization and hierarchy dominate in academia. Talent from other streams like statistics, basic sciences, information technology has a lot to offer in health research. Medical schools are not much successful in attracting such talent for the benefit of the people at large.

We would deliberate on such issues and potential solutions shortly. ICMR is propagating these ideas through Multidisciplinary Research Units and Model Rural Health Research Units. Sadly, the regional representation of such ICMR units is disproportionate, and it is prudent to leverage the experience of these units to strengthen RRCs in identifying and solving a complex web of regional health research needs.

Many educationists had advocated persistently the need to improve research in Indian medical schools.[ 6 , 11 , 18 , 23 , 24 , 25 ] It is blatant to evaluate how India fared in medical research considering resources, educational environment and students' attitudes. India's contribution to worldwide biomedical research was just about 2%. However, with this meager contribution, India ranks 12 th with just four countries viz. US, UK, Germany, and Japan were contributing almost 50% of the worldwide research. It is a matter of pride that even though India lagged, the research output from India is steadily increasing.[ 9 ] Interestingly, China recorded a leap in research contribution from 1999 to 2008 – From 16 th to the fourth rank. Unlike India, medicine is a graduate program in the US, and most students in the UK take a yearlong intercalated graduation program before entering medical schools. The students thus have a better opportunity to explore research and enter a physician-scientist career.

The students' attitude toward research globally is quite motivating. Students from developing countries reported a lack of mentors, time, and infrastructural support as main barriers in research.[ 26 ] There have been various attempts to instill research skills in medical schools. These mainly include Mandatory Research Projects, Elective Research Projects, and Audit Projects.[ 27 ] In both these endeavors, India leads the developing world. The critical question is whether India should incorporate a mandatory research project in undergraduate medical education. The answer is not straightforward and needs some serious brainstorming. At present, an elective research project, along with strengthening research training through a national-level portal, sounds workable.

The quality and quantity of methodical and pertinent research need to be scaled up. The education in research should start at the undergraduate level. The Government should ensure enough resources for training and conduction of research. Handholding/mentoring is a key to shape future researchers. We may try innovative approaches like RRCs and amending the rules by NMC that restrict optimal use of resources.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Acknowledgment

We thank the reviewers Dr. Srinivas, Dean ESIC, Hyderabad, Dr. Rakesh Sahay, Professor and Head, Department of Endocrinology, Osmania Medical College and Osmania General Hospital, Hyderabad, Dr. Manisha Sahay, Professor and Head, Department of Nephrology Osmania Medical College and Osmania General Hospital, Hyderabad Dr. Anil Mahajan, Rheumatologist, Former Prof. and Head Postgraduate Department of General Medicine, GMC, Jammu and Kashmir, India, Dr. Sudha Sharma, Gynecologist, Former Professor Department of Obstetrics and Gynecology GMC, Jammu and Kashmir, India Dr. Neelam Aggarwal, Obs Gynae, Professor, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India Dr. Navneet Takkar, Gynecologist, Government Medical College and Hospital, Chandigarh, Punjab, India.

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• Published: 30 August 2024

Comparison of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment: a randomized clinical trial

• Raziyeh Ghafouri 1 ,
• Vahid Zamanzadeh 1 &
• Malihe Nasiri 2  

BMC Medical Education volume  24 , Article number:  949 ( 2024 ) Cite this article

Metrics details

Since effective education is one of the main concerns of every society and, in nursing, can lead to the education of successful people, the development of learning and teaching methods with greater effectiveness is one of the educational priorities in every country. The present study aimed to compare the effect of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment.

The present study was a Parallel randomized clinical trial study. The participants were 166 nursing students. The clinical trial data was collected from December 14, 2023, to February 20, 2024. The inclusion criteria were nursing students who had passed the first semester, who were willing to participate and install the app on their mobile devices, and who had no experience with the designed application for this study. The participants were allocated to four groups with colored carts. In the first group, teaching was performed via gamification in a flipped learning environment; in the second group, teaching was performed via the gamification method. A flipped class was implemented in the third group. In the fourth group, the usual lecture method was used. The practical performance to assess the physical health assessment with 10 questions using the key-feature questions, along with the satisfaction and self-efficacy of the students, was also checked with questionnaires.

In this study, 166 nursing students, (99 female and 67 male), with an average (standard deviation) age of 21.29 (1.45) years, participated. There was no statistically significant difference in the demographic characteristics of the participants in the four intervention groups ( P  > 0.05). Comparing the results before and after the intervention, the results of the paired t test indicated a significant difference in the satisfaction, learning and self-efficacy of the learners ( P  < 0.001). In the comparison of the four groups, the ANOVA results for the comparison of the average scores of knowledge evaluation and satisfaction after intervention among the four groups indicated a statistically significant difference ( P  < 0.001). When the knowledge evaluation scores of the groups were compared, the scores for gamification in the flipped learning environment were significantly different from the other methods ( P  < 0.05), and there was no significant difference between the scores for the flipped class and lecture methods ( P  = 0.43). According to the ANOVA results, when comparing the satisfaction scores of the groups, the students in the flipped learning environment and gamification groups were more satisfied than the flipped class and lecture groups ( P  < 0.01).

Based on the results of the present research, it can be concluded that teaching methods have an effect on students’ learning and satisfaction. The teaching method has an effect on the satisfaction of the students, and the use of the flipped class method with the use of gamification was associated with more attractiveness and satisfaction in addition to learning. Teachers can improve the effectiveness of education with their creativity, depending on situation, time, cost, and available resources, by using and integrating educational methods.

Peer Review reports

Introduction

Effective education is one of the main concerns of every society [ 1 ]. Because the traditional methods of teaching, learning and management have little effectiveness [ 2 ], multiple learning strategies of active learning and the use of technologies [ 3 , 4 , 5 ], it is helpful to integrate the classroom approach among these methods. The reverse is the use of a playful method [ 6 , 7 ]. The flipped classroom was presented in 2007 by Bergmann and Sams, two chemistry teachers at Woodland Park High School in Colorado (USA). Their goal was to ensure that students who could not attend class for various reasons could proceed at the pace of the course and not be harmed due to not attending class [ 8 ]. Bergmann and Sams videotaped and distributed instructional content and found that this model allowed the teacher to focus more attention on the individual learning needs of each student [ 5 , 8 ].

In 2014, the Flipped Learning Network (FLN) was introduced, in which flipped learning was defined as “an educational approach in which direct instruction is transferred from the group learning dimension to individual learning, and in a dynamic and interactive learning environment, where the instructor guides students in applying concepts and engaging creatively with course content”. The four pillars of flexible environment, learning culture, purposeful content and professional instructor have been described in opposite directions [ 9 , 10 ]. In addition to the ever-increasing complexity of the healthcare environment and the rapid advancement of healthcare technology, a global pandemic (COVID-19) has affected educational structures. The pandemic has caused a global educational movement toward blended learning to meet students’ technological and hands-on learning needs. Indeed, at no time in history has there been such a sudden transition to this type of learning [ 11 ], where the flipped classroom was widely used [ 9 ].

In nursing education, the use of flipped classrooms [ 9 , 12 ] and technologies [ 3 , 5 ] has been emphasized. The results obtained in the systematic review of the effect of the flipped classroom on academic performance in nursing education indicated its positive effect, and the opinions of most students about this method included aspects such as its usefulness, flexibility, greater independence or greater participation [ 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. According to the cognitive bases related to the Bloom’s taxonomy, with the flipped classroom method, the student works in the first stage of the learning process at home, which is the simplest stage, and in the second stage, through active learning with the help of the teacher and classmates, in class time, which is used to increase and empower more [ 20 , 21 ]. In addition, the flipped classroom method has certain advantages over traditional learning. The flipped classroom is student-centered and makes students responsible for their own learning [ 22 ], and its use in nursing has been emphasized in systematic review studies [ 3 , 23 , 24 ].

One of the interactive teaching methods using computers is the gamification method. Gamification in education includes the use of game elements to increase motivation and participation and to involve students in the personal learning process [ 1 , 25 ]. Gamification is an active education method. The gamification system increases the level of engagement and motivation of learners by provoking excitement and creating challenges for them. Additionally, with this method, it is possible to provide an opportunity for testing, and in that test, in addition to creating a challenge, learners are given the opportunity to display their achievements through competition [ 26 ].

Nursing education institutions are obliged to improve the ability of nursing students to make correct clinical judgments through various educational programs and the use of new teaching methods [ 27 , 28 ] so that when nursing students enter the clinic, they can fulfill their role as members of the medical team [ 27 ]. Therefore, it is necessary to carry out more research regarding the identification of effective teaching methods that can improve the attractiveness of education and its satisfaction among nursing students [ 1 , 27 ].

This study addresses the lack of comparative research on the effectiveness of flipped classrooms and gamification in nursing education, an area that has not been sufficiently explored. The advantages of combining education methods are that they can be used together [ 6 , 7 ]. For example, by combining education using the flipped class with gamification, more study time is provided by using the flipped class, and the attractiveness of the method is provided by gamification [ 7 ]. Therefore, considering the attractiveness of the new application that is prepared in a flipped class, the current research was conducted aimed at comparing the effects of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in terms of client health assessment.

The present study was a parallel randomized clinical trial research aimed at comparing the effect of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment. The clinical trial data was collected from December 14th, 2023, until February 20th, 2024.

Participants

First, in a call, 247 nursing students registered to participate in the study. After checking the entry criteria, 188 people met the entry criteria for the study. The inclusion criteria were nursing students who had passed the first semester, who were willing to participate and install the app on their mobile devices, and who had no experience with the designed application for this study. Exclusion criteria were: miss the mobile and drop out of study, for example, because of transferring, migration or do not like to continue participating in the study. So, 18 students were excluded from study for unwillingness to continue, 2 students because of migration were excluded, and 2 people were excluded for missing their mobile (Fig.  1 ).

Study and sampling process

The participants were allocated to four groups with using colored carts. Before sampling, 188 carts in 4 blue, red, black and white colors (from each color, 45 carts) were prepared in one enveloped pocket. After completing the informed consent and pre-test questionnaires, each student took a colored card from the enveloped pocket. Then, with the lottery, it was determined that the participants with the blue card participated in the gamification in a flipped learning environment, the red cart in the gamification, the black cart in the flipped class, and the white cart in the lecture method. The study and sampling process is shown in Fig.  1 .

Intervention

The education course was 4 class in 60 min of health status assessment in 4 weeks. Each group has a classroom weekly. Education content was health assessment and clinical examination courses of the Bachelor of Nursing Education curriculum. Course plan was developed based on the curriculum.

For intervention, the application was designed using the cascade model (initial analysis, system analysis, design, programming, testing (alpha and beta), implementation and modification) [ 29 , 30 ]. In the initial analysis stage, the need or the desired problem, which is the issue of education improvement, is raised, and can technical solutions be provided for it? If there are possible solutions, the practicality is evaluated, and in the analysis of the visual appeal system, the up-to-date information, simple language, and comprehensiveness of the information provided in the educational content are checked. In the design phase, the design of the desired system was written, and a program was written by the programmers according to the initial design of the system.

The educational content of the application was prepared based on the health assessment and clinical examination courses of the Bachelor of Nursing Education Program, approved by an expert panel. The application was designed in two parts: education and scenario-based games. In the education section of the application, the content of the education was presented, and in the scenario base game section, the 10 scenarios of health status assessment and clinical examination were designed based on real situations.

In the scenario base game section of the application, the application was embedded as a game in such a way that the student, at the first, observes the chief compliance of the patient, and they must complete patient examinations and choose the correct answer. If they choose correctly, they will take a green cart, and if they make a mistake, they will take a red cart. They could take 4 green carts in each scenario. A yellow cart was shown when the answer was not incorrect, but it was not an exact answer. In each scenario, they must find the correct nursing diagnosis. They must provide a nursing diagnosis based on the priority of care in the scenario.

The fundamental elements of gamification are mechanics (motivating students through points, budgets and rewards), dynamics (engaging users through stories and narratives), and aesthetics (user experiences from applications about being user-friendly and attractive) [ 31 , 32 , 33 ]. The mechanics element was considered in the application, with green carts in each stage. The dynamic element was considered in the scenarios. The aesthetic element was considered and checked in alpha and beta tests.

In the test phase, the Application was checked for errors, and it was tested for user acceptance in two parts, the alpha and beta tests. In the alpha test, the program was used by the designers (four academic nurses and 4 IT men) as users, and in the beta test, a group of users (20 nursing studentsThe fundamental elements of a flipped class are that the students must read the content before the class and do the assignment in the class. In this study, this element was considered, and the provided content was given to participants at first. The students read content for each class before the class, and they solved the assignment in the class. The provided content for the flipped class group was designed in the PowerPoint files, and for the gamification in the Flipped Learning Environment group was designed in the application.

It was improved based on their opinions, and in the next stage, the approved application by the designer and user was used in this study.

Lecture group

In the Lecture group, the content of the education was held in the lecture method, and in each section, at the end of class, a scenario of the designed was given to the students as an assignment. They must solve it by next week. At the end of the study, four scenarios were performed by the students as assignments in this group.

Flipped class group

In the Flipped class group, the content was prepared in the four voiced PowerPoints and presented them to the students in the first session. Students read the content of each class, and in class they discussed the educational content and solved the scenarios as an assignment. Eight scenarios were discussed by the students as assignments in this group.

Gamification group

In the Gamification group, in each class, after the educational content was presented, the homework was presented, and students played a scenario of application in the class. Four scenarios were performed by the students as assignments in this group.

Gamification in the flipped learning environment group

In the Gamification in the Flipped Learning Environment group, the designed mobile application was presented in the first session of the course. Students must read the content of the session before the class, and in class they discussed the educational content and solved the scenarios as an assignment. Eight scenarios were performed as homework by students in a gamification environment.

Data collection tools

In this study, a questionnaire with 10 key-feature questions (KFQs) was designed by an expert panel of 10 academic nurses. After designing a KFQ questionnaire, its validity and reliability were examined. Validity was confirmed with a content validity ratio (CVR) of 14 expert (academic nurses) and qualitative validity with 7 academic and 7 clinical nurses; reliability was checked by test-retest. The CVR of the questionnaire was 0.96 and was confirmed. All seven academic and seven clinical nurses confirmed the qualitative validity of the questionnaire. The content validity coefficient based on the number of participating professors (at least 10 people) is 0.49 as the minimum acceptable according to the Lauwshe Tables (18, 19) and the necessity of the items of tools was confirmed.

For the test-retest of KFQ questionnaire, 10 nursing students participated. They filled out the questionnaire twice, with an interval of two weeks. The correlation coefficient between their answers was 0.93 with Spearman’s correlation coefficient. The correlation coefficient above 0.7 is good [ 34 , 35 ].

Additionally, education satisfaction was investigated with the Measuring Student Satisfaction Scale from the Student Outcomes Survey [ 27 ], which includes 20 items. The validity of it was confirmed with CVR, and the reliability was checked by Cronbach’s alpha. The CVR of the questionnaire was 0.91 and was confirmed. Cronbach’s alpha was 0.69. Cronbach’s alpha coefficient above 0.7 is good, 0.3–0.7 is good, and less than 0.3 is poor [ 34 , 35 ]. The overall Cronbach’s alpha was appropriate reliability.

The Sherer questionnaire tool was used to assess the self-efficacy of the nursing students [ 36 ]. This tool contains 17 items on a five-point Likert scale. Sherer et al., confirmed the reliability of the questionnaire with Cronbach’s alpha 0.76 [ 36 ]. Also, for this questionnaire, the validity was confirmed with CVR, and the reliability was checked by Cronbach’s alpha. The CVR of the questionnaire was 0.90 and was confirmed. Cronbach’s alpha was 0.45.

Data analysis

The analysis of the research data was performed using the Statistical Package for Social Sciences version 20. The Kolmogorov-Smirnov test was used to assess the normality of the data. Data analysis was performed by using descriptive tests, such as percentage, mean and standard deviation, and statistical tests, such as the chi-square test, paired t test, and ANOVA. In all statistical tests, a significance level was considered less than 0.05.

In the present study, 166 nursing students, 99 women and 67 men, with an average (standard deviation) age of 21.29 (1.45) years, were participated. The demographic characteristics of the participants are shown in Table  1 . The homogeneity of the intervention and control groups was checked with statistical methods, and the results are reported in Table  1 . There was no statistically significant difference in the demographic characteristics of the participants in the groups ( P  > 0.05).

Comparing the results before and after the intervention, the results of the paired t test indicated a significant difference in the satisfaction, learning and self-efficacy of the learners ( P  < 0.001). Table  2 shows the results of paired t tests.

The ANOVA showed that a statistically significant difference between the mean scores of knowledge and satisfaction after intervention in the four groups ( P  < 0.001). The result of the ANOVA was not significant difference between the mean of the self-efficacy after intervention in the four groups ( P  = 0.101).

In the analysis of the groups, there was a significant difference in the comparison of the knowledge evaluation scores, such that there was a significant difference between the average of the gamification methods in the flipped learning environment group and the gamification compared to the inverted class and lecture, considering equal variance ( P  < 0.001). There were significant differences at the 0.05 level between the two gamification methods in the flipped learning environment group and the gamification group ( P  = 0.03). Gamification and flipped classes had no significant difference ( P  = 0.054). There was no significant difference between the two methods of flipped class and lecture ( P  = 0.43).

According to the ANOVA results, when comparing the satisfaction scores of the groups, there was no significant difference between the means of gamification in the flipped learning environment and the gamification method ( P  = 0.49); however, there was a significant difference between the gamification in the flipped learning environment and the gamification with the flipped class and the lecture. Additionally, there were significant differences between the flipped class and the lecture method ( P  < 0.01).

Discussions

This study aimed to compare the effects of the lecture method, flipped class and gamification in a flipped learning environment on the performance of nursing students in assessing the health status of clients. The demographic characteristics of the participants (gender, age, academic semester, grade point average and theory course score) had the same distribution among the four groups, and there was no statistically significant difference ( P  < 0.05).

Comparing the results before and after the training, the results of the paired t test indicated a significant difference in the satisfaction, learning and self-efficacy of the learners ( P  < 0.001). The results indicate that all four teaching methods effectively affected the learning, satisfaction and self-efficacy of students in evaluating the health status of their clients. However, in the comparison of the 4 groups, ANOVA revealed a statistically significant difference ( P  < 0.001). In the analysis comparing the knowledge evaluation scores of the gamification group with those of the other methods group, there were significant differences ( P  < 0.05), and there was no significant difference between the two methods (Flipped class and lecture) ( P  = 0.439). According to the ANOVA results, the satisfaction scores of the groups were greater for the gamification in the flipped learning environment and gamification groups than for the flipped class and lecture groups ( P  < 0.01). The results of the present research indicate that teaching methods have an effect on students’ learning and satisfaction.

Rachayon and his colleagues also used a task-based learning method in combination with digital games in a flipped learning environment to develop students’ English language skills, and their results also indicated the success of combining the above methods [ 7 ]. Muntrikaeo and his colleagues also used a similar model of task-based learning in combination with games in a reversed environment for teaching English, and their findings were also successful [ 6 ]. The results of the current research, which involved the integration of the gamification in the flipped learning environment for teaching health status assessment to nursing students, are similar to those of the above research.

Zou et al., in their systematic review, found that success in the flipped classroom is related to teachers’ creativity in making the classroom interactive, students’ readiness, and the use of technology [ 37 ]. In the present study, the flipped class, along with the use of gamification in the flipped learning environment, increased learner satisfaction and learning. Therefore, their findings are similar to the findings of the present study.

Hernon and his colleagues reported that the use of technology plays a significant role in the development of nursing students’ skills [ 4 ]. Regarding the use of educational applications for health assessment, the results of their research are the same as the current research, and the use of technology not only plays a role in learning but also it has role in education satisfaction. Considering the results of the present study and similar studies, we can conclude that the use of gamification in the flipped learning environment is an interactive teaching method and can be used to improve nursing education. Gamification can increase the attractiveness of education and promote education. If a good application is designed as a flipped enviroment, it provides more time in the classroom for discussion, interaction, and scenario-based education and promotes education satisfaction.

In this study, the satisfaction with education had a significant difference between the groups, but the students’ self-efficacy, despite the significant difference before and after the intervention, did not have a significant difference between the groups. Since all three studied methods were effective in students’ learning and self-efficacy, it can be said that teachers can improve educational effectiveness and satisfaction by using different methods and combining them in educational situations by considering resources and conditions.

The gamification method was associated with higher satisfaction, but it requires more resources, equipment, and skilled personnel. The flipped class method requires fewer resources, is more cost-effective, and provides more time for practice and group discussion. By combining these two methods, the advantages of both can be used, which is confirmed by the results of the present study. It seems that the upside-down environment provides a good opportunity for life-long training, including the promotion of interaction and teamwork, and along with other methods, it is also associated with more effectiveness and benefits.

In this study, knowledge and satisfaction of education had significant differences between groups, but students’ self-efficacy had not significant difference between groups. Maybe it was due to the fact that we participated in the second and third semesters of nursing students, and the interactive skills of students were not assessed. So, the researchers recommended that more research be conducted with the aim of investigating interactive and communication skills using gamification in a flipped environment.

Therefore, this method is helpful in nursing education as well as other medical fields. It is suggested that this method could be combined with other educational methods, such as task-based and team-based methods, to develop the possibility of developing team-based education and task-based education. Integrated gamification methods in the flipped learning environment with mobile applications have greater attractiveness and satisfaction with effective education, and with the use of appropriate applications, it is necessary to create a sense of competition and learning. But, in this study, the interactive skills of students were not assessed. Finally it is emphasized that teachers can improve the effectiveness of education with their creativity, depending on situation, time, cost, and available resources, by using and integrating educational methods.

The teaching method has an effect on students’ satisfaction with the teaching method, and the use of gamification in the flipped learning environment is more effective than the flipped class method, gamification, and the lecture method. Based on the results of the present research, it can be concluded that teaching methods have an effect on students’ learning and satisfaction. The teaching method has an effect on the satisfaction of the students, and the use of the flipped class method with the use of gamification was associated with more attractiveness and satisfaction in addition to learning. Teachers can improve the effectiveness of education with their creativity, depending on situation, time, cost, and available resources, by using and integrating educational methods.

Limitations

Not installing the program on IOS phones made it impossible for these users to use the application and drop out study, so we recommended that designed application for android and IOS. The ability of the professor to teach with the method of gamification in the flipped learning environment and his mastery of the application are necessary to provide necessary training to the teachers regarding the above methods.

Integrated gamification methods in the flipped learning environment with mobile applications have greater attractiveness and satisfaction. But, in this study, the interactive skills of students were not assessed. So the researchers recommended that more research be conducted with the aim of investigating interactive and communication skills using the gamification method in an upside-down environment.

Data availability

Data is provided within the manuscript or supplementary information files.

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Acknowledgements

The authors also wish to thank all the participants and those who helped us in carrying out the research especially all the staffs of Department of Medical Surgical Nursing of School of Nursing & Midwifery of Shahid Beheshti University of Medical Sciences.

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VZ and RG formulates the research question that represents the systematic review objective. VZ and RG provide proposal and reports. RG collected the data. MN: Data analysis. All authors read and approved the final manuscript.

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This study was approved by the ethics committee of Shahid Beheshti University of Medical Science (IR.SBMU.PHARMACY.REC.1402.152), and all methods were carried out in accordance with the research ethical codes of the Iran National Committee for Ethics in Biomedical Research. The authors guarantee that they have followed the ethical principles stated in the Declaration of Helsinki (to protect the life, health, dignity, integrity, right to self-determination, privacy, and confidentiality of personal information of research subjects) in all stages of the research. This is the online certificate of the research ethical code: https://ethics.research.ac.ir/ProposalCertificateEn.php?id=404003&Print=true&NoPrintHeader=true&NoPrintFooter=true&NoPrintPageBorder=true&LetterPrint=true . This study was registered in the Iranian Registry of Clinical Trials ( https://irct.behdasht.gov.ir ) on 14/12/2023, with the IRCT ID: IRCT20210131050189N7. To observe ethical considerations, School of Nursing & Midwifery of Shahid Beheshti University of Medical Sciences agreed to participate in the study; the research goals and procedures were elucidated to the participants, the participants were assured of information anonymity and confidentiality, and informed written consent was obtained from each participant and documented. They participated in the study voluntarily and could leave the study at any stage.

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Ghafouri, R., Zamanzadeh, V. & Nasiri, M. Comparison of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment: a randomized clinical trial. BMC Med Educ 24 , 949 (2024). https://doi.org/10.1186/s12909-024-05966-2

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Received : 15 March 2024

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DOI : https://doi.org/10.1186/s12909-024-05966-2

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