The effectiveness of a flipped classroom on the development of Chinese nursing students' skill competence: A systematic review and meta-analysis

Objectives: Skill competence is essential for nursing students and flipped-classroom teaching has become increasingly popular in China's nursing education. However, no studies have yet specifically examined the effect of a flipped classroom versus a traditional classroom on their skill competence. Design: A systematic review and meta-analysis of randomised controlled trials. Data sources: The China National Knowledge Infrastructure, Wanfang Data, VIP, Superstar, PubMed, and Web of Science databases were searched from their inception until 9 June 2018. Review methods: We screened the studies according to inclusion and exclusion criteria, extracted the data, and assessed the quality. Then, a meta-analysis was conducted. Results: Twenty-two studies were eligible after reviewing 484 citations. The flipped classroom increased the students' skills score compared with the traditional teaching method (standardised mean difference = 1.79, 95% confidence interval: 1.32-2.27, p = 0.000). Additionally, it improved the cooperative spirit and sense of teamwork (effect size = 1.60, 95% confidence interval: 1.15-2.06), practical ability (effect size = 1.47, 95% confidence interval: 0.93-2.01), enjoyment of the course (effect size = 1.39, 95% confidence interval: 0.81-1.97), expression and communication (effect size = 1.41, 95% confidence interval: 0.69-2.12), the curriculum's effects (effect size = 1.32, 95% confidence interval: 1.00-1.64), interest in participation (effect size = 1.58, 95% confidence interval: 1.28-1.87), ability to think and analyse problems (effect size = 1.62, 95% confidence interval: 1.24-2.00), and resolution and resilience (effect size = 1.62, 95% confidence interval: 1.29-1.94). Conclusions: The results suggest that the flipped classroom is more effective for the nursing students' skill competence than traditional teaching in China. However, due to heterogeneity and bias risk, a large sample and high-quality studies are needed in future to confirm its effectiveness.