Students’ motivation, study-effort and perceptions of teachers’ goals when engaging in a learning design within the flipped classroom | BMC Medical Education

Introduction

Competence in cardiopulmonary resuscitation (CPR) is a critical requirement for both registered nurses and nursing students. Mastery of CPR demands not only up-to-date theoretical knowledge and technical skills but also confidence and the ability to collaborate effectively in interprofessional teams [1]. To support the development of these essential competencies, the Norwegian University of Science and Technology (NTNU) has implemented a learning approach inspired by the flipped classroom model in its bachelor’s degree program in nursing [2, 3]. It includes two pre-class and two in-class activities, aiming to enhance student motivation, engagement, and competence in CPR. This design not only integrates theory and practice but also promotes continuous learning and real-world readiness.

This article addresses a pressing need in nursing education by presenting a structured and sustainable learning design based on the flipped classroom approach. The CPR course described herein serves as a concrete example of this model. While previous research has identified the limitations of traditional teaching methods [1,2,3,4], few studies have proposed comprehensive educational frameworks that effectively integrate theoretical instruction with practical application.

By introducing a flipped classroom model tailored specifically to CPR training this study contributes to the growing body of literature on active learning in healthcare. The model offers a replicable framework that enhances knowledge retention, skill acquisition, and clinical preparedness among nursing students. Its emphasis on student motivation, engagement, and real-world relevance represents a meaningful advancement in educational design, with potential implications for curriculum development and patient safety.

The flipped classroom approach

In the education of nurses, there has been a transition from traditional classroom teaching to the flipped classroom approach [1, 5]. This pedagogical approach is characterized by pre-class preparation, in-class engagement, student-centered and interactive learning, and flexible learning pathways. Within this model, the teacher’s role transitions from being the primary source of knowledge to that of a facilitator and guide. Overall, the flipped classroom is designed to foster deeper understanding, critical thinking [4], as well as improving engagement, student performance and learning outcomes [4, 6, 7].

Building on the benefits of the flipped classroom approach, studies have shown that it positively influences nursing students’ motivation and learning [5, 7,8,9,10,11]. However, a successful implementation of the flipped classroom requires a structured design which will help students identify their learning objectives and understand how to achieve them [7, 12]. At the same time studies have also reported challenges associated with the approach—particularly during pre-class activities. These include increased study-effort, unfamiliarity with the format, and a lack of motivation among students [3, 13].

In the context of CPR education, various multimodal strategies have been explored to improve training outcomes. These include the use of real-time feedback technologies, self-instructional materials, online modules, and interactive simulations [14,15,16,17]. Despite these innovations, research consistently shows that CPR competence among nursing students declines rapidly after initial instruction. Even after completing their CPR training, nursing students often struggle to apply their skills effectively [17, 18].

A meta-analysis by Zeng et al. [19] found that high-fidelity simulation improved knowledge and skill performance compared to low-fidelity simulation and traditional manikin-based training. However, the benefits of high-fidelity simulation diminished over time, with no significant advantage in knowledge retention after three months or in skill performance after one year [19].

To address these challenges, the flipped classroom offers distinct advantages for CPR instruction. By combining theoretical preparation with repeated hands-on practice, this approach supports long-term retention and progressive skill development. At NTNU, the structured learning design was implemented across all three years of the nursing program aiming to integrate theory and practice as well as promoting continuous learning and real-world readiness.

The flipped classroom learning design

There was a clear need to revise the traditional approach to a flipped classroom model due to several persistent challenges. Conventional methods, which often rely on lectures and isolated skills training sessions, have shown limited effectiveness in promoting long-term retention of both theoretical knowledge and psychomotor skills. Research indicates that students tend to forget critical CPR competencies shortly after training [17, 18], posing a significant risk in clinical practice where rapid and accurate responses are essential.

Furthermore, traditional teaching formats often fail to actively engage students or connect learning to real-life clinical scenarios, resulting in fragmented understanding and limited transferability of knowledge [17, 18]. To address these challenges, we developed a more integrated, student-centered learning model grounded in the course’s defined learning outcomes. These outcomes encompass theoretical knowledge, practical skills, and general competence, outlining the level of proficiency students are expected to achieve by the end of the course. This revised approach not only facilitates knowledge acquisition but also cultivates critical thinking, decision-making, and teamwork—competencies essential for effective performance in cardiac arrest situations. The learning design consists of four interrelated activities—two pre-class and two in-class—deliberately structured to form a cohesive and progressive learning experience. This structure ensures that students build competence incrementally, with each activity reinforcing and expanding upon the previous one. The design is implemented consistently across all three years of the nursing program to support continuous learning and prevent the decline of CPR knowledge and skills over time [17, 18].

It combines non-mandatory pre-class activities with mandatory in-class activities, aiming to enhance students’ competence in assessments, decision-making, and actions related to CPR. This design begins with a theoretical individual study activity including recommended course material and culminates in simulation-based practicums where students work in teams, mimicking real-world nursing environments.

The four activities are:

1. 1.

   Multiple-choice questions (MCQ): Based on European Resuscitation Council (ERC) guidelines, these questions are made available on the learning platform four weeks prior to the in-class sessions. Students are encouraged to use course literature and can complete the quiz multiple times within a set timeframe. Although optional, most students complete it once, typically in about one hour.

2. 2.

   Skills training with Resuscitation Quality Improvement (RQI). This skills training involves a mannequin-based station that provides real-time, computer-generated feedback on chest compressions and ventilations. The RQI module is available three weeks before the in-class sessions and must be completed beforehand. Students usually spend around 30 min on this activity.

3. 3.

   Team-based learning (TBL). Facilitated by instructors, this session involves collaborative problem-solving in small groups. Students apply their theoretical knowledge to case-based discussions aligned with the learning outcomes of the CPR course. The session is scheduled and lasts approximately 2.5 h.

4. 4.

   Simulation (low- to high-fidelity). Conducted in realistic clinical settings, this activity requires students to work in teams to manage simulated cardiac arrest scenarios. It integrates knowledge from the MCQ and TBL sessions with hands-on skills from the RQI training. This session is also scheduled and lasts 2.5 h.

The design evolves through the three years of study. In the first year, the focus is on basic CPR skills. In the second and third years, the emphasis shifts to communication, teamwork in acute care settings, and advanced CPR techniques. The pre-class activities (MCQ and RQI) are non-mandatory but strongly encouraged, while the in-class activities (TBL and simulation) are mandatory and scheduled within a two- to six-week window.

This structured and longitudinal approach aims to foster deeper engagement, promote autonomy, and ensure that students are well-prepared to respond effectively in real-world cardiac emergencies.

Theoretical frameworks

Achievement goal theory and self-determination theory

When studying student engagement and motivation, both achievement goal theory and self-determination theory are central theoretical frameworks [20, 21]. These frameworks emphasize the importance of providing students with appropriately challenging academic tasks and fostering a supportive learning environment where teachers act as facilitators rather than mere transmitters of knowledge [20]. Research shows that students are more likely to be motivated when they perceive their teachers as supportive of their learning goals [22,23,24]. These theories offer complementary perspectives on how motivation is shaped by both individual dispositions and contextual factors.

Achievement goal theory

Achievement goal theory as described in Anderman et al. [25], explains why and how students engage in academic activities and their perceptions of contexts that affect their engagement and motivation. The theory distinguishes between two primary goal orientations: mastery goals and performance goals, each with approaching and avoidance components [25, 26].

Mastery goals refer to students’ eagerness for understanding and personal improvement, whereas performance goals refer to the desire to outperform others [25]. The personal dimension relates to students’ ability to achieve competence in learning situations [27]. The contextual aspect relates to classroom goal structures. This represents the teacher’s goal-related communication and the student’s perception of their teachers’ goals [20, 24, 26, 28].

Existing evidence indicates that a classroom mastery goal structure positively influences students’ own mastery goals [29]. Students construct meaning for performing learning activities based on their classroom perceptions [28]. Learning outcomes, fellow students, and teachers’ pedagogical approaches affect students’ quality of engagement in learning activities [28]. Teachers who are mastery-focused promote a positive interpersonal climate, engaging in motivationally supportive interactions with students [26]. Such interactions include encouraging and supporting students, being persistent, using humor, and showing enthusiasm. Thus, the main goal is to develop competence, which is associated with motivation, positive emotions, and positive student-teacher relationships [21, 26].

Students oriented towards mastery goals are more likely to engage in behaviours that promote achievement [26, 28]. The perception of success varies among students. When success is defined as learning, understanding, and skill development, students engage more deeply in classroom activities and demonstrate resilience in the face of learning challenges. Conversely, if success is seen as outperforming others, students may resort to shortcuts to avoid difficult tasks, leading to superficial engagement and learning [21, 26].

Self- determination theory

Self-Determination Theory (SDT), developed by Ryan and Deci [30], provides a comprehensive framework for understanding human motivation. It emphasizes the quality of motivation, distinguishing between autonomous and controlled forms along a continuum of internalization [30,31,32].

According to SDT, students have three basic psychological needs: autonomy, perceived competence and relatedness [23, 30]. The fulfillment of all three needs is essential for fostering effective learning and promoting optimal personal development [23, 33]. Autonomy is supported when students are offered meaningful choices within a structured learning environment—for instance, by allowing them to determine how they approach their learning activities. A sense of competence arises when students overcome academic challenges, understand the course material, and perceive progress in their skills [23, 31].

Furthermore, SDT emphasizes that behavior is shaped within a social context [23]. When students experience a sense of relatedness—that is, when they feel connected to peers or teachers—they are more likely to engage deeply with the learning process and experience enhanced motivation and growth [23, 33].

Autonomous motivation is defined as engaging in activities for inherent interest and enjoyment [23, 30]. It includes intrinsic motivation as well as integrated and identified regulation. In contrast, controlled motivation arises from pressure and demands. The more internalized the motivation is, the more it becomes part of a student’s identity. When motivation is internalized, students are more likely to see their learning activities as aligned with their personal values and interests, leading to deeper engagement and sustained effort. Thus, autonomous motivation is also associated with higher study-effort, and consequently better learning [23, 30].

SDT thus provides a broad framework for understanding aspects that facilitate or undermine autonomous motivation, and learning, which are directly relevant to educational settings. Research shows that both intrinsic motivation and well-internalized forms of extrinsic motivation predict positive outcomes across educational levels and cultural contexts [30].

Linking the frameworks

Several studies have demonstrated a strong association between autonomous motivation and mastery goals [34,35,36]. Chen et al. [35] reported that the mastery goals approach was related to intrinsic motivation among university students, and that achievement goals mediated the need for support. A study by Rothes et al. [36] showed that both mastery goals and autonomous motivation were significant predictors of student engagement and learning [36].

Together, these frameworks provide a robust foundation for examining how flipped classroom designs can enhance motivation, engagement, and learning outcomes in nursing education.

Present study

This study investigates nursing students undergoing CPR training within a structured flipped classroom learning design. The design is intentionally aligned with principles of autonomous motivation and mastery goal orientation, aiming to enhance both theoretical knowledge and practical skills in CPR.

By examining how students’ motivation, study-effort, and perceptions of teachers’ goals relate to their perceived learning outcomes, this research contributes to a deeper understanding of how flipped classroom models can support competence development in nursing education. The study offers empirical insights into the mechanisms that underpin effective learning in practice-oriented settings and provides evidence to inform the development of innovative, student-centered teaching strategies.

The research question explored is

How do students’ motivation, study-effort and perceptions of teachers’ goals associate with their perceived learning outcomes in a flipped classroom learning design?

Contribution to the field

By exploring these dimensions, the study aims to advance the pedagogical foundations of nursing education and support the implementation of evidence-based teaching practices that promote lifelong learning and clinical competence.

This study is significant for several reasons:

1. 1.

   It addresses a critical educational need: Improving CPR competence among nursing students is essential, as these skills are directly linked to patient survival in emergency care.

2. 2.

   It explores the role of motivation and instructional alignment: Understanding how students’ internal motivation and their perceptions of teacher support influence learning outcomes can inform more effective teaching practices.

3. 3.

   It provides a model for evidence-based curriculum development: The findings may guide the implementation of active learning strategies within flipped classroom designs that foster lifelong learning and clinical readiness.

Aims and hypotheses

The aim of this study was to investigate the associations between nursing students’ autonomous motivation when performing the four learning activities in the flipped classroom learning design and their perceptions of teachers’ goals, study-effort and perceived learning outcomes. By using CPR as an educational case, the following three hypotheses were tested via stepwise regression analysis.

1. H1

   When students perform four learning activities, autonomous motivation affects their perceived learning outcomes (PLO).

2. H2

   Perceptions of teachers’ goals (PTGs) affect students’ perceived learning outcomes.

3. H3

   Study-effort affects students’ perceived learning outcomes.

The tested hypothesized associations