Cameras on! Requiring Cameras “on” in the Virtual Classroom

by Sydney Kennedy, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

The Covid-19 pandemic forced employees of many industries into remote work, most often from home. Likewise, students were forced to rapidly transition to remote learning.  The rapid transition from in-person to remote instruction posed challenges to both learners and educators. From an educator’s standpoint, requiring the use of cameras during remote instruction most closely approximates the face-to-face interaction that occurs in an in-person classroom.  The assumption is that interacting “face-to-face” will increase student participation, but is this true? There is controversy about whether requiring cameras to be “on” during meetings and classes improves the quality of the meeting or the instruction. The lay press reports how students and workers are feeling drained after attending face-to-face virtual meetings.  Some call this phenomenon “Zoom fatigue.” The impact on students who have been, by necessity, forced to learn in a virtual environment has not been studied. There may be consequences of the virtual environment caused by prolonged video conferencing.  Just because you ‘can’ use video cameras does not necessarily mean that using video leads to better outcomes.

A recent study entitled “The Fatiguing Effects of Camera Use in Virtual Meetings: A Within-Person Field Experiment” reveals the negative impact that a “camera’s on” policy might have. This was a four-week field experiment.  The authors hypothesized that virtual meetings would be more fatiguing for women and those who were newer members of the organization.  The study was performed to gather insights about best practices for virtual meetings. The study involved 103 employees that were largely female (56.3%) who had been with the organization, on average, for about three years. The participants were randomly assigned to the camera study condition, “on” or “off.” The camera “on” or “off” condition was the independent variable, and all participants were given a survey instrument that included questions about how they felt during the meeting. Fatigue was significantly greater in the camera “on” group (p < 0.001). Camera use also negatively effected engagement (p < 0.001). This was assessed by participant ratings on the survey after each meeting to the question, “in meetings today, when I had something to say, I felt like I had a voice.” The association between camera use and fatigue was stronger for women than men (p < 0.001). Additionally, there was a positive relationship between camera use and fatigue among those employees with the shortest tenure with the organization (p < 0.001). Overall, these results suggest that camera use is particularly fatiguing for women and newer employees.

The results of this study align with the theory that virtual meeting participants feel that they need to actively manage impressions when their cameras are on.  When the participants’ are on camera, they experience a “self-presentation” effect that causes fatigue. Thus, encouraging (or requiring) employees or students to turn cameras on may be harmful and actually hinder engagement. 

To date, there are no studies that have evaluated whether different camera angles would be less fatiguing by being able to give the learner the ability to minimize the self-presentation effects. Self-presentation may be fatiguing due to pressure to “look” competent while maintaining societal appearance standards. There are limitations to these findings, however, such as not being able to evaluate the long-term effects of virtual meetings over time and whether the size of the virtual meetings contributes to these effects.

While this study evaluated people in an employment context, I believe the results can be extrapolated to the virtual classroom. Similar to students, employees are being evaluated on performance and engagement in discussions. There may be additional reasons contributing to fatigue in the virtual classroom. The amount of close-up eye contact with the instructor and other students is not a natural distance when compared to in-person classrooms. Furthermore, students may be spending a lot of time acknowledging self (e.g., looking at themselves) rather than the educator — a phenomenon that does not occur during in-person classes. Additionally, the frame of the camera is small and limits normal mobility.  This can be physically straining. Lastly, the cognitive load is higher in a video environment because it’s more challenging to pick up on nonverbal cues and therefore work much harder to send and receive signals. 

There have been several proposed solutions to these problems. It may be beneficial to reduce the size of the window on the monitor to reduce the student’s face size. For those who use laptop computers, external keyboards can increase the distance between the learner and the video monitor. It has also could be suggested to build in camera “off” time spaced throughout the day to give the students nonverbal rest. 

Admittedly, this topic is controversial.  But the results of this study provide some evidence that requiring “cameras on” during video conferencing may not always be beneficial and may contribute to a negative learning environment. Clearly, we need to learn more about the effects of cameras on student learning and performance! However, educators should be cognizant of some of the negative consequences of “cameras on” in their virtual classrooms.

References

1. Shockley KM, Gabriel AS, Robertson D, et al. The fatiguing effects of camera use in virtual meetings: A within-person field experiment. J Appl Psychol. 2021 Aug;106(8):1137-1155.
2. Ramachandran V. Stanford researchers identify four causes for ‘Zoom fatigue’ and their simple fixes.. Stanford News 2021. Accessed November 2021.

Creating Psychological Safety in Learning Environments

by Emily Keveryn, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital - North Mississippi

Student engagement is often something teachers and educators strive to achieve for lots of reasons — to have students actively thinking about the material and responding to questions, to validate that what is being taught is being understood, and to promote positive attitudes toward the material. But why is there a lack of engagement so common in many learning environments? As a teacher, it may be easy to forget how stressful or daunting the feeling of speaking up in front of a group of peers or instructors is.  For students, this is one of the most common barriers to active engagement in group learning settings. Having an environment where students feel comfortable enough to interact without concerns of sounding silly or being embarrassed is challenging to achieve, especially in very large groups and, conversely, in very small groups too. 

Amy Edmondson, an American scholar of leadership, teaming, and organizational learning, coined the term "psychological safety” to describe “the feeling that one is comfortable expressing and being themselves, and sharing concerns and mistakes without fear of embarrassment, ridicule, shame, or retribution.”^1,2 While Edmondson’s research focuses on psychological safety in teams in business and healthcare settings, many of the ideas and behaviors she observed are relevant to the classroom and other learning environments. It is human nature to want to be accepted, heard, and understood.  And, perhaps more importantly, to avoid rejection, embarrassment, or punishment.  Therefore, fostering a psychologically safe learning environment is critically important and it creates a climate where the material and learning process is engaging, exciting, and lively!

Whether it is in a large classroom, during medical rounds, interacting with an intern on a job site, or in any situation where an educator is teaching something, psychological safety must be present for many reasons.  It encourages learning by making the learner comfortable asking questions when they may not understand the material. It stimulates innovation by encouraging higher-level thinking and understanding.  And it provides a sense of belonging whereby learners feel they can express their thoughts on a subject without being ridiculed or feeling rejected. In one study that addressed psychological safety in a simulation with medical residents in a trauma scenario, researchers found that increased stress impaired knowledge recall and decreased clinical performance.  The medical resident’s performance was measured using a standardized assessment form and a global rating checklist.³ In another study, researchers found that feeling psychologically safe reduced anxiety in nursing students who were participated in simulation activities.  Anxiety was measured by pre- and post-surveys completed by the students.⁴ While these studies looked at psychological safety during simulation activities, the results strongly suggest that the environment, psychologically speaking, has a significant impact on learners' ability to perform activities, recall information, and feel confident.

Timothy Clark writes that there are four stages of psychological safety that individuals go through that reflect basic human needs: inclusion safety, learner safety, contributor safety, and challenger safety.⁵ Inclusion safety is the feeling of belonging and being accepted. One way to provide this type of safety is to learn and use students' names, welcome them to the classroom, and include the learner, and listen to their input. This can be challenging when educating multiple learners, balancing the time between each. Learner safety, which may arguably be the most important stage for educators, occurs when individuals feel comfortable asking questions, receiving feedback, asking for help, and even making mistakes. By actively listening and offering gentle, clear guidance, educators can increase learner safety. This stage is especially important when trying to encourage the learner to speak up and not fear retribution. Contributor safety satisfies the need to feel like we are contributing in a meaningful way and making a difference. When a learner feels included and safe to make mistakes, they feel more inclined to contribute and use the knowledge that they possess to make a difference. This builds off of learner safety, which bolsters confidence in asking questions, and encourages the learner to contribute ideas without fear. Lastly, challenger safety encourages individuals to use what they have learned and strive to make things better in the learning environment and beyond. Challenger safety occurs when students feel they can directly challenge the status quo, recommend an idea or a process, without feeling like the suggestion or comment may damage their reputation.

The Do’s and Don’ts of Psychological Safety:

DO	DON’T
Stay attentive to what is happening and if things seem to be feeling unsafe for some students, listen carefully to understand what may be causing others to feel this way, and ask questions to clarify how they feel.	Don't let uneasiness stop you from discussing what needs to be discussed - if you are feeling uncomfortable, it is likely they are too!
Offer encouragement and support to ensure that each learner knows they are heard and will not be subject to ridicule or embarrassment.	Don’t use sarcasm or emotive language, it can cause others to feel as though we may not be taking them seriously.
Reinforce a conversational culture by making it safe for anyone to talk about anything.	Don’t be defensive or apathetic; it will likely result in the situation continuing and the learner being afraid to speak up again

Psychological safety in learning environments is often something that educators struggle to achieve but is one of the best ways to increase student engagement, interaction, and learning. By role modeling an open and comfortable environment, we are also are fostering the skills within our learners as they learn how to interact with patients and colleagues … and students in the future! Educators need to understand the stages and the ways to create a psychologically safe learning environment to ensure learners get the greatest benefit from the learning process. 

References:

1. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly 1999; 44: 350–383.
2. Edmondson A. The Fearless Organization: Creating Psychological Safety in the workplace for learning, Innovation and Growth. Hoboken, NJ: Wiley; 2018.
3. Harve A, Bandiera G, Nathens AB, and LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. Journal of Trauma and Acute Care Surgery 2012; 72: 497–503.
4. Ignacio J, Dolmans D, Scherpbier A, et. al. Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: A mixed methods study. Nurse Education Today 2015; 35: 1161–1168.
5. Clark TR. The 4 stages of psychological safety: Defining the path to inclusion and Innovation. Oakland, CA: Berrett-Koehler Publishers, Inc.; 2020.

Collaborative Teaching: One Way to Improve Teaching and Learning

by Giang Le, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-Golden Triangle

I came across this interesting article the other day entitled “Teacher collaboration in curriculum design teams: effects, mechanisms, and conditions.”¹ This article got me thinking about my years in school. I recall only a few class sessions that had two or more teachers providing instruction together. For many courses, students are essentially learning from one teacher’s perspective — which is to say, one person’s perspective. Students might assume that what that teacher says is accurate and that piece of information must be the best answer.  I’m not sure that’s always true.  From the teacher’s perspective, I wonder if they get bored teaching the same materials every year? Do teachers ever get so used to their way of teaching that they become reluctant to change? Or unaware of the need to update their content or instructional methods? Maybe teachers need a partner. Maybe instruction is better when taught by a team. Indeed, there is evidence that collaborative teaching can help teachers update their knowledge, improve their practice, and enhance learners’ outcomes.^1,2

What are collaborative teaching design teams? These teams involve educators working together to design all classroom activities, including developing a curriculum, selecting the most effective teaching methods, creating test questions, and developing tools to assess performance. An essential part of being an educator is to continue to learn – not only about the content but also ways of teaching. However, it can be hard to keep up with all the newly available information, especially when there are thousands and thousands of scientific articles published every day. In the process of balancing work life and personal life, teachers can find themselves in situations where they quickly skim an abstract or a summary. Teachers often rely on their existing knowledge and beliefs to develop learning materials. This is when collaborative teaching can be of benefit. Having people with different knowledge, skills, and perspectives on a team creates more opportunities to share knowledge.¹ If a conflict arises (a conflict of ideas, not philosophies or personalities), teachers will have to provide evidence to support their reasoning and convince their peers. In this process of solving “constructive” conflicts, teachers begin to self-reflect on their existing knowledge and their ways of practice. Self-reflection is a critical and we should practice it every day, but it is always easier said than done. Collaborative design teams create the opportunities for constructive conflict and stimulate self-reflection.

One may agree that collaborative teaching can improve teachers’ knowledge, but the more important question is: Can it improve learner outcomes? That’s the ultimate goal that every educator should strive to achieve — improvements in students performance. This means that at the end of the course, we want our students to not only understand or recall but also be able to apply the materials in a variety of circumstances. Theoretically, all teachers should have a tool to assess the students’ performance to guide their teaching. With collaborative teaching design teams, teachers can work together to create these tools. Everyone can contribute based on their experience and what’s available in the educational literature. 

In a recent study, the investigators examined three specific forms of collaboration in teaching: (1) instruction-related, (2) project-related, and (3) organization, performance, and problems-related. Their study is a secondary analysis of the German Program for International Assessment (PISA) data. A sample of 869 schoolteachers was matched with a corresponding sample of 869 students. Students’ achievement in this study was measured by comparing their grades in the first half-year of the academic period. The relationship between the different forms of teacher collaboration and student achievement was estimated through a structural equation model. They found that the third form of collaboration—modified teaching based on students’ performance—positively influenced students’ achievement. However, an interesting aspect of this study was that the subject matter taught were primarily sciences (like maths, biology, physics, and chemistry). This might explain why the third form of collaboration focusing on practice problems would produce a positive outcome. In other subjects involving more discussions and debates, the knowledge-sharing and planning process might play a more important role.

Collaborative teaching design teams can theoretically improve other aspects of the learning process. For example, I remember when my class was divided into groups to do group assignments. From time to time, the professor would be occupied with one group and unavailable to others. This quickly led to frustration among students who had a hard time understanding the materials. Instructions that may seem easy to follow for the professor might not be interpreted the same way by the students. To finish the assignment within the class period, the students would turn in poorly done work and minimal learning occurred. Collaborative teaching would give students greater access to more instructors. This benefit also applies to practical labs where one professor cannot supervise the whole class to ensure everybody follows the instructions.

How do we implement effective collaboration? This process can be time-consuming since it requires team members to gather, discuss, and revise the course materials. A course may need to be developed a year in advance and regularly revised based on students’ feedback and performance. Another strategy for effective collaboration is to allow time to build relationships and foster a culture of trust, respect, and humility between the teachers on the team.³ It is best if each team member is willing and able to contribute in meaningful ways to the work of the group. Here is my favorite quote about teaching collaboration: “As a successful co-teacher, you need to (a) know yourself, (b) know your partner(s), (c) know your students, and (d) know your ‘stuff’.”⁴  Teachers will vary in their ability to effectively collaborate. Some may find it hard to work with partners who have different beliefs and teaching styles.  Others may find it hard to assess how well the students understand the materials. If teachers know their strengths and weaknesses, they can complement each other and support one another. While team teaching can be great, forcing collaboration when teachers are not on the same page will create more classroom confusion and negatively affect learners’ outcomes.

Collaborative teaching is an ongoing process with evidence that it can improve teachers’ and learners’ outcomes. Teachers may find the collaboration not only a beneficial way to enhance their knowledge but also an opportunity to update what and how they teach.  Like any form of collaboration, the process will take time, effort, and commitment to achieve success.

References

1. Voogt JM, Pieters JM, Handelzalts A. Teacher collaboration in curriculum design teams: effects, mechanisms, and conditions. Educational Research and Evaluation. 2016; 22: 121-140.
2. Mora-Ruano JG, Heine JH, Gebhardt M. Does teacher collaboration improve student achievement? Analysis of the German PISA 2012 sample. Frontiers in Education. 2019; 13: Article 3389. (Accessed 2021 Oct 12).
3. Lauren D. Teacher collaboration: how to approach it in 2020. Schoology Exchange. 2020. https://www.schoology.com/blog/teacher-collaboration (Accessed 2021 Oct 12).
4. Keefe EB, Moore V, Duff F. The four “knows” of collaborative teaching. Teaching Exceptional Children. 2004; 36 (5): 36-42.

Listen, Clarify, and Appreciate! Best Practices When Receiving Feedback

by Camron Jones, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

 “It takes humility to seek feedback. It takes wisdom to understand it, analyze it and appropriately act on it”
-Stephen Covey.¹

What do you feel when you hear the word feedback? Do you feel nervous?  Perhaps scared about what the person might say? Do you clam up thinking you have done something wrong? I have a love/hate relationship with feedback. I love knowing how I am performing.  But I sometimes fixate on the things I did “wrong.” It can be intimidating and sometimes we get stressed out about the small things. For many people, it’s hard to accept feedback because it’s perceived as a negative judgment. I have grown to appreciate feedback because it helps me understand what I am doing well and what I need to work on. I think it’s intimidating to ask for feedback. This is something that I am working on. Not only is feedback hard to ask for, but it’s hard to give.

Feedback is the act of someone providing information about a person’s performance of a task and the recipient using the information as a basis for improvement.² Frequently we talk about how to formulate feedback so that we can help another person excel. But receiving feedback is a critical skill too. All of us need to learn to receive feedback graciously and not jump to conclusions. Both giving and receiving feedback are difficult! If we use the right techniques, we can learn as well as teach others. Let’s take a deep dive into receiving feedback by examining the best practices and how to teach it.

There are three crucial steps that should be adhered to if we want to maximize the benefits of receiving feedback. These include actively listening, clarifying the feedback, and expressing gratitude.^3,4  Listening with an open mind is a huge part of the feedback process. Listening promotes our personal and professional growth. Too quickly we jump the gun and interrupt the person providing the feedback. In the Christian Bible, there is a saying that resonates with that I believe applies to receiving feedback: “..let every man be swift to hear, slow to speak.” When receiving feedback, we must consider all of it before responding. Reflecting on the feedback is so important because it helps us grow.

When you hear words that you interpret as negative it can bring you down. But it’s important to ask questions because without getting clarification, you can create an injustice and take feedback too personally. The feedback is about your performance, not about you as a person. I feel like this is critical to understanding how to receive feedback. The person giving the feedback is only trying to help us succeed and grow.  If we dismiss or reject the feedback, we are disadvantaging ourselves.  So, ask clarifying questions!  Make certain you fully understand what the person giving the feedback is telling you. Ask for specific examples.

Finally, it’s important to express appreciation to the person providing the feedback. Remember, the person giving the feedback is usually uncomfortable.  Giving feedback and telling someone something they might perceive as negative can be intimidating. It's easier just to not say anything.  Or to tell someone everything is perfect. But the person giving feedback took the time to carefully consider how to help you improve and they want you to succeed! If we show appreciation, they will feel encouraged and more willing to share with us. 

Tips for Receiving Feedback:3

Be a good listener When in doubt, ask for clarification Embrace the feedback session as a learning opportunity Remember to pause and think before responding Avoid jumping to conclusions, and show that you are invested in the learning process and keen to improve Think positively and be open to helpful hints Learn from your mistakes and be motivated Be a good sport and show appreciation Be proactive – ask for feedback!

Studies have repeatedly shown that effective feedback has a powerful influence on how people learn. In one study involving medical students, they looked at methods to teach how to use feedback. They developed a 2-hr workshop that focused on writing goals in a learning contract, defining effective characteristics of feedback and practicing the use of feedback in response to feedback received. Following the workshop, student group scores increased significantly. They also looked at how coaching improved students' perception of their feedback skills. They noted how students' feedback interactions improved, especially during informal interactions. In a model that defines the communication pathway, they described how the process of feedback could falter. This could be due to previous experiences from the receiver, also the fear of damaging relationships between the giver and receiver.⁴

Another study enrolled second and third-year internal medicine residents. This study focused on a One-Minute Preceptor model. This was a conversation between the resident and the teacher to help improve the resident's clinical skills. One of the greatest benefits of the One-Minute Preceptor model is feedback. At baseline, feedback was ranked as one of the weaker areas. Significant improvements were reported at the end of the study. Feedback was shown to have the greatest impact on performance.⁵ 

Another good resource is the ask-tell-ask feedback model.⁶ For example, say you are a student, and you provided education to a patient about anticoagulation therapy. With the first ask, the preceptor asks the student to talk about how they thought the experience went. The preceptor then gives feedback on what was observed, both positive and negative aspects of the performance.  This is the tell component of the model. During the last ask, the student then reflects on what the preceptor has told them and they both set goals moving forward.⁶ This allows the receiver to actively participate in the conversation and formulate an action plan. I personally experienced this method of feedback in my last year of pharmacy school. Not only did it help me improve, but it also helped me be more open to feedback.

As teachers, we must learn to give feedback in a way that positively affects our students. We should allow students time to self-reflect before giving feedback. This gives the students an opportunity to think about the strengths and weaknesses of their performance. As a learner, we must learn from the feedback and use it as a tool for us to improve. Be sure to listen, clarify, and appreciate!

References

1. Covey, SR. Stephen R. Covey interactive reader-4 books in 1: The 7 habits of highly effective people, first things first, and the best of the most renowned leadership teacher of our time (Internet). Mango Media. 2015 (Cited 2021Oct1)
2. “Feedback”. Merriam-webster.com dictionary, merriam-webster. www.merriam-webster.com/dictonary/feedback. (Cited 2021Sept29).
3. Hardavella G, Aamil-Gaagnat A, Saad N, et. al. How to give and receive feedback effectively. Breathe 2017; 13:327-333. 
4. Bing-You RG, Bertsch T, Thompson JA. Coaching medical students in receiving effective feedback. Teaching and Learning in Medicine 1998; 10(4):228-231. 
5. Furney SL, Orsini AN, Orsetti KE, et al. Teaching the one-minute preceptor. J Gen Intern Med. 2001;16:620-624.
6. Jug R, Jiang X, Bean S. Giving and receiving effective feedback: a review article and how to guide. Arch Pathol Lab Med 2019; 143 (2):244-250.

The Flipped Classroom Model in the Age of Virtual Learning

by Emily Plauche, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Virtual learning played a huge role in higher education during the COVID-19 pandemic. In March 2020 when the pandemic first began to spread in the United States, educators had little time to transition to an online learning environment. Some schools gave students a few weeks off to allow time for administrators and teachers to make plans and learn how to use the technology while others immediately transitioned to an online platform with little guidance. Virtual teaching can be done synchronously via platforms such as Zoom and asynchronously using pre-recorded lectures or other online resources. Live classes allow for more interactive learning but may be limited by technical difficulties and students’ access to technology. Pre-recorded lectures provide students with more flexibility in terms of how and when they prefer to study, but students may feel disconnected from their classmates and instructors.¹  In order to best recreate the flipped classroom model, asynchronous pre-class assignments with synchronous/ live in-class activities would be ideal. Now that the education system has had more time to adapt and is able to provide almost all features of an in-person classroom experience in a virtual platform, it raises the question of whether the flipped classroom model is still effective in a virtual learning setting.  Giving students the option to attend class in person or online may become common practice as the COVID-19 pandemic persists, technology advances, and our comfort with virtual learning grows. 

The flipped classroom model is a somewhat new teaching strategy that focuses on in-class application, rather than lecturing. Instead of homework after class, students complete pre-class assignments in order to prepare for class and class time is reserved for discussions, case studies, and other activities that require students to apply what they learned prior to class. The flipped class has become increasingly popular over the last decade. A meta-analysis studying the flipped classroom model in health professions education found that the model provided several benefits including a statistically significant improvement in learner performance compared with traditional teaching methods, more time for active learning during class time, and the opportunity for students to study at their own pace before class. The analysis also found that more students favored this method of learning over traditional lecturing. However, this model requires students to prepare ahead of time in order for the activities in class to be productive. The increased burden on the student can be a limitation to its success and should be considered when teachers assign out-of-class activities.²

Traditionally, pre-class assignments are done remotely via pre-recorded lectures and required readings, and the interactive classroom activity is done in person. However, COVID-19 required all learning activities to be done virtually. Educators wanting to implement this model while teaching virtually should provide both pre-recorded lectures and live but virtual classes in order to effectively mimic the model. The question is whether a flipped classroom model is still effective in an online learning environment. A study performed in Spain specifically compared performance and emotions towards the flipped classroom model in undergraduate STEM courses before and after the COVID-19 pandemic comparing two groups: “face to face” and “face to screen.” The course consisted of three hours of live class with pre-recorded lessons to watch in preparation for class in both groups. The instruction methodologies, syllabi, and structure were identical in both groups. The study did not disclose what type of assessments were used but the “pass rate” was similar in the two groups with 67.1% of students in the face-to-face group achieving a “passing” score compared with 70.3% in the face-to-screen group.  The difference was not statistically significant. Face-to-face instruction was associated with more positive emotions such as enthusiasm, confidence, tranquility, and fun while face-to-screen instruction was associated with more negative emotions including concern, nervousness, fear, and boredom.³

Some of these negative emotions observed in the face-to-screen group were likely influenced by the uncertainties at the beginning of the pandemic and were not solely due to virtual learning. As students become more acquainted with distant learning, it is likely the virtual classroom will be perceived less negatively. However, student engagement and attention in the virtual classroom may be persistent challenges. It is promising that there was not a statistically significant difference in performance between the groups, suggesting that the flipped classroom is an acceptable approach to teaching in a virtual setting.

Instructors can work to increase virtual student engagement by offering a variety of ways for students to participate. Some may prefer to use the microphone, type in a chat box, or use the raise hand feature. By offering multiple options, students are able to interact in a way that they feel most comfortable. Breakout rooms can also be used to facilitate work in small groups, which might reduce students' anxiety about taking in front of a large group. Teachers can also ask their students for feedback throughout the semester to better understand students’ needs and concerns. To minimize technical difficulties, teachers should perform test runs before live class sessions to ensure Zoom links, internet connection, and sound are working properly.

The flipped classroom model allows for more interactive classroom experiences between students and teachers and has been shown to improve student performance when compared to more traditional methods to teach. While we have limited data from studies, the flipped classroom method still works in a virtual classroom setting. Teachers planning to utilize the flipped classroom model in an online class may face challenges including technical difficulties along with reduced student engagement, attention, and attitude towards virtual learning. Teachers should keep this in mind as they develop material to teach virtually. As more research is published about online teaching methods, educators will have a better understanding of how to approach teaching in virtual classrooms.

References:

1. Camargo CP, Tempski PZ, Busnardo FF, Martins M de A, Gemperli R. Online learning and COVID-19: a meta-synthesis analysis. Clinics 2020;75: e2286.
2. Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ. 2018;18(1):38.
3. Jeong JS, González-Gómez D. A STEM Course Analysis During COVID-19: A Comparison Study in Performance and Affective Domain of PSTs Between F2F and F2S Flipped Classroom. Front Psychol. 2021;12:669855.