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comprehensive faculty development, and flexible ad-

aptation to each institution’s disciplinary and techno-

logical context.

Keywords: Flipped classroom, higher education

in health, autonomous learning, academic perfor-

mance, clinical skills

Flipped classroom in higher educa-

tion in the area of health: A system-

atic review of the literature.

Aula invertida en la educación superior

en el área de la salud: Una revisión sis-

temática de la bibliografía.

RESUMEN

El presente estudio se planteó como objetivo ge-

neral analizar los beneficios, desafíos, tendencias y re-

comendaciones reportadas en la literatura científica re-

ciente sobre la implementación del aula invertida en la

educación superior en salud. Para ello, se desarrolló

una revisión sistemática de la bibliografía bajo el enfo-

que cualitativo interpretativo, utilizando el método

PRISMA como guía metodológica. El corpus final es-

tuvo compuesto por 27 estudios empíricos publicados

entre 2021 y 2025, seleccionados según criterios de

pertinencia temática, acceso completo y enfoque me-

todológico. Los hallazgos evidenciaron tres grandes

beneficios del modelo: (i) fortalecimiento del aprendi-

zaje autónomo, al fomentarla autorregulacióny la ges-

tión independiente del conocimiento; (ii) mejora en el

rendimiento académico, con diferencias estadística-

mente significativas en diversas evaluaciones respecto

al modelo tradicional; y (iii) desarrollo de habilidades

clínicas, particularmente en contextos de simulación,

resolución de casos y práctica autónoma. No obstante,

también seidentificaron desafíos estructurales como la

falta de capacitación docente, limitaciones tecnológi-

cas, carencias evaluativas y resistencia institucional.

En conclusión, el aula invertida representa una estrate-

gia pedagógica efectiva para el desarrollo de compe-

tencias clave en salud, pero la efectividad en su imple-

mentación requiere un rediseño curricular progresivo,

formación docente integral y adaptación flexible a los

contextos disciplinares y tecnológicos de cada institu-

ción.

Andrea Urgilés-Arcentales¹ & Johanna Garrido-

Sacán²

1

Coordinación Zonal 6 de Salud, Cuenca

2

Universidad Nacional de Educación Ecuador, Av. Indepen-

dencia S/N Sector Chuquipata

Correspondencia :

angie16_1992@hotmail.com

johanna.garrido@unae.edu.ec

Recepción: 27 de junio de 2025 - Aceptación: 9 de enero de

2

026 - Publicación: 29 de enero de 2026.

ABSTRACT

This study aimed to analyze the benefits, chal-

lenges, trends, and recommendations reported in re-

cent scientific literature on the implementation of the

flipped classroom in health higher education. To this

end, a systematic review was conducted using an in-

terpretive qualitative approach, with the PRISMA

method as the methodological guide. The final corpus

comprised 27 empirical studies published between

2021 and 2025, selected according to thematic rele-

vance, full-text availability, and methodological focus.

The findings identified three major benefits of the

model: (i) strengthening autonomous learning by fos-

tering self-regulation and independent knowledge

management; (ii) improving academic performance,

with statistically significant differences across several

assessments compared with the traditional model; and

Palabras clave: Aula invertida, educación supe-

rior en salud, aprendizaje autónomo, rendimiento aca-

démico, habilidades clínicas.

(

iii) developing clinical skills, particularly through

INTRODUCTION

simulation contexts, case resolution, and autonomous

practice. However, structural challenges were also

identified, including insufficient faculty training, tech-

nologicallimitations, assessment constraints, andinsti-

tutional resistance. In conclusion, the flipped class-

room is an effective pedagogical strategy for develop-

ing key health competencies, but successful imple-

mentation requires progressive curricular redesign,

Training highly qualified health professionals

is a major challenge for higher education, espe-

cially given the complexity and dynamism of to-

day’s global healthcare environment. Historically,

pedagogical approaches in this field have been

strongly teacher-centered, shaping a dynamic that

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limits students’ protagonism in their own learning

process (Mascolo, 2009). This teacher centrality—

together with the predominance of one-way lec-

tures—has often encouraged passive knowledge

assimilation, weakening the critical and practical

capacities professionals need to respond to the sec-

tor’s technological change and demands (Gatica &

Rubí, 2021).

In this context, it is essential to rethink meth-

odological approaches in health higher education.

The integration of pedagogical strategies that foster

active participation, reflective thinking, and auton-

omous learning has become an urgent need to over-

come the limitations of the traditional model and

better meet professional-context demands (Durán

and instructors’ experiences and valuations—to

generate recommendations that guide adoption and

support sustainable integration into educational

programs.

Within this framework, the present study is

proposed as a systematic review of scientific liter-

ature published between 2021 and 2025 on flipped-

classroom implementation in health higher educa-

tion. Through rigorous compilation and analysis of

empirical studies, it aims to clarify its real impact;

document benefits in autonomous learning, aca-

demic performance, and clinical skills; identify

common challenges; and synthesize trends, good

practices, and recommendations to better leverage

its educational potential in university health pro-

grams. This contribution seeks to strengthen peda-

gogical processes in health education toward more

participatory, reflective, and contextualized learn-

ing, helping prepare professionals for 21st-century

sector demands.

&

Vigueras, 2023). The flipped classroom has

gained prominence as a didactic alternative capable

of transforming educational practices by placing

the student at the center of the process and increas-

ing involvement in learning.

The flipped classroom reshapes pedagogical

relationships by moving prior theoretical learning

to virtual environments, using digital resources—

videos, podcasts, interactive presentations, and

guided readings—that students can review at their

own pace (Xi, 2022; Prieto et al., 2021). This reor-

ganization of instructional time frees face-to-face

sessions for discussion, collaborative work, case

analysis, problem solving, and practical application

of knowledge, creating a participatory setting that

strengthens meaningful learning.

Health education is particularly well suited to

flipped-classroom adoption because it must con-

nect theoretical knowledge with clinical skills that

can only be developed through well-guided practi-

cal experiences (López et al., 2021). International

and local evidence indicates that this approach can

improve academic performance, autonomy, and

student motivation, while promoting stronger en-

gagement and active participation in class (Moreira

The flipped-classroom strategy has achieved

broad international recognition in health higher ed-

ucation. Evidence—especially from quasi-experi-

mental studies and controlled reviews—suggests

that its application yields meaningful gains in aca-

demic performance, practical skill development,

and student motivation (Evaristo et al., 2019; Hew

& Lo, 2018). Across multiple contexts, digital re-

sources (videos, presentations, readings) are pro-

vided before face-to-face sessions so that class time

can focus on participatory dynamics such as de-

bates, clinical cases, and problem solving (Bar-

ranquero et al., 2022). International meta-analyses

report improvements in grades (d ≈ 0.33; p < 0.001)

when the flipped classroom includes initial diag-

nostic assessments (Hew & Lo, 2018), as well as

positive effects on autonomy and active participa-

tion (Moreira & García, 2024). At the same time,

benefits appear moderated by educational context:

for instance, studies in Asia describe mixed student

perceptions, including overload or lower efficiency

when institutional support or resources are insuffi-

cient (Barranquero et al., 2022).

&

García, 2024). However, effective implementa-

tion also faces barriers, including faculty resistance

to change, insufficient technological infrastructure,

limited training in the pedagogical use of digital

tools, and still-limited systematized evidence to

clarify the model’s real impact in this field.

Accordingly, there is an urgent need for stud-

ies that examine the effects of the flipped classroom

in health higher education in depth, considering

both reported benefits and the conditions that ena-

ble or constrain its effectiveness. It is also crucial

to understand stakeholder perceptions—students’

In Latin America, progress has been more lim-

ited but still generally positive. Mariscal et al.

(2024) note that most regional studies come from

Mexico, Spain, Peru, Chile, Colombia, and Brazil.

In Peru, Evaristo et al. (2019) found that dentistry

students taught with a flipped approach outper-

formed peers in biostatistics taught traditionally

(32.6 vs. 27.9; p < 0.001), and Brazilian studies re-

port improvements in nursing and dentistry (da

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Silva et al., 2025). In Colombia, the experience is

more incipient, but Mora (2020) highlights the

combination of the flipped classroom with prob-

lem-based learning as a promising practice to

strengthen clinical reasoning. Ecuador has also

joined this expansion: Aguilera et al. (2024) report

that medical students using the flipped classroom

achieved averages close to 96/100 (Kruskal–Wal-

lis, p = 0.000) compared with conventional meth-

ods, helping counter demotivation and low perfor-

mance.

The flipped classroom is theoretically

grounded in constructivism and active learning,

emphasizing students’ central role in knowledge

construction (Díaz et al., 2024; Biggs, 1999). It re-

organizes the traditional instructional sequence into

three phases: pre-class, in-class, and post-class

Faculty likewise report that inverting class-

room time enables closer, more personalized guid-

ance, supporting deep learning and stronger inte-

gration between theory and practice (Prieto et al.,

2019). Nevertheless, studies note that preparing

materials and redesigning instruction increases fac-

ulty workload and may generate resistance when

adequate training and institutional support are lack-

ing (Phillips & Wiesbauer, 2022; Barranquero et

al., 2022).

Key challenges include the digital divide and

limited resources in some educational contexts—

especially in Latin America (da Silva et al., 2025;

Prieto et al., 2019)—students’ reliance on self-dis-

cipline to prepare in advance (Barranquero et al.,

2022), and resistance to change among faculty or

students accustomed to traditional dynamics (Phil-

lips & Wiesbauer, 2022). Gaps also remain regard-

ing long-term effects and impacts on real clinical

performance or patient health outcomes (Bar-

ranquero-Herbosa et al., 2022). To address these

obstacles, studies converge on the need for peda-

gogical and technological training for instructors,

equitable access to digital resources, careful plan-

ning of all model phases, a participatory and col-

laborative classroom culture, and assessment strat-

egies aligned with active-learning principles (da

Silva et al., 2025; Prieto et al., 2019). They also rec-

ommend piloting projects, gradual integration into

curricula, and academic communities that share ex-

periences and good practices to strengthen sustain-

ability and expansion of the flipped classroom in

health higher education (Aguilera et al., 2024;

Prieto et al., 2019).

(Barranquero et al., 2022). In pre-class, students ac-

cess content at home at their own pace; in-class fo-

cuses on problem solving, clinical case analysis,

and competency practice in collaborative settings

with the instructor as facilitator; and post-class con-

solidates learning through exercises or summative

assessments integrating the content (Prieto et al.,

2

019).

In line with Bloom’s taxonomy, the flipped

model shifts more memoristic learning (remember-

ing, understanding) to virtual environments and re-

serves face-to-face time for higher-order operations

(applying, analyzing, evaluating) (Phillips &

Wiesbauer, 2022; Díaz et al., 2024). This logic also

informs the “adaptive flipped classroom,” which

seeks to personalize in-person sessions based on

prior diagnostics and attention to students’ zone of

proximal development (Prieto et al., 2019; Díaz et

al., 2024).

METHODOLOGY

Benefits of the flipped classroom in health ed-

ucation have been widely documented: consistent

improvement in academic performance (Hew &

Lo, 2018; Barranquero et al., 2022), stronger en-

gagement and self-regulation of learning (Moreira

This study is a systematic review of the scien-

tific literature aimed at examining empirical evi-

dence on the implementation of the flipped class-

room in health higher education. The review was

conducted and reported in accordance with

PRISMA 2020 (Preferred Reporting Items for Sys-

tematic Reviews and Meta-Analyses), ensuring a

structured, transparent, and reproducible process

across the core phases of identification, screening,

eligibility, and inclusion (Figure 1).

&

García, 2024), and development of transversal

competencies such as teamwork, critical thinking,

and communication (Evaristo et al., 2019; Bar-

ranquero et al., 2022). Student evaluations also

suggest that flexible study timing, clear objectives,

and opportunities to deepen content during face-to-

face sessions enhance overall satisfaction with

training (Hew & Lo, 2018; Barranquero et al.,

2

022).

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Figure 1. PRISMA Flow Diagram

Design and epistemological approach

records marked ineligible by automation tools (n =

), and records removed for other reasons (n = 0).

0

The review adopts a qualitative documentary

approach within an interpretive paradigm, prioritiz-

ing the qualitative interpretation of findings and

avoiding overgeneralization. The goal was to re-

construct and understand the evidence on the

flipped classroom by identifying patterns, regulari-

ties, and divergences across reported experiences in

university-level health programs. Findings were or-

ganized inductively around the review objectives:

reported benefits, barriers/obstacles, and recom-

mendations for effective implementation.

Subsequently, 156 records were screened, and 74

were excluded at title/abstract level. Full texts were

then sought for retrieval (n = 82), with 0 not re-

trieved, and 82 reports were assessed for eligibility.

After eligibility assessment, 55 reports were ex-

cluded with reasons: 48 narrative reviews, 6 meta-

analyses, and 1 letter to the editor. The final corpus

included 27 empirical studies (Figure 1).

Eligibility criteria

Inclusion criteria were: (a) empirical research

published between January 2021 and May 2025;

Data sources and search process

(b) implementation of the flipped classroom in uni-

An advanced search was conducted in major

academic databases: Scopus, Web of Science, Pub-

Med, SciELO, Redalyc, and Dialnet. The search

and selection process yielded 156 records in total:

versity-level health programs; (c) availability of

full-text; (d) indexed in recognized databases or re-

trievable through systematic complementary

sources; and (e) written in English or Spanish.

Exclusion criteria included: (a) narrative re-

views, (b) methodologically unsupported essays,

(c) letters to the editor, (d) studies outside higher

9

3 identified through databases and 63 identified

through other sources. Before screening, the fol-

lowing were removed: duplicate records (n = 0),

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education, and (e) studies that did not report meas-

urable results related to autonomous learning, aca-

demic performance, or clinical skills. In the final

eligibility stage, the excluded full-text reports cor-

responded to 48 narrative reviews, 6 meta-anal-

yses, and 1 letter to the editor (as reflected in the

PRISMA flow).

Table 1

Risk of bias judgment by included study

Between-group Compa- Objective academic out- Objective clinical/skills out- Overall

Study

rison

come

RoB

Dong et al. (2021)

Yang et al. (2021)

Yang et al. (2024)

Li & Yang (2021)

Yes

No

Yes

No

Yes

No

Moderate

High

No

High

Yeh (2022)

No

Yes

High

Joseph et al. (2021)

Behmanesh et al. (2022)

Teo et al. (2022)

Yes

No

High

Rehman & Fatima (2021)

El Sadik & Al Abdulmonem

Yes

High

No

Yes

High

(

2021)

Sivarajan et al. (2021)

Khodaei et al. (2022)

Londgren et al. (2021)

Sointu et al. (2023)

No

Yes

No

Yes

No

Yes

No

Yes

No

High

Yes

No

High

Wehling et al. (2021)

Zhu & Zhang (2022)

Chick et al. (2021)

No

Yes

No

High

Yes

No

High

Ortego et al. (2021)

Plaza & Cabezón (2025)

McLean & Attardi (2021)

Álvarez et al. (2022)

Beltrán et al. (2025)

Garrido et al. (2024)

Antezana (2023)

Yes

No

High

No

High

No

Yes

No

High

Yes

No

Moderate

Unclear

Moderate

High

No

Yes

No

Ñique & Díaz (2021)

Aguilera et al. (2024)

Andrade & Guevara (2022)

Yes

No

High

Yes

High

Scope (population and sample logic)

geographic regions (including Latin America, Eu-

rope, Asia, and North America), as represented in

the included corpus.

The target “population” comprised all studies

globally evaluating flipped-classroom strategies in

health higher education. The “sample” was an in-

tentional selection of studies meeting the above cri-

teria and offering analytic value across diverse

health disciplines (e.g., medicine, nursing, dentis-

try, pharmacy, physiotherapy, biochemistry) and

Data extraction and synthesis

Data were extracted using structured matrices

capturing: authors, year, country/setting, disci-

pline, design, sample size/type, outcomes and ben-

efits (autonomous learning, academic performance,

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clinical/skills development), limitations, and im-

plementation features (tendencies and good prac-

tices). Analysis followed an inductive logic: mean-

ingful units were coded and then grouped into the-

matic categories aligned with the review objectives

three broad categories that demonstrate its positive

impact on university training. First, the strategy

stands out for its contribution to autonomous

learning, self-regulation, and active student

participation. Evidence indicates that the flipped-

classroom model strengthens pre-class engagement

through resources such as videos, guides, quizzes,

and other multimedia materials that enable students

to manage their time and study pace, fostering

metacognitive skills that are essential in health

education (Dong et al., 2021; Yang et al., 2021;

Khodaei et al., 2022).

(benefits, barriers, recommendations). Interpreta-

tion emphasized (i) the relationships between re-

ported outcomes and contextual conditions, (ii) ap-

plicability across settings, and (iii) enabling and

limiting factors for implementation.

Methodological quality / risk of bias assessment

For example, Joseph et al. (2021) reported that

100% of students accessed the videos before class

and 78% acknowledged improvements in

motivation and concentration, while Álvarez et al.

(2022) and Garrido et al. (2024) highlight advance

planning, note-taking, and self-management as key

indicators of autonomy. Likewise, studies such as

Yang et al. (2024) and Rehman and Fatima (2021)

describe that the flipped classroom strengthens

reflection and the habit of independent study,

supporting self-regulation, which is indispensable

in professional health training. Regarding

academic performance, the findings are also

consistent.

Several studies have documented statistically

significant improvements in final grades and in

assessments that evaluate both theoretical and

applied knowledge. Dong et al. (2021) reported

higher mean scores in the experimental group

compared with the traditional group (79.22 vs.

73.31, p < 0.001), Aguilera et al. (2024) reported

an overall mean close to 98.32/100 with highly

significant differences (p = 0.000), and Yang et al.

(2021) recorded improvements in post-class tests

and clinical analysis (FC: 35.81 ± 1.66 vs. LBT:

27.42 ± 1.91; p = 0.0016). In addition, Chick et al.

(2021) reported a significant increase in pre-class

scores (from 67% to 80%; p = 0.031), and Antezana

(2023) highlighted an average increase of 1.4

points in nursing compared with biochemistry (p =

To provide a formal and transparent assess-

ment of methodological quality / risk of bias, we

applied a pragmatic, study-level RoB judgment

based solely on what was explicitly reported in the

extraction matrix: (1) presence of an explicit be-

tween-group comparison, (2) reporting of objective

academic outcomes (e.g., grades/scores/pass rates

rather than perceptions only), (3) reporting of ob-

jective clinical/skills outcomes, and (4) whether

key outcomes were not reported (NR). Using an a

priori decision rule, studies were rated Moderate

RoB only when they reported a between-group

comparison plus at least one objective outcome;

they were rated High RoB when these safeguards

were absent; and Unclear RoB when missing/NR

reporting prevented a defensible judgment. The

study-by-study RoB classification is reported in

Table 1.

Ethics and academic integrity

Because this review used only previously pub-

lished studies and secondary sources, it did not in-

volve human participants and therefore did not re-

quire ethics committee approval. Academic integ-

rity was ensured through responsible citation, re-

spect for copyright, and full traceability of con-

sulted sources through the PRISMA-guided selec-

tion process and the extraction matrices.

0

.02).

These findings are consistent with El Sadik

and Al Abdulmonem (2021) and Ñique & Díaz

2021), who note that the flipped classroom

RESULTS

(

Benefits of implementing the flipped classroom

in health-related degree programs

promotes deeper reasoning, more durable

understanding, and effective transfer of knowledge

to new assessment contexts. Finally, clinical skills

development is another domain in which the

strategy has shown notable benefits. Yeh (2022)

reported that recorded simulations strengthen

The benefits of implementing the flipped

classroom in health-related degree programs have

been widely documented and can be grouped into

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understanding of technical procedures and learning

in nursing settings, while Joseph et al. (2021)

documented that integrating clinical cases and

simulations into the flipped class enhances applied

skills. Similarly, Yang et al. (2021) found

improvements in patient management (p = 0.0007),

critical thinking (p = 0.0014), and teamwork (p =

flipped group improved technical skills such as

orthodontic wire bending (p < 0.01), supporting the

model’s value for hands-on content. Likewise,

Behmanesh et al. (2022) and Rehman and Fatima

(2021) reported improvements in procedures such

as probing, suturing, and exam interpretation due to

advance preparation with videos and interactive

resources.

0

.0117) through guided discussions of real cases.

Sivarajan et al. (2021) showed that students in the

Table 2

Benefits of implementing the flipped classroom (NR = not reported)

Study

Autonomous learning

Academic performance

Clinical skills

Improved critical thinking (41.8%

Experimental > traditional (79.22 vs. vs. 23.3%, p = 0.007), self-confi-

Promotes autonomous study via vid-

eos/cases; supports self-regulation, re-

flection, metacognition.

Dong et al.

(

2021)

73.31, p < 0.001).

dence (42.9% vs. 23.3%, p =

.004), and teamwork.

0

Higher perceived usefulness; im-

proved patient management (p =

0.0007), critical thinking (p =

0.0014), teamwork (p = 0.0117)

via guided real-case discussions.

Better post-class performance (78.06

vs. 65.16; p = 0.0024) and clinical

analysis (FC: 35.81 ± 1.66 vs. LBT:

Facilitates self-learning at own pace

through interactive videos; improves

understanding, autonomy, preparation.

Yang et al.

2021)

(

2

7.42 ± 1.91; p = 0.0016).

Significant gains in standardized as-

sessment (M = 4.29), independent

study (M = 4.23), reflection (M =

No standardized testing; reports better Better case analysis, clinical-

Yang et al.

2024)

analytic capacity and application of

theory in clinical contexts (satisfac-

tion/self-evaluation).

question formulation, and partici-

pation in problem solving through

real-case discussions.

(

4

.22); more pre-class autonomy.

Encourages self-learning, self-regula-

tion, active participation; interactive

learning with continuous teacher feed-

back; flexible repeated access.

Not measured directly; increased self-

efficacy (indirect predictor of aca-

demic improvement).

Li & Yang

2021)

NR

(

Improved technical execution and

clinical understanding via rec-

orded simulations and autono-

mous practice.

Flexible repeated access improved pre- Not measured directly; perceived bet-

Yeh (2022)

class preparation and self-regulation

habits.

ter preparation/comprehension for ex-

ams and practicals.

1

00% viewed pre-class videos; 78%

Significant improvement in overall

performance and clinical-analysis

items (p < 0.0001).

Although theoretical, used prob-

lem-solving exercises based on

relevant clinical cases.

Joseph et al. reported better motivation/concentra-

(

2021)

tion; pre-quizzes strengthened prepara-

tion.

Better IV injections, probing, su-

turing; perceived efficacy and im-

proved pre-class audiovisual re-

view.

Significant gains in knowledge and

practical skills (p < 0.05); higher satis-

faction and positive learning attitude.

Behmanesh et Better pre-class preparation; higher

al. (2022)

motivation and learning efficiency.

Not explicit; inferred improvement in Slight improvement in oral compre-

autonomous understanding via in-class hension/reading (listening: +0.7; read- NR

Teo et al.

(

2022)

interaction with clinical reality.

ing: +0.6).

Strengthened self-regulation through

resources (videos, guides, VLE,

WhatsApp); active-learning approach; 24.60 points, p < 0.05) attributed to

Significant improvement (19.67 to

Effective clinical analysis and de-

cision-making via interactive

cases centered on pregnancy.

Rehman &

Fatima (2021)

>

50% assumed responsibility for

active instructional design.

learning.

El Sadik & Al Supported self-study via videos/read-

Abdulmonem ings; study at own pace; fostered self-

Significant gains in cognition and

analysis (Cohen’s d = 1.41 and 1.01),

NR

(

2021)

directed/continuous learning.

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Study

Autonomous learning

Academic performance

Clinical skills

improving deep anatomy understand-

ing.

Significant improvement in complex Effective development of ortho-

Early access to videos enabled individ-

ual practice and pre-class preparation

strategies.

Sivarajan et

al. (2021)

components (e.g., Adams clasp, Z-

spring); FC more effective for ad-

vanced tasks.

dontic practical skills via autono-

mous pre-practice and instructor

guidance.

Significant increases in self-manage-

Khodaei et al. ment, self-control, and desire to learn

No direct clinical practice; in-

cluded simulated theoretical exer-

cises (cardiovascular/renal dis-

eases).

Not measured directly; strengthened

metacognitive skills as indirect perfor-

mance predictors.

(

2022)

(p ≤ 0.001) using LMS/WhatsApp; im-

proved self-regulation and confidence.

Class time fully dedicated to su-

pervised clinical practice with im-

mediate feedback; strengthened

technical competencies.

Pre-class preparation with available

materials increased active involvement

and responsibility.

Londgren et

al. (2021)

No grades reported; instructors per-

ceived better cognitive preparation.

Improved self-regulation, time man-

Sointu et al. agement, responsibility via structured

No grades; student satisfaction linked

to better understanding and motiva-

tion.

NR

(

2023)

pre-materials and clear initial guid-

ance.

Promoted pre-class preparation with

interactive videos; active learning fo- NR

cused on clinical problems.

Oriented to clinical practice (oto-

laryngology); useful to contextu-

alize and solve clinical problems.

Wehling et al.

(

2021)

Strong promotion of self-regulation/re-

Not directly applicable; strength-

ened transversal skills (critical

analysis, collaboration) relevant

to clinical settings.

Not measured quantitatively; positive

flection via modules/quizzes; students

perceptions of deep, applied, critical

learning.

McLean &

Attardi (2021) valued active role and instructor as fa-

cilitator.

Clear improvement in pre-class

scores, especially in less advanced

residents (p < 0.05).

Not directly measured; prepara-

tion enabled more effective in-

class clinical discussions.

Chick et al.

2021)

Increased pre-class preparation

through videos; promoted autonomy.

(

Home-delivered simulations/ma-

Pre-access to recorded classes sup-

ported autonomous preparation at the

student’s pace.

Zhu & Zhang

2022)

Perceived improvement; scores ques- terials; limited effectiveness as a

tioned due to possible online cheating. replacement for in-person prac-

tice.

(

Supported communication and

key palliative-care skills, though

not direct practical skills.

Ortego Maté Promoted self-regulation, autonomy, High perceived utility to acquire

et al. (2021) responsibility.

knowledge and pass the course.

Plaza del Pino

&

Cabezón- Fostered autonomous and collaborative

Fernández learning.

2025)

Álvarez Váz- Increased self-regulation, responsibil-

Benefits in clinical interpersonal

skills (not technical skills).

NR

(

Facilitated pathology analysis

through simulated clinical cases;

no direct clinical practice.

Significant improvement in partial-

exam results vs. traditional approach.

quez et al.

2022)

ity, motivation; encouraged active pre-

class preparation.

(

Beltrán et al. Promoted self-regulation, independent

NR

(

2025)

work, and pre-class preparation.

Garrido-Urru- Encouraged self-paced study, self-reg-

tia et al.

2024)

ulation, responsibility; used videos,

readings, note guides.

NR

(

Significant improvement in experi-

Not explicit; inferred improved pre-or- mental-group grades (p = 0.02), aver- Improved analysis, problem solv-

Antezana He-

redia (2023)

ganization and independent review via age increase up to 1.4 points (e.g.,

technological resources.

ing, integrated clinical thinking,

Nursing POST = 63.7 vs. Biochemis- teamwork.

try/Pharmacy POST = 50.8).

Not directly applied; improved

communication, teamwork, and

theoretical application.

Ñique-Carba- Promoted self-learning, self-regula-

jal & Díaz- tion, interest, active reflection.

Improved retention and understanding

of contents.

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Study

Autonomous learning

Academic performance

Clinical skills

Manchay

(

2021)

Aguilera-

Meza et al.

Very high experimental-group mean

(93.22/100); significant differences (p NR

= 0.000).

Supported through pre-activities and

personalized pace.

(

2024)

Andrade-En-

calada & Gue-

vara-Vizcaíno

Stimulated via digital technologies,

motivation, and mastery of the virtual NR

environment.

Not specified; mentions general

skills linked to the healt

(

2022)

Zhu and Zhang (2022) demonstrate that the

that favored passive models (Li & Yang, 2021; Or-

tego et al., 2021). As a result, face-to-face sessions

are not always fully leveraged for the active work

the flipped classroom requires.

A further challenge is the lack of pedagogical

training among faculty in active-learning strategies

and the use of technological tools. As noted by

Beltrán et al. (2025) and Aguilera et al. (2024), in

many contexts instructors do not receive special-

ized preparation to redesign their practice under

this approach; consequently, implementations can

become superficial and end up reproducing lecture-

based dynamics under new formats.

flipped classroom is adaptable to remote simulation

environments through tools such as Virtual

Canadian Vista or supervised home practice,

facilitating higher levels of technical competence.

Overall, the synthesized evidence confirms that the

flipped classroom is an effective educational

strategy in health higher education, positively

impacting autonomous learning, academic

performance, and clinical skills development.

Challenges and limitations in implementing the

flipped-classroom strategy

Limitations in assessment also emerge as a ma-

jor barrier, because traditional instruments do not

align well with the flipped-classroom logic, hinder-

ing the appraisal of deep learning and critical think-

ing in clinical environments (Sointu et al., 2023;

Andrade & Guevara, 2022). Likewise, scarcity of

institutional resources can compromise implemen-

tation quality: insufficient infrastructure, interac-

tive platforms, educational software, and well-de-

signed audiovisual material negatively affect the

model’s effectiveness (Wehling et al., 2021; Ante-

zana, 2023).

In addition, the complexity of adapting clinical

and procedural content to the flipped-classroom

format poses specific challenges in the health sci-

ences. Certain technical skills require direct super-

vision and practice in real settings; therefore, vir-

tual content must be articulated with guided face-

to-face sessions that enable the consolidation of

clinical competencies (Sivarajan et al., 2021; Teo

et al., 2022).

Studies examining the implementation of the

flipped classroom in health higher education have

identified a set of challenges and limitations that

must be understood to ensure an effective and eq-

uitable adoption of the model. One of the most sig-

nificant difficulties concerns technological gaps

and structural inequalities, particularly in rural set-

tings or contexts with limited connectivity, where

lack of access to devices and stable internet restricts

the autonomous participation on which this strat-

egy depends (Rehman & Fatima, 2021; Zhu &

Zhang, 2022; Yeh, 2022). In addition, faculty

workload and resistance have been repeatedly doc-

umented as barriers. Reconfiguring the teaching

role—from transmitter to learning facilitator—re-

quires substantial time and effort to design peda-

gogical resources and digital materials, often with-

out sufficient institutional support, which generates

demotivation and slows innovation (Khodaei et al.,

2

022; McLean & Attardi, 2021; Chick et al., 2021;

Yeh, 2022).

Another key obstacle is the limited culture of

Finally, a cross-cutting limitation is the weak

measurement of objective outcomes supporting the

impact of the flipped classroom. Many studies re-

port positive student perceptions but lack empirical

evidence demonstrating concrete improvements in

grades, practical performance, or the acquisition of

autonomous learning among students. Many stu-

dents have not developed strong habits of inde-

pendent study, self-regulation, or intrinsic motiva-

tion, largely due to prior educational experiences

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clinical competencies, which limits their capacity

to persuade institutions regarding the model’s ef-

fectiveness and sustainability (Garrido et al., 2024;

Londgren et al., 2021). Taken together, these barri-

ers indicate that expanding the flipped classroom in

health higher education depends on a systemic ap-

proach that includes technological resources, fac-

ulty development, curricular redesign, coherent as-

sessment strategies, and a clear institutional com-

mitment to active and autonomous learning.

Table 3

Challenges and limitations in implementing the flipped classroom in health-related degree programs

Category

Observed consequences (brief)

Reference

Technological Limitati- Hinders students’ pre-class preparation and reduces learn- Rehman & Fatima (2021); Zhu & Zhang

ons

ing autonomy.

(2022)

Increases work-related stress and undermines sustainability Khodaei et al. (2022); McLean & Attardi

Faculty workload

without institutional support.

(2021)

Resistance to pedagogi- Delays institutional adoption and reduces model effective-

Chick et al. (2021); Yeh (2022)

cal change

ness.

Low student motivation Wastes class time and weakens the effectiveness of face-to-

Li & Yang (2021); Ortego et al. (2021)

or preparation

face sessions.

Leads to superficial implementations that do not change

traditional classroom dynamics.

Beltrán et al. (2025); Aguilera et al.

(2024)

Lack of faculty training

Evaluations fail to capture real development of practical

skills or deep cognitive learning.

Sointu et al. (2023); Andrade & Guevara

(2022)

Assessment difficulties

Limited institutional re- Poor materials demotivate students and reduce the model’s

Wehling et al. (2021); Antezana (2023)

Sivarajan et al. (2021); Teo et al. (2022)

sources

Difficulty adapting clini- Risk of superficial practical understanding unless comple-

cal content mented with guided in-person sessions.

impact.

Limited impact evalua- Insufficient robust evidence to support institutional-scale Garrido et al. (2024); Londgren et al.

tion

implementation.

(2021)

Trends, best practices, and recommendations

A prominent trend is the increasing integration

of the flipped classroom with other active

methodologies, such as problem-based learning,

clinical case studies, and simulation in virtual

environments, which strengthens the transition

from theoretical knowledge to simulated clinical

practice. This methodological integration has been

shown to foster analytical skills, critical thinking,

and problem solving—competencies that are

central to contemporary medical education

(Behmanesh et al., 2022; Zhu & Zhang, 2022;

Ortego et al., 2021). In parallel, several studies

emphasize that the model is particularly beneficial

for students with lower prior academic

performance, because it provides greater exposure

to content, ongoing formative feedback, and

increased opportunities for active participation in

class (Chick et al., 2021; Joseph et al., 2021). This

feature positions the flipped classroom as a strategy

with potential to reduce educational gaps and

inequalities.

The analysis of recent studies on the flipped

classroom in health education reveals a coherent set

of trends, best practices, and recommendations that

guide its effective curricular implementation. The

reviewed research consistently highlights that this

pedagogical strategy has contributed significantly

to strengthening autonomous and self-regulated

learning, by enabling students to access content in

advance, manage their time more efficiently, and

assume greater responsibility for their learning

process (Li & Yang, 2021; Khodaei et al., 2022;

Garrido et al., 2024). This autonomy is supported

not only by the model’s didactic structure but also

by the use of technological resources such as virtual

learning

environments

(VLEs),

academic

messaging platforms, and multimedia materials,

which allow students to study at their own pace and

revisit content according to their cognitive needs.

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Table 4

Evidence on the flipped classroom in health education

Dimension

Subcategory

Key evidence (brief)

Studies

Promotes autonomy, active learning, responsi- Li & Yang (2021); McLean & At-

bility, and self-management (with or without tardi (2021); Sointu et al. (2023);

Flipped classroom as a

self-regulation tool

technological mediation).

Aguilera et al. (2024)

Combined approach:

Integrated with simulation, gamification, and Yang et al. (2024); Yeh (2022);

flipped classroom + ac- service-learning to strengthen clinical think- Beltrán et al. (2025); Dong et al.

tive methods

ing.

(2021)

1

. Research trends

Impact on vulnera-

ble/low-performing

groups

Benefits tend to be greater among students

with prior difficulties or low academic perfor-

mance.

Joseph et al. (2021); Chick et al.

(

2021)

Post-COVID transition Consolidated as a post-pandemic hybrid strat- Zhu & Zhang (2022); Wehling et

to hybrid models

egy; emphasis on flexibility and accessibility. al. (2021); Garrido et al. (2024)

Structured pre-class

preparation and asyn-

chrony

El Sadik & Al Abdulmonem

Use of sequenced, flexible-access multimedia

(2021); Rehman & Fatima (2021);

resources (videos, podcasts, guides).

Antezana (2023)

Intentional use of digital Platforms such as Moodle, Canvas,

platforms and collabora- WhatsApp, Zoom, H5P, and institutional

Khodaei et al. (2022); Garrido et

al. (2024); Zhu & Zhang (2022)

tion tools

VLEs support learning.

2

. Pedagogical best

Formative assessment

and continuous feedback feedback aligned with active learning.

Rubrics, formative quizzes, and immediate

Sivarajan et al. (2021); Yeh

(2022); McLean & Attardi (2021)

practices

Clinical contextualiza-

tion within the flipped

model

Simulation, clinical cases, debates, medical- Behmanesh et al. (2022); Teo et al.

record analysis, and remote practical tools.

(2022); Londgren et al. (2021)

Emotionally safe, colla- Instructor–student interaction and emotional Sointu et al. (2023); Plaza & Cabe-

borative environments support facilitate implementation.

zón (2025)

Training needed in instructional design, edu-

Technical and pedagogi-

Li & Yang (2021); Khodaei et al.

(2022); Chick et al. (2021)

cational technologies, and active-learning dy-

cal faculty development

namics.

Progressive, institution- Gradual integration recommended; avoid cog- Yang et al. (2024); Dong et al.

. Curricular imple-

level curricular redesign nitive overload and align with training level. (2021); Beltrán et al. (2025)

3

mentation recom-

mendations

Mixed-method impact Combine objective outcomes (tests, grades)

Yeh (2022); Aguilera et al. (2024);

Ortego et al. (2021)

evaluation

with perceptions and metacognition.

Methodological flexibil-

ity by discipline and

level

McLean & Attardi (2021); Zhu &

Zhang (2022); Andrade & Guevara

(2022)

Avoid mechanical standardization; adapt to

content, skills, and clinical context.

Another relevant finding is that flipped-

classroom implementation has accelerated and

consolidated as part of emerging hybrid models

after the COVID-19 pandemic. The asynchronous

nature of many resources supports pedagogical

continuity even in contexts of disruption or remote

education, expanding institutional legitimacy of the

flipped classroom as a sustainable and resilient

teaching strategy (Zhu & Zhang, 2022; Beltrán et

al., 2025).

videos, interactive guides, directed readings, and

pre-class quizzes has been widely valued by

students, who report that these inputs improve

understanding, motivation, and readiness for in-

class work (McLean & Attardi, 2021; El Sadik &

Al Abdulmonem, 2021). This is reinforced by the

importance

of

accessible

technological

environments that not only facilitate content access

but also enable interaction, individualized

monitoring, and instructor feedback—especially

relevant in practice-oriented programs such as

Medicine, Nursing, and Dentistry.

Regarding best practices, studies stress the need

to offer high-quality materials intentionally

designed for pre-class preparation. The use of short

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Studies also recommend transforming

assessment practices by prioritizing formative

assessment and continuous feedback, rather than

relying exclusively on summative exams. This

approach supports metacognition, learning

regulation, and progressive improvement in student

performance (Sivarajan et al., 2021; Yeh, 2022).

Face-to-face sessions, freed from the burden of

theoretical exposition, can then be devoted to

simulated clinical activities, debates, case analysis,

or collaborative exercises that consolidate

knowledge transfer to real or simulated situations.

This reorganization of instructional time is

consistently identified as a structural strength of the

model (Londgren et al., 2021; Antezana, 2023).

In terms of recommendations, the reviewed

evidence clearly indicates that successful flipped-

classroom implementation requires comprehensive

faculty development, encompassing not only

technological tool mastery but also instructional

redesign, multimedia material production, and the

management of student-centered methodologies.

Instructors must move from the role of lecturer to

that of mediator, guide, and facilitator of active

learning—an evolution that requires continuous

professional development and institutional support

pedagogical sustainability. This flexibility is

crucial so that the flipped classroom is not

understood as just another technique, but rather as

a structural commitment to a more participatory,

critical, and student-centered health education.

DISCUSSION

The findings confirm that the flipped class-

room tends to enhance autonomous learning and

improve academic outcomes, in line with interna-

tional evidence. In this review, we identified clear

benefits in self-regulation, grades, and the develop-

ment of clinical thinking, reflecting patterns re-

ported in prior literature. Similarly, Hew and Lo

(2018) found in a meta-analysis a significant over-

all effect in favor of the flipped classroom in health

education (SMD≈0.33; p<0.001), and Naing et al.

(2023) reported that flipped-classroom students

achieved

better

academic

performance

(SMD≈0.57) and higher satisfaction (SMD≈0.48)

compared with traditional teaching. Banks and Kay

(2022) also indicate that most health-sciences stud-

ies observe improvements in academic perfor-

mance (67% of cases) and student satisfaction

(54%) after implementing the flipped model. These

figures align with our results: several included arti-

cles showed statistically significant increases in

grades and clinical case resolution in the flipped

group, along with high levels of self-reported satis-

faction and motivation. Likewise, reviews in nurs-

ing highlight neutral-to-positive academic out-

comes with the flipped classroom (Betihavas et al.,

2016) and predominantly favorable results in

knowledge, skills, and attitudes (Youha-san et al.,

2021), which is consistent with our overall pattern

of learning improvement.

(Khodaei et al., 2022; Aguilera et al., 2024).

In addition, the flipped classroom should not be

integrated into curricula in an improvised or

fragmented manner; rather, it should be part of a

progressive and contextualized curricular redesign

that considers the type of course, training level,

learning objectives, and real infrastructure

conditions. Integration should be gradual, flexible,

and continuously evaluated to ensure alignment

with the pedagogical goals of health programs

(Yang et al., 2024; Beltrán et al., 2025). In this

regard, studies recommend adopting mixed

methods to evaluate the model’s impact, combining

quantitative indicators (e.g., grades, pass rates,

academic progression) with qualitative analyses

Concordantly, prior literature emphasizes that

the flipped classroom stimulates self-directed

learning. This analysis specified how students use

videos and pre-class materials to study at their own

pace, as shown by Li & Yang (2021) and other

cited authors, who found that most Chinese stu-

dents considered this method highly useful for

strengthening self-learning capacity, problem solv-

ing, and teamwork. Banks and Kay (2022) attribute

positive performance changes to well-designed

curricula that promote self-efficacy, noting that

participants reported greater autonomy, preparation

of their own summaries, and reflection on their

study—elements consistent with self-regulation ef-

fects. From a clinical perspective, although the

(e.g., student perceptions, satisfaction, reflection,

or knowledge appropriation), thereby enabling a

more comprehensive understanding of this

modality’s pedagogical effects (Yeh, 2022; Ortego

et al., 2021).

Finally, studies agree that there is no single

flipped-classroom model applicable to all contexts.

Implementation should respond to the particular

characteristics of each institution, course, cohort,

and region, adapting resources, timing, and

methodologies to ensure equity, inclusion, and

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prior evidence base is smaller, observations of im-

proved reasoning and case-based participation

align with individual studies (e.g., Yang et al.,

well-structured training strategies to improve satis-

faction and self-efficacy. In this sense, both the

global evidence base and the present study recom-

mend that the flipped classroom be implemented

gradually, with adequate technological support

and, when possible, with multimedia resources de-

veloped by experts to optimize instructor time and

didactic quality.

2

021) suggesting advances in critical thinking and

application of concepts in simulated contexts.

However, as Li et al. (2020) also point out, there

are practically no data measuring long-term effects

on professional practice or patient outcomes. This

underscores that the contribution to clinical skills

remains preliminary and requires more longitudinal

research, as recent reviews recommend.

Nevertheless, discrepancies and limitations

also emerge. Some authors report variability in

benefits or less conclusive evidence. In this review,

we observed that changes in the teaching role,

workload, and technological gaps can reduce the

expected impact. This is consistent with Li et al.

Finally, the results of this review contribute

some original perspectives to the existing corpus.

We included very recent studies (up to 2025) and

contexts less represented in earlier reviews. For in-

stance, we synthesized current Latin American and

Middle Eastern research pointing to emerging

trends: combinations of the flipped classroom with

clinical simulations, problem-based learning, or

gamification—elements only marginally addressed

in previous meta-analyses. This expansion also in-

cludes, for example, adaptive educational designs

inspired by Díaz et al. (2024) that personalize pre-

study according to individual level, a still-emerging

topic in the international literature. Moreover, the

present study’s emphasis on validating results with

objective indicators (as reflected in the “weak

measurement of outcomes” category) responds to

an explicit call by authors such as Naing et al.

(2023), who advocate for better-designed studies.

Overall, while this review aligns with prior re-

views regarding the flipped classroom’s core bene-

fits, it extends the discussion by highlighting spe-

cific barriers and actionable interventions (optimal

video length, interactive tools, use of collaborative

platforms) that complement general recommenda-

tions in the literature and offer more detailed prac-

tical guidance for health educators..

(2020), who warned that students reported greater

workload and perceived inefficiency compared

with traditional classes. Our analysis also high-

lighted that producing interactive content often de-

mands substantial faculty time, as other studies

likewise indicate. Similarly, Chen et al. (2017), re-

viewing flipped medical classrooms, detected

highly heterogeneous effects on knowledge (effect

sizes from –0.27 to 1.21, median ~0.08), suggesting

that in many cases differences versus traditional

teaching are not statistically robust. Evans et al.

(

2019) also concluded that, although most studies

report specific improvements, the evidence is not

conclusive” regarding the flipped classroom’s ef-

“

fectiveness beyond traditional instruction.

In our sample, we observed conditions similar

to those described in prior reviews: limited longitu-

dinal follow-up, infrequent use of objective metrics

(standardized tests, real performance), and the fre-

quent absence of randomized control groups—lim-

itations noted both in our study and in the review

by Naing et al. (2023). This aligns with broader cri-

tiques of combining subjective data (perceptions,

surveys) with hard academic outcomes to draw ro-

bust conclusions.

Regarding pedagogical constraints, we identi-

fied that factors such as infrastructure and educa-

tional culture influence outcomes. Several included

studies mention inequitable access to technological

resources and resistance among some students to

autonomous methods—issues also reported in in-

ternational research. For example, just as this study

confirmed challenges in faculty training and

adapted curricular design, the systematic review by

Banks and Kay (2022) emphasized the need for

CONCLUSION

This review clarified the pedagogical founda-

tions underpinning the flipped-classroom strategy

in university-level health programs, highlighting its

constructivist basis and its capacity to reconfigure

traditional teaching through student autonomy and

active participation. The literature indicates that

this model positively influences self-regulation,

personal organization, and intrinsic motivation, en-

abling face-to-face time to be used more effectively

for problem solving and reflection on professional

practice. Evidence also shows that the flipped

classroom contributes to improved academic per-

formance, with statistically significant gains in

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knowledge tests and theoretical–practical assess-

ments, alongside greater retention and understand-

ing of course content. Likewise, its implementation

has proven particularly useful for strengthening

clinical skills development by facilitating the inte-

gration of theory and practice through simulations,

case-based learning, and preparatory materials that

optimize in-person sessions.

However, the review also identified challenges

such as faculty resistance to methodological

change, workload increases associated with in-

structional redesign, insufficient technological

training, and unequal student access to digital re-

sources—factors that condition the strategy’s ef-

fectiveness depending on the institutional context.

Among the most notable trends is the integration of

the flipped classroom with other active methodolo-

gies, such as problem-based learning, simulation,

and gamification, which can amplify its impact and

promote collaborative and reflective engagement.

The evidence also points to best practices, includ-

ing the production of well-designed digital content,

continuous formative assessment, and the reorgan-

ization of class time toward complex problem solv-

ing.

Recommendations emerging from the re-

viewed studies include providing targeted peda-

gogical training for instructors, ensuring adequate

technological conditions, integrating the model

gradually into curricula, and implementing evalua-

tion processes that combine objective measures

with qualitative appraisals. As a limitation of the

present work, we acknowledge that the review pri-

oritized international studies and, in some cases, re-

lied on participants’ self-reported outcomes, with-

out consistently incorporating standardized indica-

tors of clinical performance. Even so, this synthesis

offers a rigorous contribution to understanding the

scope of the flipped classroom and the conditions

required for its effective implementation in health

higher education.

tología. Impacto y satisfacción del alumnado. In II Jor-

nada«AprendizajeEficazconTICenlaUCM» (pp.75-

86). Ediciones Complutense. https://produccioncienti-

fica.ucm.es/documentos/63ddb46d2a23c12be0a22666

Antezana, E. (2023). Impacto del aula invertida en el rendi-

miento académico: Una experiencia en estudiantes de

51–60.

http://doi.org/10.62349/revistauno.v.3i5.21

Banks, L. & Kay, R. (2022). Exploring flipped classrooms in

undergraduate nursing and health science: a systematic

review. Nurse Education in Practice , 64, 103417.

http://doi.org/10.1016/j.nepr.2022.103417

Barranquero, M., Abajas, R. & Ortego, C. (2022). Effective-

ness of flipped classroom in nursing education: A sys-

tematic review of systematic and integrative re-

views. International Journal of Nursing Studies , 135 ,

1

04327. https://doi.org/10.1016/j.ijnurstu.2022.104327

Behmanesh, F., Bakouei, F., Nikpour, M. & Parvaneh, M.

2022). Comparing the effects of traditional teaching

(

and flipped classroom methods on Midwifery students’

practical learning: the embedded mixed method. Tech-

nology,

Knowledge

and

Learning,

1-10.

https://doi.org/10.1007/s10758-020-09478-y

Beltrán, A., Riquelme, C., Sandoval, J. & Chuhuaicura, P.

(2025). Metodologías de amplio impacto en la forma-

ción odontológica en la Universidad de La Frontera,

Chile. International Journal of Odontostomatology,

1

9 (1), https://doi.org/10.4067/S0718-

81X2025000100040

Betihavas, V., Bridgman, H., Kornhaber, R. & Cross, M.

2016). Theevidencefor‘flippingout’:Asystematicre-

view of the flipped classroom in nursing educa-

tion. Nurse education today , 38 , 15-21.

https://doi.org/10.1016/j.nedt.2015.12.010

40 –44.

3

(

Cantuña, A. & Cañar, C. (2020). Revisión sistemática del

aula invertida en el Ecuador: aproximaciónal estadodel

arte. Estudios pedagógicos (Valdivia), 46 (3), 45-58.

http://dx.doi.org/10.4067/S0718-07052020000300045

Chen,F.,Lui,A.& Martinelli,S.(2017).Asystematicreview

oftheeffectivenessofflippedclassroomsinmedicaled-

ucation. Medical

education , 51(6),

585-597.

https://doi.org/10.1111/medu.13272

Chick, R., Adams, A., Peace, K., Bohan, P. & Schwantes, I.,

Clifton, G. & Vreeland, T. (2021). Using the flipped

classroom model in surgical education: efficacy and

traineeperception. Journalofsurgicaleducation , 78 (6),

1803-1807. https://doi.org/10.1016/j.jsurg.2021.05.008

Clark, R., Kaw, A. & Braga, R. (2022). Adaptive learning:

Helpful to the flipped classroom in the online environ-

ment of COVID?. Computer Applications in Engineer-

BIBLIOGRAPHY

Aguilera, C., Delgado, E., Montes, C., Moreira, J. Zambrano,

W. (2024). Eficacia del modelo aula invertida en el ren-

dimiento académico de estudiantes universitarios. Re-

vistaCienciasPedagógicasEInnovación, 12(2),27-38.

https://doi.org/10.26423/rcpi.v12i2.791

ing

Education , 30 (2),

517-531.

https://doi.org/10.1002/cae.22470

da Silva, E., Moura, E., Bezerra, A. & Lima, S. (2025).

Flipped classroom in higher health education: a system-

Álvarez, M., Hernández, C., de Diego, C. & García, L.

(2023). Aplicación del aula invertida adaptativa en His-

https://doi.org/10.5281/zenodo.18422330

30

South American Research Journal, 5(2), 17-32

https://www.sa-rj.net//index.php/sarj/article/view/70

ISSN 2806-5638

atic review. Research, Society and Develop-

Li, L.& Yang, S.(2021). ExploringtheInfluenceofTeacher-

Student Interaction on University Students' Self-Effi-

cacy in the Flipped Classroom. Journal of Education

ment , 10 (14),

e434101422083.

https://doi.org/10.33448/rsd-v10i14.22083

Díaz, M., Nuñez, R., Brito, X., Jameson, A., Moscoso, F. &

Riquelme, P. (2024). Flipped Classroom as an Active

Strategy in Higher Education. American J Sci Edu Re:

AJSER-217 . https://www.cmjpublishers.com/wp-con-

tent/uploads/2024/11/flipped-classroom-as-an-active-

strategy-in-higher-education.pdf#:~:text=is%20oppo-

sed%20to%20rote%20lear-

and

Learning , 10 (2),

84-90.

https://eric.ed.gov/?id=EJ1290544

Li, S., Liao, X., Burdick, W. & Tong, K. (2020). The effec-

tiveness of flipped classroom in health professions edu-

cation in China: a systematic review. Journal of Medi-

cal Education and Curricular Development, 7,

2382120520962838.

ning,out%20by%20Vygotsky%20is%20that

Londgren, M., Baillie, S., Roberts, J. & Sonea, I. (2021). A

survey to establish the extent of flipped classroom use

prior to clinical skills laboratory teaching and determine

potential benefits, challenges, and possibilities. Journal

of Veterinary Medical Education , 48(4), 463-469.

https://doi.org/10.3138/jvme-2019-0137

Dong, Y., Yin, H., Du, S. & Wang, A. (2021). The effects of

flipped classroom characterized by situational and col-

laborative learning in a community nursing course: A

quasi-experimental design. Nurse Education To-

day , 105 ,

105037.

https://doi.org/10.1016/j.nedt.2021.105037

López,M., Hincapié, D., Rodríguez, M., Peña, A., Pinzón, N.

& Consuelo, N.(2021). Consideracionesacercadelaula

invertida AI (FLIPPED CLASSROOM). Revista Rep-

ertorio de Medicina & Cirugía , 30 (2), 188-194.

https://revistas.fucsalud.edu.co/index.php/repertorio/ar-

ticle/view/1087

Durán, M. & Vigueras, J. (2023). Aula invertida inteligente

como estrategia didáctica emergente para la enseñanza

aprendizaje de matemática. Revista Cubana de Educa-

ción Superior , 42 (1 ene-abr), 243-259. https://www.re-

searchgate.net/profile/Jose-Vigueras-Moreno-2/publi-

cation/378347543

ElSadik, A. & AlAbdulmonem, W. (2021). Improvementin

student performance and perceptions through a flipped

anatomy classroom: Shifting from passive traditional to

active blended learning. Anatomical Sciences Educa-

tion, 14(4), 482-490. https://doi.org/10.1002/ase.2015

Evaristo, T. & Mattos, M. (2019). Flipped learning for teach-

ing biostatistics to peruvian dental students. Journal of

Mariscal, S., Mariscal, N., Santur, J. & Mariscal, Z. (2024).

ElusodelaulainvertidaaniveluniversitarioenLatinoa-

mérica

y

España. TECNOLOGI-K , 7 (1), 60-79.

http://revista.istb.edu.ec/index.php/tecnologi-k/arti-

cle/download/55/39

Mascolo, M. (2009). Beyond student-centered and teacher-

centered pedagogy: Teaching and learning as guided

participation. Pedagogy and the human sciences , 1 (1),

Oral

Research , 8 (2),

159-165.

3-27.

https://scholarworks.merri-

https://doi.org/10.17126/joralres.2019.025

mack.edu/phs/vol1/iss1/6/

Garrido, C., Rojas, F., & Raiqueo, E. (2024). Metodología de

aula invertida en educación remota de emergencia para

estudiantes de Odontología. Antofagasta, Chile. EDU-

McLean, S. & Attardi, S. (2018). Sage or guide? Student per-

ceptions of the role of the instructor in a flipped class-

room. Active Learning in Higher Education, 1–13.

https://doi.org/10.1177/1469787418793725

elo.sld.cu/pdf/edu/v16/2077-2874-edu-16-e2718.pdf

Gatica, M. & Rubí, P. (2021). La clase magistral en el con-

texto del modelo educativo basado en competen-

cias. Revista Electrónica Educare , 25(1), 321-332.

http://dx.doi.org/10.15359/ree.25-1.17

Hew, K. & Lo, C. (2018). Flipped classroom improves stu-

dent learning in health professions education: a meta-

analysis. BMC medical education , 18, 1-12.

https://doi.org/10.1186/s12909-018-1144-z

Mora, J. (2020). La educaciónbasada en problemas ylaclase

invertida para los procesos de enseñanza aprendizaje en

medicina. En D. L. Durán, C. A. Barajas, M. C. Tocan-

cipá, M. Torres, I. Silva, O. A. Martínez, M del P. Bo-

nilla & M. Y. Arandia. Formación y manejo del cuerpo

desde la educación para la salud y la antropología (1

edición, pp. 121-137) Fundación Universitaria Juan N.

Corpas. Centro Editorial Ediciones FEDICOR.

https://doi.org/10.26752/9789589297445.7

Joseph, M., Roach, E., Natarajan, J., Karkada, S. & Cayaban,

A. (2021). Flipped classroom improves Omani nursing

students performance and satisfaction in anatomy and

Moreira, D. & García, M. (2024). Motivation in academic

performance. International Research Journal of Man-

agement, IT and Social Sciences , 11 (1), 30-38.

https://doi.org/10.21744/irjmis.v11n1.2403

physiology. BMC

nursing , 20 ,

1-10.

https://doi.org/10.1186/s12912-020-00515-w

Naing, C., Whittaker, M., Aung, H., Chellappan, D. & Rie-

gelman, A. (2023). The effects of flipped classrooms to

improve learning outcomes in undergraduate health

professional education: a systematic review. Campbell

Khodaei, S., Hasanvand, S., Gholami, M., Mokhayeri, Y. &

Amini, M.(2022). Theeffectoftheonlineflippedclass-

room on self-directed learning readiness and metacog-

nitiveawarenessinnursingstudentsduringtheCOVID-

Systematic

Reviews , 19(3),

e1339.

19

pandemic. BMC

nursing , 21 (1),

22.

https://doi.org/10.1002/cl2.1339

https://doi.org/10.1186/s12912-022-00804-6

https://doi.org/10.5281/zenodo.18422330

31

South American Research Journal, 5(2), 17-32

https://www.sa-rj.net//index.php/sarj/article/view/70

ISSN 2806-5638

Ñique, C. & Díaz, R. (2021). Nivel de satisfacción de los es-

tudiantes de bioquímica sobre la metodología de aula

invertida aplicada durante lapandemia por COVID-19

en una escuela de enfermería. FEM: Revista de la Fun-

dación Educación Médica , 24 (5), 245–249.

https://doi.org/10.33588/fem.245.1144

dent experiences in flipped classrooms. Higher Educa-

tion , 85 (3), 503-520. https://doi.org/10.1007/s10734-

022-00848-2

Teo, T., Khazaie, S. & Derakhshan, A. (2022). Exploring

teacher immediacy-(non) dependency in the tutored

augmented reality game-assisted flipped classrooms of

English for medical purposes comprehension among

the Asian students. Computers & Education, 179,

104406.

https://doi.org/10.1016/j.compedu.2021.104406

Wehling, J., Volkenstein, S., Dazert, S., Wrobel, C., van

Ackeren, K., Johannsen, K. & Dombrowski, T. (2021).

Fast-trackflipping:flippedclassroomframeworkdevel-

opment with open-source H5P interactive tools. BMC

Ortego, M., Briones, E., Melero, M., Palacios, B., Prieto, A.,

&

Fernández, R. (2021). Valoración del Aula Invertida

como metodología en la educación para el final de la

vidaporestudiantesdeEnfermería. RevistadelCongrés

Internacional de Docència Universitària i Innovació

(CIDUI), (5). https://www.raco.cat/index.php/Revista-

CIDUI/article/download/389935/486503

Paredes, K., Salazar, J. & Simancas, L. (2024). Modelo del

docente: Profesionalización y mejora del desempeño

pedagógico y tecnológico. European Public & Social

Medical

Education , 21 (1),

351.

https://doi.org/10.1186/s12909-021-02784-8

Innovation

https://doi.org/10.31637/epsir-2024-1845

Review , 9 ,

1-16.

Xi, J. (2022). Research on flipped classroom of university

curriculum using eye movement analysis and LSTM

neural network. Wireless Communications and Mobile

Phillips, J. & Wiesbauer, F. (2022). The flipped classroom in

medical education: A new standard in teaching. Trends

in Anaesthesia and Critical Care, 42, 4-8.

https://doi.org/10.1016/j.tacc.2022.01.001

Plaza, F. J., & Cabezón, M. (2025). Training intercultural

competence in nursing studies through flipped class-

room and podcasts / Formación en competencias inter-

culturales en los estudios de enfermería a través del mé-

todo del aula invertida y el uso de pódcast. Culture and

Computing , 2022 (1),

2559864.

https://doi.org/10.1155/2022/2559864

Yang, F., Lin, W. & Wang, Y. (2021). Flipped classroom

combinedwithcase-basedlearningisaneffectiveteach-

ing modality in nephrology clerkship. BMC Medical

Education , 21, 1-7. https://doi.org/10.1186/s12909-

021-02723-7

Yang, W., Zhang, X., Chen, X., Lu, J. & Tian, F. (2024).

Based case-based learning and flipped classroom as a

meanstoimproveinternationalstudents’activelearning

and critical thinking ability. BMC Medical Educa-

tion , 24 (1), 759. https://doi.org/10.1186/s12909-024-

05758-8

Education , 37 (2),

41.https://doi.org/10.1177/11356405251330734

526-

5

Prieto,A., Barbarroja,J., Álvarez, S.& Corell, A.(2021). Efi-

cacia del modelo de aula invertida (flipped classroom)

enlaenseñanzauniversitaria:unasíntesisdelasmejores

evidencias. Revista de educación , (391), 149-177.

https://uvadoc.uva.es/handle/10324/73963

Prieto, A., Barbarroja, J., Lara, I., Díaz, D., Pérez, A., Mon-

serrat, J. & Álvarez, M. (2019). Aula invertida en ense-

ñanzas sanitarias: recomendaciones para su puesta en

práctica. FEM:RevistadelaFundaciónEducaciónMé-

Yeh, Y. (2022). Student Satisfaction with Audio-Visual

Flipped Classroom Learning: A Mixed-Methods

Study. International Journal of Environmental Re-

search

and

Public

Health , 19(3),

1053.

https://doi.org/10.3390/ijerph19031053

Youhasan, P., Chen, Y., Lyndon, M. & Henning, M. (2021).

Exploringthepedagogical designfeaturesoftheflipped

classroom in undergraduate nursing education: a sys-

dica, 22(6),

https://dx.doi.org/10.33588/fem.226.1031

253-262.

Rehman, R. & Fatima, S. (2021). An innovation in Flipped

Class Room: A teaching model to facilitate synchro-

nous and asynchronous learning during a pan-

demic. Pakistan journal of medical sciences , 37 (1),

tematic

review. BMC

nursing , 20 ,

1-13.

https://doi.org/10.1186/s12912-021-00555-w

Zhu, M. & Zhang, Y. (2022). Medical and public health in-

structors’ perceptions of online teaching: A qualitative

study using the Technology Acceptance Model 2. Edu-

cation and information technologies , 27 (2), 2385-2405.

https://doi.org/10.1007/s10639-021-10681-2

Zumstein‐Shaha, M. & Grace, P. J. (2023). Competency

frameworks, nursing perspectives, and interdisciplinary

collaborationsforgoodpatientcare:Delineatingbound-

131-142. https://dx.doi.org/10.12669/pjms.37.1.3096

Sivarajan, S., Soh, E., Zakaria, N., Kamarudin, Y., Lau, M.,

Bahar, A. & Naimie, Z. (2021). The effect of live

demonstration and flipped classroom with continuous

formative assessment on dental students’ orthodontic

wire-bending performance. BMC Medical Educa-

tion , 21 , 1-12. https://doi.org/10.1186/s12909-021-

aries. Nursing

Philosophy , 24(1),

e12402.

02717-5

https://doi.org/10.1111/nup.12402

Sointu, E., Hyypiä, M., Lambert, M., Hirsto, L., Saarelainen,

M. & Valtonen, T. (2023). Preliminary evidence of key

factors in successful flipping: Predicting positive stu-

AI Use Statement: Artificial Intelligence was used

exclusively for editing purposes in this article.

https://doi.org/10.5281/zenodo.18422330

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