Multilevel factor analysis of flipped classroom in dental education: A 3-year randomized controlled trial

PURPOSE: Previous studies have rarely attempted to test the confounding factors that may affect learning outcomes of the flipped classroom. The purpose of this study was to assess how flipped classrooms affect the acquisition of knowledge in clinical dental education based on multilevel factor analysis. METHOD: The authors conducted a 3-year (2017, 2018, and 2019) randomized controlled trial in a series of introductory prosthodontics courses in dental education. A total of 137 participants were randomly assigned to flipped classroom (n = 70, 51%) or lecture (n = 67, 49%) formats. The flipped group was instructed to self-learn knowledge-based content through online preparation materials, including videos and text, while the lecture group was given text only. Both groups were provided with the same study content and opportunities for different styles of learning. The session attendance rate and number of times the materials were accessed were monitored. Individual and team readiness assurance tests (IRAT/TRAT) were conducted to evaluate knowledge acquisition. A multilevel linear regression analysis was conducted on both instructional styles (flipped vs. lecture) as an intervention factor, and confounding factors that could affect the outcomes were implemented. RESULTS: The average number of online accesses was 2.5 times per session in the flipped group and 1.2 in the lecture group, with a significant difference (p < .05). The average IRAT score was significantly higher in the flipped than in the lecture group (effect size [ES] 0.58, p < .001). The number of online accesses was significantly and positively correlated with IRAT scores (0.6 [0.4, 0.8]). The instructional style was significantly and positively correlated with TRAT scores (coefficient [95% confidence interval]: 4.6 [2.0, 7.3]), but it was not correlated with IRAT (4.3 [-0.45, 9.0]). CONCLUSIONS: The flipped classroom was more effective than the lecture format regarding knowledge acquisition; however, the decisive factor was not the instructional style but the number of individual learning occasions. The employment of the flipped classroom was the decisive factor for team-based learning outcomes.