Flipped teaching method (intervention)

Six months prior to the study period, three medical teachers were engaged in the preparatory phase of the flipped learning approach. According to the backward instructional design, first learning goals (NTS) were identified and then opportunities for pre-learning were discussed and active learning strategies were specified. Afterwards the final design of the flipped learning was determined, which included the four pillars of F-L-I-P ™, as described by the “Flipped Learning Network” (Flexible environment, Learning culture, Intentional content, Professional educator) [37].

The contents which were carried out in flipped learning were the definition and explanation of NTS with reliance to the AS-NTS rating system and relevant benchmarks, which took mostly place in the individual learning space. The students were given the task to prepare themselves in the best possible way on NTS and AS-NTS and its benchmarks, in order to carry out the debriefing in the upcoming training. This step was designed to foster reflection on NTS prior to the second training.

To facilitate learner-centered environment, all the teaching activities were designed based on instructional scaffolding:

Pre-training (class) contents.

Brief seminar on NTS held at the end of the baseline training (twenty minutes) This seminar included following contents: History of how NTS were translated from aviation to healthcare. An introduction to the rating system Anaesthesiology Students´ NTS (AS-NTS) [11] with explanatory behavioural benchmarks for each dimension of the AS-NTS. For this purpose, scenarios and situations were talked through with focus on how good NTS performance would be like.

At the end of this seminar teaching materials were provided, which included a script on NTS and behavioural benchmarks, a PowerPoint courseware and a detailed description about how AS-NTS was developed and how its application works.

Individual learning space (instructional activities): A set of clear defined work assignments, which included to work through the provided teaching materials; to complete a written debriefing of the three scenarios which the students had observed in the baseline training (reflection, cold written debriefing)- hereby the application and description and definition of fitting behavioural benchmarks (targets for action) were encouraged (NTS score based on the AS-NTS).

Furthermore, the students were given the assignment to get as familiar as possible with the AS-NTS, because it would be their responsibility to conduct the debriefings of the following training and to provide an AS-NTS score for each scenario.

Classroom phase (group learning space), second training.

At the beginning of the training, outstanding questions were clarified and students were asked if every assignment of the individual learning were completed and if they could define behavioural benchmarks. Then, similar to the first training, the undergraduates were divided into smaller groups (randomly) to rotate through three simulation scenarios. The small groups remained together for all three scenarios. Each scenario and its debriefing had the duration of thirty minutes.

The debriefings of each scenario were conducted by the observing students of each small group in terms of collaborative learning by team based learning: Three students conducted the scenario as physician and nurses/paramedics. The observing students (two/three) filled out an AS-NTS score while watching the scenario and took notes. The scenarios contained cardio-pulmonary emergencies, like acute coronary syndrome. After each scenario, the observing students had five minutes to discuss their debriefing in a different room, based on their AS-NTS score. Then they provided the debriefing for their peer-students. The role of the instructors was to act like a facilitator to provide a good learning environment and encourage participation.

The provision of the AS-NTS score and debriefing by the students was not for the outcome analysis. The purpose of this exercise was to enable the students to reflect on NTS and apply what they had prepared in their individual learning space. Therefore, the instructors filled out the AS-NTS as well and complemented the peer-debriefing, because the analysis of NTS performance was based on the instructor ratings.

Eight trainings were conducted as pilots to train the instructors, to close remaining gaps, to standardise the intervention and to detect necessary changes of the study design and to identify an effect size for the sample size calculation.

Pre-training (class) contents.

After the baseline training, the control group received a 90-minute lecture on NTS called “To err is human”. This lecture addressed the same learning objectives which were conveyed to the intervention group and was held by a professor of anaesthesiology and didactics whose lectures were always evaluated as outstanding.

Classroom phase (group learning space), second training.

At the beginning of the training, remaining questions were clarified and a brief summary on NTS and the contents of the lecture were given. Then, similar to the first training, the undergraduates were divided into smaller groups to rotate through three simulation scenarios.

After each scenario a debriefing was held by the instructors, based on the AS-NTS scoring (Fig. ​(Fig.11).

Depicts the research flow and procedures

Table 1. compares the two different teaching approaches in the context of our study design.

Comparison and differences of the teaching approaches

NTS Non-technical skills; AS-NTS Anaesthesiology students´ non-technical skills.