The effects of flipped classroom versus lecture-based learning on academic performance and perceptions of classroom environment among nursing students: a randomized controlled trial

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INTRODUCTION: Nursing students often struggle with the fluids and electrolytes course because of the complexity, extensive detail, and fleeting nature of the content. Evidence indicates that the flipped classroom approach can enhance learning and performance among students in the medical professions compared to traditional methods. This study aimed to compare the effects of two teaching approaches, the flipped classroom and traditional lecture-based learning, on nursing students' academic performance and perceptions of the classroom environment. METHODS: This was a single-blind, parallel-group, pretest-posttest randomized controlled trial. The study was conducted with 58 nursing students at Qom University of Medical Sciences, Iran, during the 2019-2020 academic year. Participants were randomly assigned using a computer-generated block randomization sequence to either the intervention group (flipped classroom, n = 29) or control group (lecture-based learning, n = 29). The primary outcome was academic performance, measured by researcher-developed 20-item multiple-choice knowledge test. The secondary outcome was perceptions of the classroom environment, assessed using the College and University Classroom Environment Inventory (CUCEI). Data were analyzed using descriptive and inferential statistics with SPSS version 26. All analyses followed the intention-to-treat principle and included all 58 randomized participants. RESULTS: There was no statistically significant difference in the mean scores of knowledge test between the two groups prior to the intervention (t = 1.265, 95% CI: [-0.30, 1.33], P = 0.211). After controlling for pretest scores, ANCOVA revealed a significant and large effect of the flipped classroom on post-test knowledge (F = 104.719, P < 0.001, partial η² = 0.65). A one-way MANOVA on the seven CUCEI subscales yielded a significant multivariate effect (Pillai's Trace = 0.93, F = 109.30, P < 0.001, partial η² = 0.93). With a Bonferroni-corrected alpha of 0.007, the flipped classroom group demonstrated significantly higher scores on Satisfaction, Involvement, Task Orientation, and Innovation, while no significant differences were found for Personalization, Student Cohesiveness, and Individualization. CONCLUSION: The findings suggest that the flipped classroom approach can improve nursing students' academic performance and perceptions of the classroom environment. These results highlight the potential value of integrating active, student-centered pedagogies into nursing curricula. However, given the small sample size, short study duration, lack of long-term follow-up to assess knowledge retention, and single-institution design, further research with larger and more diverse samples is needed to confirm these results. TRIAL REGISTRATION: The study was retrospectively registered in the Iranian Clinical Trials Registry (IRCT) with the trial number IRCT20240610062078N2 on December 21, 2025.