Introduction

The flipped classroom is an educational paradigm that inverts traditional elements of lecture and homework in course design [1, 2]. It allows students to initially engage with the learning material before class, thus repurposing class time for active learning exercises in small groups, which facilitates a deeper understanding of the subject matter. Flipped learning is attractive to both students and teachers because it provides pre-class self-regulated learning, in-class active learning with peers, ongoing after-class activities, and assessments aligned to achieve the desired objectives [3]. Teachers can spend their face-to-face time supporting students in deeper learning processes [4]. The flipped classroom is a student-centred learning strategy in which each student is responsible for coming to class with a basic understanding of the material so that he or she can fully participate and engage in class [5]. This emphasis on student-centred active learning fosters students’ motivation to acquire knowledge and enhance skills [6]. In particular, deliberative practices, such as cadaver dissection, require more attention and engagement in the activities to improve performance [3]. The success of flipped learning in cadaveric dissection teaching may depend on students’ undertaking substantial independent out-of-class work [7].

Cadaver dissection plays a formative role in the development of professional competence in medical education. It facilitates learning about the human body, as well as confronting–and developing reasoned and compassionate attitudes toward—death and dying [8, 9]. Dissection helps to build teamwork that requires students to work cooperatively under difficult, emotionally demanding conditions to accomplish their shared goals related to their future profession [10]. However, there is an uneven level of participation within a group because some students are still adapting to the stresses of dissection, and some have not prepared well before dissection sessions [11, 12]. Peer-assisted learning in dissection laboratories is an effective way to encourage student participation and peer group interaction, but the tendency to rely on competent peers often persists [13, 14]. Ultimately, an individual’s attitudes and behaviours are related to motivation [7]. Flipped learning in dissection courses has the potential to enhance the development of self-directed learning as a professional attribute, but few studies have investigated the application of flipped learning to dissection practice [12, 15].

Abeysekera et al. proposed that flipped learning pedagogy can increase students’ intrinsic and extrinsic motivation if it creates a sense of competence, autonomy, and relatedness according to self-determination theory [7]. Flipped learning allows students to have the autonomy to study material at their own pace before class, actively learn related content for in-class discussion with peers, and determine their competencies through embedded self-assessment [3, 7]. The benefit of autonomous motivation is positively associated with behavioural persistence, depth of learning, and satisfaction [16]. Therefore, flipped learning has been incorporated into existing peer-assisted learning in cadaver dissection to improve individual engagement and learning outcomes. The first half of the dissection practice was conducted using the traditionally implemented peer-assisted learning method, where student tutors who prepared for the dissection in advance helped peers to learn, with the peer tutors reinforcing their own knowledge through the act of teaching. The second half included the addition of a flipped learning method, in which all students studied video-based materials and solved accompanying quizzes prior to the dissection. This study aimed to compare students’ motivation, out-of-class work, and academic achievement between traditional peer-assisted learning and flipped learning, as applied to cadaver dissection. The research questions were as follows:

1. Are there any significant differences in students’ motivational scores and practice test scores between traditional methods and the flipped learning method?
2. With the flipped learning method, is there any significant variation in students’ motivational scores and practice test scores according to the extent of learning material completion?
3. How satisfied would students be with flipped learning in a gross anatomy dissection course?

Methods

Results

The students’ mean motivational score for the attention subscale was significantly higher in association with the flipped learning method than with traditional learning. However, the students’ mean motivational scores for the relevance, confidence, and satisfaction subscales were not significantly different between the methods. Additionally, the mean anatomy practice test score was significantly higher in association with flipped learning than with traditional learning (Table 1).

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Table 1. Comparison of students’ motivational scores and anatomy practice scores between the traditional method and flipped learning method.

https://doi.org/10.1371/journal.pone.0298067.t001

Table 2 summarises the ANOVA and Tukey test findings. The ANOVA analysis revealed significant differences in the students’ motivational and practice test scores—associated with flipped learning—according to the extent of learning material completion. Tukey post hoc analysis revealed that students’ motivational scores were significantly higher among students scoring in the top quartile in terms of completion extent compared with those scoring in the bottom two quartiles.

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Table 2. Differences in students’ motivational scores and anatomy practice scores associated with flipped learning according to the extent of completion.

https://doi.org/10.1371/journal.pone.0298067.t002

After undertaking the flipped learning approach, the students stated that, by incorporating visual images before the actual sessions, the method effectively enhanced the learning process, especially in areas where conveying information solely through text is limited. Participants noted that this approach acted as a reliable guide, providing clear instructions on how to approach the sessions, including details like incision sites and direction. The preliminary video-based learning also served as an effective review tool through subsequent quizzes, reinforcing acquired knowledge and aiding retention. Consequently, students reported improved time management and reduced confusion during the dissection sessions. The utilisation of visual aids also facilitated the identification of anatomical structures without the risk of getting lost or causing damage. Another significant advantage was the promotion of independent practice, reducing reliance on practice group tutors. Regarding areas for improvement, the students noted discrepancies between the state or structure of the cadaver shown in the video and the actual cadaver used in dissection sessions. Some professional techniques and practice tools demonstrated in the video differed from the reality of the sessions. Participants also provided mixed feedback regarding the video durations. Some found it challenging to digest the amount of content presented and expressed difficulty with developing a thorough understanding of the vast material. Conversely, some participants expressed the desire to have access to the omitted intermediate process videos, suggesting that it would enhance their learning experience. Additionally, there were technical issues with video playback, resulting in interrupted viewing experiences (Table 3).

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Table 3. Students’ feedback about the advantages and disadvantages of the flipped learning method.

https://doi.org/10.1371/journal.pone.0298067.t003

Discussion

The present study affirmed the efficacy of flipped learning in medical education, particularly for courses demanding high levels of professional performance from students, such as human gross anatomy dissection. This study revealed that students who used the flipped classroom for cadaveric dissection–based learning demonstrated higher attention scores than students in the traditional classroom. These findings show that relevant multimedia content—for example, images or videos in e-Anatomy^Ⓡ—consumed during the pre-class sessions in flipped learning can play an important role in stimulating student attention [3]. In terms of a motivational design approach like the ARCS model used in this study [17], online learning content should be aligned with the four dimensions to enhance student motivation and academic achievement [18]. Although learning in the flipped classroom may not yield crucial discrepancies in terms of relatedness with students’ goals, competence in performance, and satisfaction with achievement, online content facilitated students’ interest and curiosity. Hence, to effectively deliver the flipped learning process in medical education, it is important to understand the four key dimensions (e.g., attention, relevance, confidence, and satisfaction) before designing course content.

This study also investigated the extent to which completion rates of the e-Anatomy^Ⓡ learning materials in the flipped classroom affected students’ motivation levels and learning achievement. The analyses showed that students who completed more of the material tended to report higher levels of motivation across the four different dimensions and demonstrated better learning outcomes. These findings appear to be consistent with the findings from Yoon et al.’s study, wherein the self-regulated learning group showed higher video completion rates than the non self-regulated learning group [19]. That is, students’ rigorous self-regulated learning in the pre-class sessions implies active behavioural engagement (e.g., video completion), which could lead to enhanced academic performance [19]. During the COVID-19 pandemic, a nationwide survey in Korea found that medical schools transitioned to exclusively using e-Anatomy^Ⓡ videos or adopted a hybrid approach incorporating online e-Anatomy during the semester, followed by hands-on dissection later [20]. This shift to a de facto flipped classroom model in the blended learning scenario was associated with superior educational outcomes when compared with the traditional lecture-based approach prior to the pandemic [20]. Likewise, in the present study, students would have been more focused on the e-Anatomy^Ⓡ videos to facilitate their performance and understanding of critical topics in the anatomy dissection course. Consequently, these findings show that learning through the flipped classroom before an in-person anatomy dissection course could provide students with more autonomy and self-regulated learning opportunities, affecting their motivation and academic achievement.

Additionally, this study affirmed that students’ qualitative feedback will be conducive to developing effective flipped learning courses, as flipped learning is multifaceted and can be applied to variations in practice in medical education [21]. Among the numerous benefits of flipped learning that students reported, the pre-class sessions including precise instructional videos helped students prepare for dissection sessions, which enabled them to foster confidence and reduce mistakes during in-person anatomy dissection sessions. On the other hand, content quality and technical issues—such as visually contrasting cadaver imagery, lengthy instructional videos, and compatibility issues on mobile devices—may hamper their learning experiences. Quality content and a robust platform are vital for facilitating learner–content interaction, which serves as a cornerstone for further engagement with instructors and peers [22]. Therefore, instructors should critically assess and refine content in light of student feedback to ensure it is optimally tailored to stimulate active learning [23]. Overall, this study extended the findings of Fleagle et al., who found that pre-class sessions associated with the flipped classroom were useful for retaining knowledge about anatomy and dissection before the in-class anatomy dissection activities [12]. This study also argued that qualitative feedback from students should be taken into account to promote their motivation and further enhance learning experiences by ultimately designing and creating coherent flipped learning content for gross anatomy dissection courses [5, 21].

Given that flipped learning may become a widely used and powerful learning method, the present study provides crucial insights into how this approach should be designed and incorporated for both students and instructors of human gross anatomy. Importantly, the flipped classroom offers foundational functions for students in the physical classroom when pre-class sessions with computer-mediated instruction are designed effectively [3]. As such, to ensure the effectiveness of flipped learning, instructors should exploit the key principles of video-based learning that make learning effective by providing students with new learning opportunities anytime and anywhere [24]. Furthermore, the findings of this study contribute to the extension of the relevant literature in which researchers have revealed the impacts of flipped learning incorporating video-based learning on student motivation [25], successful learning experiences [26], and positive student attitudes [27]. Although this study emphasised the importance of flipped learning regarding student motivation and learning achievement, we suggest that instructors consider interactivity between tutors and tutees during in-person anatomy dissection sessions. In this sense, students are likely to improve their motivation and learning efficiency because flipped learning affords students with peer support and instructor guidance [18, 28]. On the basis of the feedback from students, this study will enhance not only the quality of flipped learning but also in-class learning during human gross anatomy courses.

This study had some limitations. One of the main limitations was that this study was conducted in a semi-experimental research setting. If well-designed experimental research is carried out and includes experimental and control groups, the effects of flipped learning can be thoroughly examined. Another limitation was that we could not accurately measure how long the students concentrate although we tried to measure the extent of completion in the flipped learning by computer-generated data, such as log datasets from LMS_. A final limitation was that customised instructional tutorials and videos were not available for our students in the gross anatomy dissection course. Faculty should develop instructional videos that are well-suited to the anatomy curriculum and course objectives based on the four dimensions of the ARCS model.

Throughout this study, we concluded that the application of flipped learning to this dissection course increased individual learning motivation, which improved in-class and out-of-class learning activities as well as academic achievement. These insights will contribute to designing effective teaching and learning strategies for gross anatomy courses and offer a novel perspective on integrating flipped learning methodologies into dissection practice. It will be necessary to track the effectiveness of flipped learning using quantitative research approaches, such as motivation scores and academic achievement, as well as qualitative research approaches, such as students’ responses.