The online inverted classroom model (oICM). A blueprint to adapt the inverted classroom to an online learning setting in medical and health education

The idea of this paper is to offer a blueprint, with that facilitators have a guide to set up a complete digital teaching scenario according to the latest insights of didactical research. The corona pandemic forced higher education institutions all around the world to radically shift their curricula from a mix of face-to-face and remote teaching methods to a fully remote curriculum. Though challenging, this time provides opportunities to implement new educational methods and improve the quality of digital teaching. The classical concept of the inverted classroom was modified to meet the special needs of online settings. The proposed online Inverted Classroom Model (oICM) includes the following phases: (1) pre-phase, (2) self-learning-phase, (3) Synchronous online face-to-face phase, (4) transfer-phase, (5) evaluation. Recommendations and potential tools are provided for each phase. The oICM is an innovative and easy to use approach to shape digital teaching and learning processes during and after the CoVid19 pandemic. This blueprint is developed by the committee "Digitalization" of the German Association for Medical Education (GMA) for facilitators without any prior experience with the ICM, but also for those who already teach in a traditional ICM. Tolks D, Romeike B, Ehlers J, Kuhn S, Kleinsorgen C, Huber J, Fischer M, Bohne C, Hege I MedEdPublish https://doi.org/10.15694/mep.2020.000113.1 Page | 2


Introduction
During the CoVid19 pandemic, educational institutions had to quickly change their curricula to digital teaching. Due to the lack of resources, such as time and experts for digital teaching, the shift in education moved from traditional lectures and seminars to online learning environments. So, we face a state that can be best described by "Emergency Remote Teaching" (Hodges et al., 2020). This is a challenging time, but it also holds opportunities to improve the quality of digital teaching and learning if applied appropriately. We would like to offer an approach to face the challenge of digital teaching and to implement a new way of online teaching using an existing concept and to modify it to the special needs of this time and the time after the crisis. Thus, we propose a blueprint for the application of the inverted classroom model in an online setting to minimise the disadvantages of online teaching and to achieve real benefits with digital teaching methods.

The traditional Inverted Classroom Model
According to several meta-analyses, the inverted or flipped classroom method (ICM) showed positive effects regarding engagement, motivation, overall satisfaction and learning outcomes (Chen, Lui and Martinelli, 2017;Lo, Hew and Chen, 2017;Cheng, Ritzhaupt and Antonenko, 2019;Låg and Saele, 2019;van Alten et al., 2019;Strelan, Osborn and Palmer, 2020). ICM has successfully been implemented in healthcare education (McLaughlin et al., 2014;O'Flaherty and Phillips, 2015;Tolks et al., 2016;Chen, Lui and Martinelli, 2017;Hew and Lo, 2018). The idea behind the concept of the inverted classroom proposed by Lage, Platt & Treglia, is to use the face-to-face time for the more challenging part of knowledge application, instead of presenting the factual knowledge in a lecture in which students have to take a passive role (Lage, Platt and Treglia, 2000). The overall goal is to focus the face-toface phase on the interactions between students and teacher and to solve problems that may arise during the application of the knowledge. According to Bloom's taxonomy, the ICM creates a learning environment that enables the learner to reach a higher level of cognition (Anderson et al., 2013). One of the basic ideas behind the concept is to activate the learner based on the concept of active learning (Snyder, 2003).

The online Inverted Classroom Model (oICM)
Faced with the challenges of the corona pandemic, universities had to adapt their curricula to online methods quickly. The traditional ICM proposed by Tolks et al. has to be adapted to the new approach (see Figure 1) (Tolks et al., 2016).
This blueprint is designed for teachers without any prior experience with the ICM, but also for those who already teach in a traditional ICM.
Online teaching can be differentiated in synchronous vs. asynchronous delivery modes. In synchronous teaching teacher and learner meet in real-time with online meeting software or video streaming. In asynchronous teaching, learning media is produced and provided via LMS. Students consume contents ad libitum. Advantages and disadvantages of both modes are listed in Table 1. As mentioned before, the most important part of the concept is to maintain learner activation. Active learning rather than passivity requires the involvement of students in the learning process, resulting in a more intense learning experience that goes beyond memorization (Snyder, 2003). Active learning leads to more sustainable knowledge acquisition, promotes problem-solving skills and has a positive effect on the motivation to learn (Chi and Wylie, 2014). Furthermore, activities and interaction create a more learner-centred environment and are based in constructivist teaching rather than a direct instructional mainly unilateral approach (Salmon, 2013). Designing wellwritten learning outcomes for online learning is just as key as for face-to-face environments.

Pre-phase
Before starting to teach, inform your learners about the concept and process of the oICM, technical requirements, and expectations. It is important to offer communication channels for your students. Usually, this will be via your

Self-learning phase
As for ICM, in this asynchronous phase, it is important to provide learning material that targets the needs of your students. Students are used to learn from videos so we recommend using videos as a source for online learning (Hurtubise et al., 2013). There are a fast variety of different methods and tools. For some recommendations, you can look at the digital tools list (German) from the committee "Digitalization" of the German Association for Medical Education (GMA): tinyurl.com/ADTLLGMA There are many ways to create learning content using videos. We would endorse three different approaches.
The easiest way to create great videos is using screencasts. Software allows you to record your presentation together with your speech. You may also include a video of you while talking. These programs are mostly free of charge and easy to use. Be aware of the fact that the presentation does not have to be perfect from a technological and rhetorical point of view. A study by Carpenter et al. has shown, that learners have a higher cognitive activity when the presentation is not perfect and that they have a better knowledge retention rate compared to perfect presentations (Carpenter et al., 2013). Care should be taken to ensure that presentations are not overloaded with content and complex animations, but are structured, high-resolution and reduced to essential elements. This applies especially to online teaching. To support the learning process, a handout could be useful. You can also use existing video tools that help you create innovative learning videos with cartoons (PowTon) or draw images with a digital pencil.
The other possibility is to record the speaker with a camera. This is often used in massive open online courses (MOOCs). These learning videos were analysed in a study by Guo et al. regarding the engagement rate of students.
To improve learner engagement, the following recommendations can help to improve the quality of the videos (Guo, Kim and Rubin, 2014): Shorter videos are much more engaging Videos that intersperse an instructor´s talking head with slides are more engaging than slides alone Video produced with a more personal feel could be more engaging than high-fidelity studio screencasts Khan-style tablet drawings tutorials are more engaging than Powerpoint slides Videos where instructors speak fairly fast and with enthusiasm are more engaging Students engage differently with lecture and tutorial videos A third approach is based on Open Educational Resources (OER). You can always use freely available learning content that is offered under an open-access licence. Many universities offer their high-quality learning material including universities like Oxford, Harvard, Cambridge or the MIT. You can use special databases such as Open Education EU.
In the online self-learning phase, quizzes should be used during and after the learning sessions to improve the learner's engagement and offer a way to assess the learning process. At the end of the self-learning phase, a final quiz should be implemented to assess the learning status of the group. If any problems or low rates in quiz occur, the teacher can address them in the upcoming online face-to-face phase. Most LMS provide tools for self-assessment.

Synchronous, online face-to-face phase
One way to reduce the limitations of an online scenario such as low retention and engagement rates of students is to use synchronous online meetings. In oICM this phase will take place online using for example video conferencing tools (VCTs), such as AdobeConnect, zoom or goToMeeting. As in ICM the session is moderated by the educator in real time and in an interactive way. Depending on the number of students this can be realized in form of interactive webinars or small group discussions making use of the break out rooms most VCTs offer.
Additionally to VCTs and to engage the learner you can use various digital tools that are easy to use. The most useful tools are audience response systems (ARS) like, Kahoot!, Mentimeter, Pingo. Using those programs, the facilitator can ask quiz questions to the students, create word clouds, rate questions and use gamification approaches such as points, leaderboards and badges (Sailer and Homner, 2019). The ICM offers a good structure to implement gamification aspects within the learning scenario (Sailer and Sailer, 2020). Technical questions with the help of ARS continuously activate the participants to collaborate on the content and thus allow a more thorough reflection. While in traditional events potentially more than half of all present participants are mentally distracted, ARS effectively counteracts this. Overall, they have a proven positive effect in learning outcomes (Nelson et al., 2012;Szpunar, Moulton and Schacter, 2013). In addition, the facilitator receives feedback of a large proportion of those present.
Once an interactive quiz is used, learners are more likely to use the chat or audio connection for discussion.
This way, the moderator gets feedback and it lowers the barrier for students to participate actively by talking or using the chat function. Case based learning, clinical reasoning and problem-oriented learning can be easily facilitated by combining an online-meeting with collaborative online documents. For creating complex classifications, students might be asked to build a mindmap.
For students who do not have the opportunity to attend the online face-to-face meeting, the session can be recorded and uploaded to the learning management system (LMS). In this case every participant has to agree to the recording and its use. However, we recommend to include some additional homework to avoid a drop-out of the regular online sessions.

Transfer phase
This phase should deepen the learning outcome with another asynchronous learning session, where the learner can apply their knowledge and transfer it to other content domains or contexts. This can be achieved with small projects students have to work on collaboratively, solving cases or virtual patients or let students develop cases or videos.

Evaluation
After the oICM, it is also important to evaluate the process and outcome of the curriculum. Especially the online face-to-face phase should be emphasized in the evaluation as it is a new approach within the ICM concept. The evaluation as to be integrated into the online face-to-face meeting to enhance the response rate.
There do already exist some validated or practical tested evaluation forms for traditional teaching units like lectures and seminars (Perry and Smart, 2007;Schiekirka et al., 2015). However, it is possible to develop a short evaluation form for online ICM based on both, existing instruments of traditional teaching and online teaching. In the Appendix 1, you find some examples for items structured by different aspects of teaching.

Conclusion
The oICM is based on the traditional ICM, focusing on synchronous digital teaching, the activation of learners and making use of VCTs and audience response systems. The oICM concept supports educators in transferring their previous face-to-face teaching into online teaching in a structured and meaningful way. An advantage of the oICM concept is that after returning to face-to-face teaching the phases 1, 3 and 4 can be used without changes. Phase 2 can be easily transformed into face-to-face teaching such as small group sessions or seminars including transferring the concept and content for using ARS.
With a few modifications of your existing ICM concept and with this easy-to-use approach, you can significantly improve your digital teaching and do not leave students alone in their learning process. Another positive aspect is that you can still use the ICM even after the pandemic in a blended learning concept. You can continue to use the online learning material provided during the self-learning phase for your teaching concept. The online audience response system can be used in the face-to-face phase to activate the learners. Another advantage is that you will have less issues regarding your teaching load if you use synchronous digital teaching. Before, during and after the CoVid19 pandemic, oICM is an innovative approach to shape digital teaching and learning processes.
We hope that ith this blueprint facilitators will be able to develop own oICM concepts in this critical time and also build concepts that are also feasible for the upcoming time. We would like to encourage all facilitators to invest more time now in the teaching concept and use this blueprint, so that these challenging times have a positive impact to teaching.

Take Home Messages
The oICM is an innovative and easy to use approach to shape digital teaching and learning processes during and after the CoVid19 pandemic.
With a few modifications of an existing ICM concept facilitators can improve their digital teaching and do not leave students alone in their learning process.
The most important part of the concept is to maintain learner activation with synchronous digital teaching using video conferencing tools and audience response systems.