There are key components to ensure that flipped classrooms are established to promote critical thinking skills. Virtual face-to-face learning activities should incorporate problem-solving and reflective practice via weekly synchronous virtual face-to-face class sessions using a web conferencing program such as Zoom. In addition, course learning objectives should address higher-level thinking and communication skills, critical thinking skills, and teamwork. Faculty must educate students on the objectives of the flipped classroom model before initiation of their courses to provide them with a clear understanding of faculty expectations and ensure accountability. It is necessary to consult the institution’s instructional designers for assistance in the initial design of each course to establish a standardized course structure and accessibility. Furthermore, consideration should be given to providing a designated area for pre-class, face-to-face, and post-class activities in each weekly course module (Fig. 1) to promote organization and student engagement. Students who are satisfied and content in a learning environment may have better academic outcomes. Table 1 describes examples of learning activities from courses in a graduate nutrition curriculum.

Faculty will provide pre-class material or foundational knowledge content to students through pre-recorded lectures that students can access through their virtual learning environment. This content should be available to students before their virtual face-to-face class session; adequate pre-class time is necessary to complete these learning activities. Dividing video lecture content into concise material is more manageable, with a maximum time of 15 minutes per recording. Students view shorter videos more often and are more likely to watch their entirety, resulting in more excellent material retention than longer videos [7]. It is essential that all pre-recorded videos can be easily downloaded from the virtual learning environment and have user control functions to pause, play, or rewind the videos. Many students prefer to access learning materials on their own time when it is most conducive to their schedules. Additional content may include readings from textbooks, journal articles, website links, YouTube videos, or other interactive web-based tutorials to complement pre-recorded lectures. Students are responsible for learning foundational knowledge, which helps facilitate higher levels of engagement and critical thinking skills during the virtual face-to-face class sessions. The following example of a pre-class activity can be adapted to any health professions curriculum.

Example: In an online medical nutrition therapy course, students take a 5-question ungraded quiz before class, which unlocks weekly module content (Supplement 1). The quiz serves as a baseline knowledge assessment of the weekly content to assist students in focusing their learning. Students have approximately 3 hours of foundational content to review prior to the virtual face-to-face class session.

The virtual face-to-face class sessions create a bridge between the pre-class lecture material and practical applications that resemble simulated clinical scenarios and can assist in developing critical thinking skills. This time reinforces foundational knowledge and key concepts through the application of active learning and problem-solving. These activities align with the objectives communicated in the pre-class content. Active learning in the classroom includes simulations (Fig. 2), role-playing, case studies, small group discussion, and live presentations. The virtual flipped classroom approach creates a student-centered structured class environment. The following examples of in-class activities can be adapted for use in any health professions curriculum (Fig. 2).

Example 1: Students are divided into pairs in breakout rooms during the virtual face-to-face class session during an online nutrition assessment and physical examination course and practice food and nutrition-related history-taking techniques. Once back in the large group, students share their reflections on the experience and discuss how to improve their techniques in preparation for supervised practice. Students reflect or debrief and faculty guide them through their experience to understand, analyze, and synthesize what they learned (Supplement 6).

Example 2: In an online ethics, professionalism, and leadership course, virtual face-to-face class activities include large- and small-group discussions that apply concepts from pre-class readings, debates on ethical issues in the clinical setting and student presentations related to current nutrition controversies. Debates allow students to argue about controversial problems using higher-order thinking skills. Both the actual debate and the preparation for the debate are considered active learning tools and can assist students in critical thinking skills development [8].

Example 3: An online course on ethically culturally sensitive interviewing and counseling integrates various role-playing encounters in the virtual face-to-face class session. The course instructors visit each breakout room to provide immediate feedback and redirection if necessary. Role-playing scenarios that involve a patient and health practitioner increase critical thinking skills [9].

Example 4: Students develop skills in formulating research questions in an online evidence-informed practice and scientific inquiry course. Students are placed in breakout rooms in pairs during the virtual face-to-face class sessions, receive a short clinical scenario, and work as a team to develop a clinical research question. Upon return to the main room, critical thinking skills are exhibited as student pairs present their case, research question, rationale, and classmates critique each other’s research question. Incorporating a flipped classroom model with pre-recorded evidence-based practice lectures and small group discussions as an active learning strategy during classroom sessions may promote critical thinking skills [10].

Assessment of learning and critical thinking skills can be achieved with formative and summative assessments using active learning techniques, quizzes, exams, self-assessment, case study presentations, and assignments that emphasize analysis, synthesis, and evaluation of student performance. Formative assessments are designed to provide the learner with quick and informative feedback, while summative assessments are utilized to evaluate knowledge and comprehension. Assessment of student performance occurs in virtual face-to-face class sessions and post-class activities. Active learning techniques such as simulation, role-playing, live presentations, and self-assessment of physical examination all occur during virtual face-to-face class sessions. It allows the faculty to provide the student with quick and informative feedback in real-time, fostering effective learning. After the virtual face-to-face class sessions, students complete post-class assignments to enhance critical thinking skills, allowing faculty to assess student performance further. Post-class formative and summative assessment strategies in flipped classrooms include short post-quizzes where students obtain immediate feedback and the rationale for the answers. Additional examples that can be assigned in many health professions programs include case studies that incorporate documentation of patient care plans, formulating research questions, and recording physical examinations performed on a volunteer. Each assignment is graded and returned to the student with extensive narrative feedback, which allows the student to improve foundational knowledge and critical thinking skills.

The flipped classroom model has been found to promote critical thinking skills in health professions students [1,5,6]. Health professions faculty can mentor students in synthesizing and analyzing foundational material, which students have reviewed in preparation for face-to-face class sessions. The flipped classroom model also allows for more “hands-on” activities and simulations during face-to-face class sessions that emphasize active learning techniques, improving understanding and enhancing the application of the material. The virtual flipped classroom model may benefit health professions faculty who teach online. This model can be modified to complement any subject matter and may facilitate the development and application of critical thinking skills.