1 Introduction

Learning Management Systems (LMS) offer an interactive web-based teaching environment with features such as sharing course materials, taking exams, giving an assignment, online chatting, and discussion forums. Therefore, in cases where face-to-face teaching in the classrooms is interrupted, an LMS has become an indispensable requirement for a higher education institution. In recent years, developments in technology across the world and the learning needs of the students born in the digital age have also accelerated the integration of distance education platforms into the education process in our country. Furthermore, during the lockdown, the most popular strategy was rapidly transferring traditional classroom instruction to distance education platforms (Uymaz & Uymaz, 2022). However, although this rapid transition has offered some advantages for institutions, the lack of interaction between students and teachers in distance education has emerged as a fundamental disadvantage, and therefore interactive learning could not be completely realized (Livingstone & Kemp, 2007; Saverino et al., 2022). Thus, the current education and training processes have begun to take advantage of teaching methods that adopt innovative technologies.

Distance education applications are carried out more frequently through digital platforms such as Big Blue Button, Google Meet, Microsoft Teams, Skype, or Zoom (Collado-Valero et al., 2021). However, web-based distance education through these platforms eliminates the interaction crucial to learning (Karabatak & Polat, 2020). Therefore, the Metaverse has become one of the popular innovative and interactive technologies adopted and studied by researchers to improve the quality of the teaching and learning process (Iwanaga et al., 2022). The concept of the Metaverse, a composite term combined the words meta (beyond) and verse (universe), means beyond world or universe (Kye et al., 2021). Metaverse, known as the next phase of the internet, enables ongoing online three-dimensional (3D) virtual settings accessed through devices such as computers, smartphones, Augmented Reality (AR), and Virtual Reality (VR) headsets (Phakamach et al., 2022). In this environment, publically available virtual experiences and real-time 3D content are connected to other similar environments (Phakamach et al., 2022). According to Jovanović and Milosavljević (2022), users of different virtual world platforms can connect synchronously by using recognizable visuals known as avatars. In addition, thanks to AR and VR technologies in metaverse environments, users can communicate and interact both with digital objects and other students using natural interaction methods such as voice, body language, facial expressions, and eye tracking (Lee et al., 2021; Rosenberg, 2023). Thanks to these advantages, Metaverse environments enable the creation and rapid distribution of embodied, interactive, collaborative, and situational learning environments (Chen, 2022). Furthermore, the flipped classroom model, an innovative education technology-supported online learning strategy (Yang, 2019), can improve educational quality when integrated with Metaverse environments.

The flipped learning method has become one of the alternative teaching methods that have recently come to the fore and supported to increase the efficiency of education. Al-Samarraie et al. (2019) stated that the time allocated for active learning activities increased with the transfer of teaching to the pre-lesson preparation process in flipped classrooms. In this way, a more effective teaching process can be carried out by allocating sufficient time to not only transfer theoretical knowledge to students, but also to other learning activities such as discussion, problem-solving, practical education, and guidance (Akçayır & Akçayır, 2018). Huang et al. (2020) emphasized that teaching in flipped classrooms is student-centered, and the primary responsibility of the teacher is to engage in class discussions on the relevant concepts with the students instead of delivering lectures. Davis (2016) stated that designing a good flipped course requires a serious planning and preparation process, and Bloom’s Taxonomy can be used as a guide for this. The taxonomy, developed by Benjamin Bloom and colleagues to categorize cognition in the 1950s (Morton & Colbert-Getz, 2017), was reorganized in 2001 from the lowest level to the highest level of cognition as “remembering, understanding, applying, analyzing, evaluating and creating” (Anderson & Kartwohl, 2001).

Distance education classes are carried out in two ways: synchronous and asynchronous. In previous studies, the number of studies on the viability of the synchronous online flipped learning in medical English classes is limited. This research presents experimental research results on the effectiveness of synchronous online flipped learning method supported by Metaverse environment at higher education level. Therefore, in this current study, we aimed to investigate how effective the synchronous online Metaverse-based flipped medical English classroom is regarding learners’ academic achievements and their thoughts on the instructional efficiency of Metaverse-based flipped learning. Additionally, we hope that this instructional design will guide other researchers and mirror the implementation of a synchronous online flipped classroom supported by Metaverse-based technology in medical English teaching. In this context, answers to the following questions are sought within the scope of this research;

  • What is the effect of synchronous online flipped learning supported by a Metaverse-based platform on medical students’ academic achievement?

  • What are the students’ views on the instructional efficiency of the synchronous online flipped learning supported by a Metaverse-based platform?

This study aims to merge the flipped learning methodology with a Metaverse-based environment designed for a medical English course. It seeks to identify the advantages or disadvantages this integration offers compared to traditional synchronous online flipped teaching methods. Grounded in the hypothesis that an immersive, three-dimensional learning space can enhance the cognitive and linguistic intelligence of medical students, the research utilizes a comprehensive mixed-method approach. It meticulously examines the comparative outcomes of both teaching methods, employing both quantitative and qualitative data. The following sections provide a thorough analysis of the efficacy and perceptions of students about synchronous online flipped learning supported by a metaverse-based platform in the teaching of medical English. Section 2 offers a thorough examination of the efficacy of flipped learning and metaverse learning settings to set the stage for our forthcoming discussions in Section 3, where we explain our methodology and research strategy. Section 4 provides a full account of our study’s findings, while Section 5 discusses their implications. In Section 6, we finally wrap up by summarizing the key insights and offer potential directions for future study.

2 Literature review of relevant studies

In this literature review, we explore significant research focusing on contemporary educational strategies and technologies. Section 2.1 evaluates the impact of Metaverse Learning Environments, a blend of virtual worlds and educational content. Section 2.2 examines the effectiveness of Flipped Learning, an approach that restructures the traditional educational model. Finally, Section 2.3 investigates the role of Extended Reality Technologies (ERTs) in enhancing anatomy and medical education, marking a transformative shift in how complex subjects are taught and learned.

2.1 Studies on the effectiveness of Metaverse Learning Environments

Nakai et al. (2022) revealed in their study that such innovative technologies as the Metaverse contributed to an increase in the interaction between teachers and students, as well as being useful for visualizing difficult structures thanks to 3D models in medical education. When evaluated from this point of view, a Metaverse-based teaching environment could be valuable to apply as an alternative teaching method for a medical English course. This course is also a part of medical education in our country and has traditionally been delivered using the LMS in recent years in our research context. Medical English courses are follow-up courses that aim to contribute to medical students gaining foreign language proficiency for their professional lives and improving their abilities to handle healthcare needs. Although the primary form of instruction used at universities is still conventional methods (Noori et al., 2022), the emphasis in medical education has moved to place more of an emphasis on utilizing digital tools and blended learning techniques in the last fifteen years (Xiao & Adnan, 2022). One of the models to achieve blended learning is the flipped classroom model (Sezer & Abay, 2019) and digital technology assisted flipped classrooms (Xiao & Adnan, 2022). Iwanaga et al. (2022) noted that studies on using the Metaverse in medical education are still in their infancy compared to those on other technologies in education.

Medical education has evolved to adopt a more student-centered approach in recent years. In this context, the metaverse’s support for cooperative learning, active learning, and situational learning provides an effective educational environment (Hui & Wagner, 2021; Mystakidis, 2022; Chen, 2022). Cooperative learning is the completion of tasks designed to achieve the desired learning outcomes with the coordinated participation of two or more students (Pluta et al., 2013). The collaborative learning paradigm enables learners to work together and communicate within the group so that learning outcomes can be equalized (Supena et al., 2021). The exploration of narrative and role-playing, in particular, has opened up countless options for collaborative and creative practices in virtual worlds mediated through an avatar, placing the creative practitioner at the heart of creative learning (Hui & Wagner, 2021). Active learning is a type of learning in which students gain knowledge through problem-solving and participation while also having the chance to reflect and self-evaluate (Collins & O’Brien, 2003). Metaverse-supported education makes students co-owners of virtual spaces. This may allow for mixed, formal, and informal active learning experiences in online 3D virtual campuses (Mystakidis, 2022). Teachers could utilize active learning techniques, along with VR/AR technology and the limitless possibilities of the Metaverse, to design game-based activities conducted in an entirely realistic environment and closely resembling real-life circumstances. (Phakamach et al., 2022). According to the situated learning approach, people remember and use knowledge where and how they learned it. This approach suggests that learning is more than just memorizing facts; it’s about actively participating in everyday life and using what you learn as part of your daily routine and culture (Stein, 1998). Therefore, a realistic learning environment should be provided to facilitate the transfer of knowledge and skills and to increase student motivation (Chen et al., 2022). Studies have found that multi-sensory experience causes tangible changes that become an automatic part of physician expertise. Virtual learning significantly increases students’ satisfaction and recall through the Metaverse, and simulated education in this universe can positively affect learning outcomes (Chen, 2022). Additionally, students are provided to experience situations that, while conceivable to explore independently, are impractical, expensive, dangerous, or impossible to uncover in the actual world (Makransky & Mayer, 2022). Since simulated training takes place in a realistic context in these environments, it helps the transfer of knowledge and skills by improving situational learning and spatial understanding and helps participants become familiar with these work environments without requiring them to be physically present in the environment (Burova et al., 2022).

2.2 Studies on the effectiveness of flipped learning

Some of the studies on flipped classrooms in the context of higher education have investigated the academic/learning performance of this teaching model (Debbağ & Yıldız, 2021; Karabatak & Polat, 2020; Martínez-Jiménez & Ruiz-Jiménez, 2020; Al-Samarraie et al., 2019; Oliván Blázquez et al., 2019; Zainuddin, 2018; Zheng et al., 2020; Mason et al., 2013), motivation (Debbağ & Yıldız, 2021; Karabatak & Polat, 2020; Zheng et al., 2020; He et al.,2018; Zainuddin, 2018;), participation (Al-Samarraie et al., 2019; Zainuddin, 2018; Murillo-Zamorano et al., 2019; Steen- Utheim & Foldnes, 2018; Khanova et al., 2015), satisfaction (Chen, 2021; Martínez-Jiménez & Ruiz-Jiménez, 2020; Bösner et al., 2015) and knowledge acquisition (Murillo-Zamorano et al., 2019; Bösner et al., 2015; Galway et al., 2014). In addition, in the study conducted by Al-Samarraie et al. (2019), it was stated that the classrooms in which the flipped teaching model was applied provide more control over what and how students learn, providing students with in-depth learning. However, some studies comparing a traditional classroom and a flipped classroom have suggested that there is insufficient evidence to support the notion that the flipped classroom model is a more effective method and improves academic performance (McLaughlin et al., 2013; Cui & Coleman, 2020). In addition, Akçayır and Akçayır (2018) emphasized that the most frequently reported problem in studies on flipped classrooms is the limited preparation process of students before the lesson. Similarly, Shibukawa and Taguchi (2019) pointed out the importance of the pre-lesson preparation process in the flipped classroom model and said that this situation also increased the burden on students. On the other hand, studies on the effectiveness of this model have revealed different results. For this reason, it would not be the right approach to conclude that the classrooms in which the flipped teaching model is applied are always effective (Martínez-Jiménez & Ruiz-Jiménez, 2020). Therefore, many scholars have advocated for conducting more thorough research on this model (Chen, 2021; El Sadik & Al Abdulmonem, 2021; Goedhart et al., 2019).

2.3 Studies on the effectiveness of extended reality technologies in anatomy and medical education

Section 2.3 separately explores anatomy and medical education due to their distinct teaching requirements and learning outcomes. While anatomy education focuses on structural knowledge and spatial relationships, medical education encompasses a broader spectrum, including clinical skills and patient communication. In this section, the potential benefits of technologies like AR and VR for anatomy, and Metaverse environments for medical education, are examined. This approach aids in understanding how the use of technology in both fields can support students’ learning objectives. This section underscores the necessity for specialized research methodologies tailored to each field’s specific needs.

2.3.1 Anatomy education in VR environments

The COVID-19 pandemic has caused several changes in anatomy teaching and materials and has unavoidably triggered the adoption of digital anatomy, which resulted in the development and use of novel online teaching tools (Xiao & Adnan, 2022). Therefore, extended reality technologies (ERTs) including virtual reality (VR), augmented reality (AR), and mixed reality (MR) have been integrated into anatomy teaching over the past few decades (Chytas et al., 2022). One of the studies that focused on the impact of VR on anatomy education was carried out by Zhao et al. (2020). In their meta-analysis of randomized controlled studies, they concluded that VR could be a useful tool for promoting learners’ anatomy knowledge. In their study, Erolin et al. (2019) developed and assessed pilot VR anatomy teaching materials to evaluate the utility value and adoption of VR for anatomy education. They pointed out that it was valuable to develop and invest in such technologies as an additional resource in anatomy education. In another study, Maresky et al. (2019) evaluated the practicality and effectiveness of the heart model created by using VR technology and they found that VR was viable and effective to teach cardiac anatomy. Ekstrand et al. (2018) compared VR training in neuroanatomy to more conventional paper-based training to assess its effectiveness in their studies. Similarly, Stepan et al. (2017) aimed to assess the efficiency of VR simulation to teach neuroanatomy and learners’ satisfaction and motivation. They proved that the VR neuroanatomy model was just as efficient as conventional teaching techniques regarding learners’ exam performance, and the VR model was better in terms of learner motivation, engagement, enjoyment, and usefulness.

2.3.2 Anatomy education in AR environments

Another area of research that scholars are interested in is the value of AR technologies in anatomy education. One of the recent studies exploring AR value in anatomy teaching was conducted by Cercenelli et al. (2022) who developed a novel Anatomical Education with an AR tool combining AR technology and an actual 3D printed model. They noted that the tool could help to improve learners’ motivation for learning, as well as their ability to understand anatomical structures in three dimensions and retain more information over the long term. In another study, Bork et al. (2021) evaluated the efficacy and viability of AR-based anatomy learning in a collaborative manner through VesARlius system in terms of academic achievement. They found out that when compared to the control group using conventional learning methods, their novel AR-based system significantly increased students’ knowledge of anatomy besides encouraging collaborative and learner-centered learning. Duncan-Vaidya and Stevenson (2021) also investigated the efficiency of AR in anatomy education and stated that AR technology would be a valuable and attractive instructional tool to teach skull anatomy to learners. Correspondingly, Barmaki et al. (2019) searched the effectiveness of an AR method for teaching anatomy and reported that learners taught with their innovative AR method performed better compared to 2D methods. In their study, Kugelmann et al. (2018) examined a new Augmented Reality Magic Mirror system as an innovative and interactive learning tool in anatomy education. The results of their study suggested that the system could be advantageously integrated into anatomy education and contribute to more engaging and learner-centered learning. Unlike these studies, a number of studies have also been conducted evaluating both VR and AR technologies. For example, Moro et al. (2021) assessed how VR and AR affected preclinical physiology and anatomy students’ test performance. Although the outcomes indicated that AR and VR were not more effective than traditional anatomy techniques, the authors suggested that they were feasible alternatives to conventional teaching techniques in health sciences and medical courses. In their review of VR and AR in anatomy education, Duarte et al. (2020) concluded that these technologies could have a favorable economic influence on higher education institutions as well as a significant potential for anatomy education. On the other hand, Moro et al. (2017) compared VR, AR, and tablet-based applications regarding learning structural anatomy and reported that both VR and AR also encouraged inherent advantages such as greater learner immersion and engagement in addition to being equally useful for teaching anatomy as tablet computers.

2.3.3 Medical education in Metaverse environments

The use of the Metaverse as an educational platform in medical education has become another attractive alternative to conventional online distance learning (İbili, 2023). A number of scholars have utilized this novel technology in different fields of medical education. Werner et al. (2022) trained specialists in gynecology and fetal medicine by using a Metaverse platform, which happened in real-time without the interference of distance. The study conducted in the United Arab Emirates with university students intended to assess learners’ views on implementing the Metaverse for medical education and their intent to use Metaverse technology (Almarzouqi et al., 2022). Similarly, in their study, Alawadhi et al. (2022) examined how medical students perceived the use of metaverse systems in medical education. In his study, Koo (2021) carried out a study on lung cancer surgery by using the Metaverse and AR and presented some details about a Metaverse training session that took place in Korea. In another study, Huh (2022) proposed medical training in which students took medical license exams in a metaverse platform and aimed to facilitate medical students’ learning.

On the other hand, some researchers have focused on the integration of the Metaverse and flipped learning in their studies. One of these studies was conducted by López-Belmonte et al. (2022) who aimed to determine whether the training method (flipped learning or e-learning) allows students to learn in the Metaverse and develop stronger abilities. Another study aimed to evaluate students’ and instructors’ attitudes toward utilizing AR technology through a Metaverse application as an educational tool and the authors expected to explore how the Flipped Classroom strategy might be integrated with the Metaverse-assisted AR teaching tool (Lham et al., 2020). Tlalpan (2021) assessed how learning activities designed to teach mathematics in a flipped classroom and enhanced using AR supported by a Metaverse application affected students’ thoughts and feelings. The findings of these studies, however, did not clearly address the debates regarding the effects of the synchronous online flipped medical English classroom model supported by Metaverse-based technology on the academic achievement and medical students’ views on the instructional efficiency of Metaverse-based synchronous online flipped learning compared to the conventional synchronous distance education model. Therefore, it is expected that this research study will both contribute to the body of literature in this field regarding the efficacy and viability of the Metaverse-based synchronous online flipped medical English classroom and provide guidance to educators who will utilize this model in their teaching.

3 Method

3.1 Research design

This study aims to examine the effects of the synchronous online flipped learning supported by a Metaverse-based platform and the conventional synchronous distance education supported by the Canvas-based synchronous distance education on students’ academic achievement in a medical English course. For this reason, only the post-test quasi-experimental design with a control group was used in the quantitative dimension of the study. In this design, which is called a popular design by Creswell and Creswell (2017), participants are randomly assigned to two groups and the intervention is carried out only with the participants in the experimental group, and at the end of the intervention, the participants in both groups are given a post-test. In the present study, the experimental group consisted of the students assisted by the Metaverse-powered synchronous online flipped learning model, whilst the control group constituted the students supported by the Canvas-based synchronous distance education. The intervention with the experimental group lasted four weeks. An academic achievement test was applied to both groups after the intervention. The qualitative data of the study consisted of the findings obtained from the focus group interview.

3.2 Research context

This study was carried out within the scope of medical English in the curriculum of the Faculty of Medicine at a state university in Türkiye. First-year medical students are required to take this 12-week elective course. The aim of the course is to address the academic and professional communication needs of the students in health-related disciplines, while also providing opportunities for students to read, write, speak and listen, and support their learning with practical applications for vocabulary acquisition and language skills. The lessons were synchronously held online for 60 min for each group in the 4th − 7th weeks of the implementation. During the synchronous online courses, the same teaching activities were organized for the students in the control and experimental groups. However, the application was different in terms of how the material was presented and used. In both groups, activities in online courses were organized by the same instructor (researcher).

3.3 Participants

The population of this study consisted of 100 first-year medical students studying at a state university in Türkiye in the spring term of the 2021–2022 academic year. In order to verify the presumption that the students were at an equivalent level in terms of General English, Basic Information Technologies, and Basic Anatomy knowledge, the results of the exemption exam taken by the students in both groups at the start of the academic year were analyzed prior to the experimental application. In the study, 50 students were randomized to the experimental group and 50 to the control group according to the mean scores obtained from the gender, General English, and Basic Information Technology exemption exams. In order to ensure the homogeneity of both groups, the students were first divided into two groups: male and female, and then the students in these groups were ranked from low to high according to the average of the scores obtained from the exemption exams. This process continued until all the students in the male and female groups were assigned to groups A and B, with the student with the lowest score assigned to group A, and the next student to group B. After the assignment, group A was determined as the experimental group and group B as the control group in the draw.

3.4 Building of the Metaverse-based synchronous online flipped classroom

Spatial AR, a metaverse platform, was utilized in this study, and screenshots of the developed metaverse environment were shared in detail in this section. These sample screenshots show the learning settings, course materials, designed activities, student-created avatars, and their interactions with both other participants and the course contents. For the four-week implementation phase, a consistent classroom setting was established, and the course materials in this setting were updated in accordance with the weekly subjects to be covered. The course materials were created using design applications such as Adobe Illustrator, 3ds Max, Blender, and Substance.

Support was gathered from websites that offered free 3D items for use in classroom settings. The model of the human figure used in this context and shown in Fig. 1a has been downloaded. In this model, body parts were colored with the help of Blender, made more suitable for the course content, and transferred to the Spatial environment. Similarly, male and female figures were created in the Blender environment and transferred to the Spatial environment in accordance with the topics to be explained and to ensure integrity in the classroom environment. Figure 1b shows the colored human model, male and female figures in the classroom in a Spatial setting. Figure 1c shows the designs of various matching activities for the anatomy of the digestive system and nervous system. In Fig. 1d, the in-class view of the designed activity in the Spatial environment is shown.

Fig. 1
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a-d Material and activity design examples prepared for the anatomy of the digestive and nervous system

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In terms of the visuals created for all activities, designs were created in the Adobe Illustrator program in accordance with the activity. In Fig. 2a, visuals prepared to teach what the symptoms of digestive system diseases are presented. Figure 2b shows its application in the current Spatial environment. Four different case designs for the diagnosis of digestive system diseases were created in the Adobe Illustrator (Fig. 2c). In-class applications of the created designs are shown in Fig. 2d.

Fig. 2
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a-d Activity design examples prepared for the symptoms, diagnosis, and treatment of digestive system diseases

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Figure 3 shows the screenshots of students completing pre-lesson activities in flipped classrooms supported by the Metaverse-based teaching environment, each setting designed for a different week (weeks 4–7, respectively) during the implementation process. In Fig. 3a, the screenshot of a student doing the activity called “the journey of food”, which is designed for the anatomy of the digestive system, is shared. Figure 3b shows a screenshot of a student who answered the quiz on digestive system diseases, symptoms, and treatment, which is the topic of the next week. Figure 3c shows a screenshot of a student solving a puzzle designed for nervous system anatomy. The matching exercise designed for nervous system diseases, symptoms, and treatment, which is the subject of the last week, is shown in Fig. 3d.

Fig. 3
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a-d Screenshots of the students in the Spatial environment while completing the activities during the intervention

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3.5 The implementation

This study was carried out for four weeks, and students in the experimental group were prepared for the Spatial AR technology orientation prior to the implementation. Then, the flipped teaching phase was continued for four weeks, and the weekly course topics of the medical English course were as follows: (1) Digestive System Anatomy and Physiology, (2) Digestive System Diseases, Symptoms, and Treatments (3) Nervous System Anatomy and Physiology, (4) Nervous System Diseases, Symptoms, and Treatments. Each online lesson covered 60 min of class time each week. As an example, Table 1; Fig. 4 provide a summary of the instructional intervention using the synchronous online flipped teaching method and course content designed for the first two weeks of the intervention. While the same activities were used for both groups, the students in the experimental group participated in the activities through the Spatial AR environment, which was a Metaverse platform. In addition, unlike the conventional Canvas-based synchronous online teaching, the flipped classroom created in the Spatial AR environment was enriched with three-dimensional objects and the students were enabled to interact with their peers.

Table 1 The implementation process of Metaverse-based synchronous online flipped medical English classroom and conventional canvas-based synchronous online medical English classroom
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Fig. 4
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Course content sample

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Learning materials for experimental group students were arranged in the Spatial AR environment (a Metaverse platform). It was ensured that the students could access them via a web page link sent to them before each lesson to support their preparation for the lesson. In-class activities were carried out online via LMS. On the other hand, the control group students accessed the learning materials presented in written form through the Canvas-based LMS. The activities were carried out online, and the students were assigned homework following the session. After the implementation, an academic achievement test was applied to all students. For the qualitative data of the research, some focus participants were invited to participate in the focus group interview at the end of the implementation.

3.6 Data collection tools

Academic achievement test

The Medical English Academic Achievement Test was constructed by researchers by quoting the reading texts and exercise sections of the book Medical English Clear and Simple: A Practice-Based Approach to English for ESL Healthcare Professionals written by Hull (2010). The exercises Hull presented were reviewed by a team of education experts and a specialist physician who was a researcher in the study. The achievement test consisted of 20 multiple-choice questions about the anatomy of the digestive and nervous systems, diseases, symptoms, treatments, and topics covering the teaching of therapeutic concepts for only 4 weeks. The test was developed after applying it to the students who took this course the previous year.

Semi-structured interview form

A semi-structured interview form including 15 open-ended questions was prepared for a focus group interview. The form included questions about the participants’ opinions on the educational effectiveness of the flipped teaching method supported by Metaverse-based technology and their intention to use it for other courses.

3.7 Data analysis

We first checked whether the assumptions of normality, linearity, and homogeneity were met prior to quantitative data analysis and interpretation of the findings. The kurtosis and skewness coefficients of the variables were examined to test the suitability of the measured variables for the statistical analyses to be made in the data distribution. In cases where the data were normally distributed and the kurtosis-skewness coefficients were between 1 and 1, a t-test, one-way analysis of variance, Bonferroni test, and Pearson correlation coefficients were used (West et al., 1995). In cases where the data did not show normal distribution, nonparametric equivalents of parametric tests were used. The homogeneity assumption of the variances was tested with the Levene test. When the dependent variables of the study met the assumption of normality in each combination of the independent variables, the Pearson chi-square test was preferred for comparisons between groups (Hinkle et al., 2003). In addition, SPSS 26 software was used for the arithmetic mean, standard deviation, and unrelated measurements in the analysis of the quantitative data.

Fifteen participants attended the focus group interview. The focus group interview’s audio recording was first transcribed, and the qualitative data were analyzed by applying the thematic analysis method, which is a technique that provides a methodical way to create codes and themes and allows researchers to explore, analyze and explain meaningful patterns in qualitative data (Clarke & Braun, 2017). To ensure inter-rater reliability, as suggested by Terry et al. (2017), two of the authors independently reviewed the transcript several times and performed the coding process in order to determine the relevant themes. Two researchers met regularly to discuss the findings and construct the themes, and the categories and themes created were periodically discussed with other researchers. As a result of the analysis, 44 codes were created, and eight themes emerged from these codes.

4 Results

4.1 Quantitative results

The quantitative data obtained from the students’ academic achievement test and their test results of general English knowledge, basic anatomy knowledge, and basic information technologies knowledge are provided in detail in this part.

The pre-readiness levels of the Experimental and Control group students prior to the implementation are given in Fig. 5.

Fig. 5
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Students’ pre-readiness levels

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As seen in Fig. 5, there was no difference between the experimental and control groups in terms of General English Knowledge, Basic Anatomy Knowledge, and Basic Information Technologies Knowledge before the application (p > .05). In addition, there was no difference between the pre-readiness levels of the experimental and control groups in terms of gender (p > .05).

The average scores obtained by the Experimental and Control groups from the Medical English exam after four weeks of practice are presented in Fig. 6.

Fig. 6
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Average scores of the students obtained from the medical English test

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According to the data in Fig. 5, the mean scores obtained by the students in the medical English achievement test after the implementation were statistically significant in favor of the experimental group (p < .00). In addition, the mean score of male students was higher than that of female students, and this difference is statistically significant.

4.2 Qualitative results

The qualitative data obtained from the participants through the focus group interview provided detailed information about their opinions on the instructional efficiency of the synchronous online flipped teaching method supported by the Metaverse-based platform and their use of intentions for other courses. The findings were categorized under eight themes. Participants expressed their views on the effects of the Metaverse-based online flipped classroom on motivation and attention. The views of the participants on this issue are presented in Table 2.

Table 2 Students’ opinions on motivation and attention
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A great majority of students (N = 8) reported that learning medical English through the Metaverse-based online flipped classroom was enjoyable. Moreover, six participants said that the online flipped classroom supported by the Metaverse-based platform attracted and increased their interest. Some students (N = 5) mentioned that they did not fear or feel anxious when they used Metaverse-based technology while four students reported that they feared and felt anxious. Additionally, three participants stated that the flipped learning method supported by the Metaverse-based learning environment was effective in terms of visualization. On the other hand, three of the participants reported that the Metaverse-based online flipped classroom could be distractive during the learning process. However, two participants emphasized that online flipped learning assisted by Metaverse-based technology aroused their curiosity.

P6: I have always found the Medical English course more enjoyable than the general English course. Both because it is professional and it includes learning through games. Learning through Metaverse-based technology was enjoyable.

P12: It was better than I expected. My interest in the lesson increased through the Metaverse.

P10: No, I did not fear or feel anxious.

P8: So I was afraid and felt anxious, yes, because you are using such an environment for the first time. However, if I wore virtual reality glasses, I could experience this fear more. When we look at certain places such as spheres in these rooms, rather than the ones created by the school for us, we can walk through different rooms. In other words, I encountered different things, I saw art galleries where some people displayed their paintings on this platform, and they created spaces where I felt as if I was visiting a gallery. However, it was a little bit scary when there was no one around me.

P3: I think it was great in terms of visuals, I think we are matching things, and it was more effective than what we could do together in the classroom.

P2: It was distractive. We could be distracted since walking around was funnier than doing activities.

P5: But after the lesson, I spent 1–2 more hours in the program. Using augmented reality for the first time made me curious.

The participants’ thoughts on learning outcomes and language acquisition in the Metaverse-based learning environment revealed the second and third themes that emerged from the qualitative analysis, and the results were presented in Table 3.

Table 3 Students’ views on learning outcomes and language learning skills
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A great majority of students (N = 6) stated that learning medical English through the online flipped classroom supported by Metaverse-based technology enhanced permanent learning. Several students (N = 5) reported that learning medical English through the Metaverse-based online flipped classroom facilitated ease of comprehending the subject. Furthermore, five participants pointed out that online flipped learning supported by the Metaverse-based learning environment promoted deep learning while two of them expressed the opposite view on this issue. Additionally, when the participants were asked about their thoughts on online flipped learning supported by the Metaverse-based platform to embody abstract concepts, they stated their opinions in two ways. While some students (N = 5) stated that it contributed to the learning process in this respect, others (N = 3) stated that it did not make any contribution. The statements of three students in the focus group interview emphasized that the online flipped classroom supported by the Metaverse-based platform provided active and effective learning. Moreover, two participants referred to 3D objects and being able to visualize them as a crucial component of the online flipped classroom supported by Metaverse-based technology. A participant’s statement in the interview underlined the learner autonomy and student-centered learning during the online flipped learning supported by Metaverse-based technology.

P6: I can say that if learning is supported by visuality, the permanence of the information increases. The integration of the Metaverse in medical English can create an amazing learning environment, and I definitely find this idea very successful.

P1: It was better compared to the traditional method and helped me understand easily.

P13: I think it had a positive effect on deep learning.

P2: Since we have already covered the subject in more detail in the anatomy course, I think it did not contribute to deep learning.

P3: I think it enabled me to embody and understand abstract concepts better.

P2: I do not think that it is useful in concretizing any abstract concepts.

P3: Learning was more effective than what we could do together in class.

P8: In other words, we, as students, felt a little more active compared to the lessons taught in a traditional classroom.

P3: For example, there was a 3D neuron model in one of the classrooms, so they were quite useful because we could see from all sides in detail. Likewise, there were 3D objects in the digestive system classroom.

P8: I think that this method ensures that we have all the responsibility in the learning process and that it is a student-centered education process.

In addition, when the participants were asked how online flipped learning supported by Metaverse-based technology contributed to learning medical English regarding language skills, a great majority of the participants (N = 8) stated that it was helpful to improve their reading skills whereas five students reported that it was useful to learn vocabulary. On the other hand, some students (N = 4) expressed that the online flipped medical English classroom supported by the Metaverse-based environment helped them to improve their listening skills:

P1: I think it contributed more to reading skills.

P2: However, it helped me to learn the names of organs.

P6: I can say that it was useful for listening and reading.

P7: I think it contributed more to reading.

The participants’ negative opinions on the online flipped classroom supported by Metaverse-based technology and the Metaverse platform and which peculiar features of them caused a negative feeling during their learning experiences constructed the fourth and fifth theme, and Table 4 shows the results of qualitative analysis.

Table 4 Students’ negative views on the Metaverse platform (Spatial.io) and Metaverse-based synchronous online flipped classroom
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The results revealed that the features of the Metaverse platform that negatively affected the participants’ learning experiences were the technical problems experienced by them while using the platform, the technical deficiencies of the platform, being time-consuming, inefficient, and unrealistic:

P2: It was said that you need to log in with an e-mail account to enter the platform and interact with the activities, but even though we logged in with an e-mail address, we could not move anything.

P8: Your avatar makes different moves when you press certain numbers. However, it was more like a dance practice. It would be better if features such as raising fingers and sitting in line were added instead, because the character is having a little fun.

P4: I mean, I didn’t want to deal with this platform because it was a waste of time for me.

P6: I think it both reduces efficiency and makes things more difficult.

P5: It doesn’t have enough realistic graphics.

On the other hand, a variety of reasons such as time-consuming activities and having difficulties in implementation regarding online flipped classroom design seemed to affect the participants’ learning experience negatively.

P6: While I was solving the puzzles, I stopped doing it by thinking that I would solve it anyway, even if I did not write after a point because it was time-consuming.

P10: I could not move or drag the words.

The participants’ opinions on using Metaverse-based technology constituted the sixth theme, which is presented in Table 5.

Table 5 Students’ views on using Metaverse-based technology
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The results showed that a great number of students (N = 8) reported that it was easy to use Metaverse-based technology; however, two of them expressed the opposite thought on this issue:

P1: So it went well for me. I could use it easily.

P14: I had difficulties while using it due to my lack of technical knowledge.

Additionally, when the participants were asked about their intentions about using this technology, they stated that they wanted to use it in the future:

P6: I think that Metaverse-based technology can be very useful for my future career as well. As someone who wants to specialize in cardiovascular surgery or plastic, reconstructive and aesthetic surgery, I would love to improve my surgery skills.

P8: That is, it should be used in all courses, not only in English.

P9: We are standing on the shoulders of technology, so why not.

Furthermore, six students stated that they were not competent enough to use Metaverse-based technology while a number of students (N = 5) expressed the opposite view, stating that they were competent:

P4: No, I do not think I am competent.

P7: I had a bit of a hard time at some points because I’m not good at technology.

P5: I think I am competent in using this technology because I learned the controls easily.

P13: Due to my generation, I think that I am prone to such things and easily grasped them.

The participants’ suggestions about the Metaverse-based online flipped classroom revealed the seventh theme as a result of qualitative analysis, and the findings were presented in Table 6.

Table 6 Students’ suggestions about the Metaverse-based synchronous online flipped classroom
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When the participants were asked about their suggestions about the Metaverse-based online flipped classroom most recommended suggestions were that the avatar should be improved and this kind of teaching method should be applied to students at the lower level of education. A number of participants (N = 3) suggested that activities should be improved while some of them (N = 3) expressed that teaching through Metaverse-based technology could be an alternative when face-to-face education was disrupted. On the other hand, two of the participants emphasized that learners should learn how to use this technology well before practicing it. Another two participants stated that it would be better if competitiveness was added to the learning process. While one of the participants suggested that in-app purchasing could be added to the platform, another participant stated that it would be better if the 3D models of the body systems were separable.

P4: So, I think the avatar should be improved.

P14: I think it would be more encouraging for secondary school or primary school students instead of university students because I don’t think university students are too excited about using it.

P2: But in some activities, such as filling in the blanks, I think it would have been easier to use if they had been in the form of a test instead of writing letters one by one.

P3: What we can do is that: the teacher teaches the lesson face-to-face and makes the reward using this technology. I think it would be good to reinforce it in this way.

P14: I think that if we have more information about this technology before starting to use it, we will feel more carefree and comfortable.

P7: I mean, if it was more competitive, it might actually be more intriguing and interesting.

P8: Maybe in-app purchasing can also be added.

P9: I wish 3D models could be separated piecemeal in Spatial, just like the models that we have the opportunity to examine in anatomy laboratories. We just wandered around systems in one piece.

The opinions of the participants on how Metaverse-based online flipped learning affected their interaction constructed the last theme. The participants’ responses emphasized the interaction between students and the interaction between teacher and students. The results are shown in Table 7.

Table 7 Students’ views on interaction
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The statements of four students in the focus group interview pointed out that Metaverse-powered online flipped learning increased the student-student interaction while three participants stated that it did not affect the student-student interaction. On the other hand, two of them claimed that it restricted student-student interaction whereas one participant reported that it restricted teacher-student interaction:

P12: My interaction increased thanks to assignments.

P6: It did not affect my interaction with my friends.

P1: So I think it limits social interaction between students.

P8: I think that even though this is the Metaverse, it breaks the communication between the teacher and the student a bit.

5 Discussion

In this study, the synchronous online flipped medical English classroom supported by a Metaverse-based platform and the conventional medical English classroom supported by the synchronous distance education utilizing Canvas-based LMS were compared in terms of different variables. In this context, a four-week experimental study was conducted with 100 students studying in medicine faculty and the results of the research are discussed below.

The results of this study revealed that the academic achievement of the experimental group students supported by the Metaverse-based synchronous online flipped teaching method was higher than the students in the control group educated with the conventional synchronous distance education. This result shows that the metaverse-based learning environment is an effective teaching tool for the synchronous online flipped learning method. In addition, in parallel with previous studies, it shows that this method is more effective in the academic success of students than the traditional distance education model (López-belmonte et al., 2022; Tlalpan, 2021). In particular, it can be said that the metaverse-based teaching environment provides more effective results in teaching in terms of its advantages such as permanent learning (Cercenelli et al., 2022; Ekstrand et al., 2018), facilitating learning (Lham et al., 2020; Zhao et al., 2020), concretization of abstract concepts (Chen et al., 2022; İbili et al., 2020), deep learning (Mystakidis, 2022; Lham et al., 2020), and 3D visualization (Cercenelli et al., 2022; Kolecki et al., 2022). In addition, it is inferred that student-centered learning takes place as students are constantly active during learning (Barmaki et al., 2019; Bork et al., 2021). In addition, the results showed that the Metaverse-based flipped learning model made learning fun and increased students’ interest in the lesson. For this reason, it can be said that this method could contribute positively to increasing the motivation of students and their willingness to participate in the lesson. These results are parallel with the findings reported by Stepan et al. (2017) and Lham et al. (2020). When it is examined in terms of language skills, it can be said that it contributes especially to students’ reading skills, vocabulary acquisition and listening skills. Qualitative data showed that thanks to the Metaverse-based teaching environment, they could participate in the learning environment whenever they wanted and study collaboratively with their friends. Besides, they had the opportunity to repeat as much as they wanted. On the other hand, due to the fact that the students gain the learning outcomes before class, they can easily relate to the content studied before class by having the opportunity to practice more and using high-level intellectual skills (analysis, synthesis and evaluation) (Goedhart et al., 2019). Therefore, it can be said that learning takes place actively and becomes more permanent. However, traditional distance education classes have limitations due to reasons such as passive learning, lack of collaborative repetition and lack of motivation due to lack of social interaction (Livingstone & Kemp, 2007; Saverino et al., 2022; Karabatak & Turhan, 2017). In this respect, it can be concluded that online flipped learning supported by the Metaverse teaching environment is more effective than traditional distance education. In addition, although the effectiveness of the flipped learning environment has been demonstrated in previous studies, some emerged limitations have been reported in these studies. For example, it may require extracurricular time and effective planning for both teachers and students, pre-lesson preparation may be time-consuming, and preparation before the class can be daunting for beginners who do not have deep knowledge of the lesson (Karabatak & Polat, 2020; Strayer, 2016). However, the research results obtained in this study show that metaverse-based teaching environments are an effective and easy-to-use teaching tool for effective teaching scenarios and flipped learning method, and students’ intention to learn with online flipped learning supported by Metaverse-based teaching environment continues.

The results also revealed that gender had an effect on academic achievement. After the four-week intervention, the findings showed that the academic success of the male students taught with the Metaverse-based online flipped learning method was higher than the female students. However, there was no valid reason for why male students’ paper-based test results were higher than female students. Some factors that contributed to male students’ higher performance levels compared to female students may be that male students are more successful in using mobile technology, male students have higher levels of cooperation in mobile-assisted learning, and male students’ motivational outcome was better (Refat et al., 2020). Besides, low anxiety level may affect female students’ academic performance (Grant et al., 2013). On the contrary, few research studies focused on performance analysis based on gender differences have been found in the literature and the results revealed that female students outperformed male students in medical English learning (Lin et al., 2021). Although the results of the research study revealed the effectiveness of the synchronous online flipped learning powered by the Metaverse-based teaching environment, the qualitative data also exposed some limitations of the Metaverse environments. During the implementation, some students reported some problems including technical issues, the need to increase reality perception, the time-consuming nature of the exercises, and application-related challenges during implementation. Within the framework of these limitations, the students suggested that Avatars should be improved; this method is more suitable for lower education levels; the number of activities and especially competitive activities should be increased; video or printed materials should be prepared to improve users’ skills of using technology; and 3D objects are more useful. Based on these findings, it is recommended to carry out research on the effectiveness of Metaverse environments by taking these suggestions into consideration in future studies.

6 Conclusion

Distance education tools have evolved into an essential prerequisite for a sustainable educational process in situations where face-to-face instruction in the classrooms is disrupted by epidemics or earthquakes. Therefore, instructional designers have begun to investigate teaching strategies that adopt cutting-edge technologies to improve their teaching. In this research study, several potential consequences of the adoption of the Metaverse-powered synchronous online flipped learning method are highlighted in light of our findings. Firstly, the quantitative results showed that synchronous online flipped learning supported by the Metaverse-based teaching environment was superior to conventional synchronous distance learning. Additionally, the results revealed that male students performed better on the paper-based achievement test than female students. However, it is crucial to highlight that this study is limited to exploring the Turkish higher education context. Therefore, the results can merely be generalized to Turkish medicine students. For this reason, the generalizability of the results might be improved by future research that evaluates the performance of various student groups. Besides, it is recommended to compare the flipped learning method supported by different learning environments with the Metaverse learning environment for distance learning classes in future research.

In this study, the results obtained from qualitative data provided crucial details about the viability of integrating Metaverse environments into online flipped classes. These findings demonstrate the positive implications of Metaverse learning environments for learning in terms of permanent learning, facilitating learning, concretizing abstract concepts, deep learning, and 3D visualization. In addition, it has been shown that students are in an active learning process in the learning process, making learning fun thanks to social interaction support and increasing students’ interest in the lesson. For this reason, it can be said that Metaverse learning environments affect the learning process positively in terms of pedagogy. However, supporting Metaverse learning environments with effective teaching scenarios is one of the primary tasks for the effectiveness of these learning environments. The results of this research have concluded that Metaverse environments make a significant contribution to the development of language skills as they allow students to learn cooperatively in social interaction and to take part in an active learning process. It can be said that it especially contributes to students’ reading skills, vocabulary acquisition and listening skills.

Thanks to the Metaverse-based teaching environment, students can participate in the learning process whenever they want, study collaboratively with their friends, have the opportunity to repeat as much as they want, and at the same time, they eliminate the passive role they once had in conventional distance learning. Therefore, it can be said that Metaverse-powered learning environments contribute to the effectiveness of a flipped class offering a more student-centered learning environment. Thus, the students had a chance to learn about the course outcomes with effective teaching methods before class, which allowed them to practice more during the lesson and helped them use high-level intellectual skills and learn more permanently. However, conventional distance learning classes have some drawbacks because of issues like passive learners, a lack of collaborative repetition, and a lack of motivation owing to a lack of social connection. In this respect, it can be said that the synchronous online flipped classroom supported by a Metaverse environment is more effective than the conventional distance learning. One of the most important indicators of this is that the students still intend to learn through the Metaverse-powered synchronous online flipped learning. However, the low perception of reality in Metaverse environments, time-consuming activities, and lack of preparation of videos or printed materials before teaching limit the effectiveness of Metaverse-based flipped learning methods. For this reason, it is recommended to pay attention to these issues while designing a flipped classroom supported by Metaverse environments in terms of future research.

By providing new insights into a novel instructional approach, this study considerably increases our understanding of how to integrate flipped learning into Metaverse-supported synchronous online medical English teaching. Our study deviates from past research presenting a viewpoint on Metaverse-supported flipped learning in different fields and its ramifications. This study sheds light on an understudied facet by combining flipped learning with a Metaverse environment for medical English teaching, which is one of its unique contributions. Moreover, the integration of gender differences in our data analysis adds a level of depth that has been overlooked in previous studies. We hope that these novel contributions will spark further discussion in the area and encourage scholars to delve deeper into the intersections between online medical English teaching through Metaverse environments and flipped learning method. On the other hand, there are some limitations of the research. First of all, the platform used in the study did not provide a statistical report on what hours the students mostly attended the Metaverse environment, which devices (AR, VR, Mobile, etc.) they used during their learning process, how long they engaged with the content, and which activities they were most involved in within the Metaverse environment. Consequently, comprehensive data on these aspects could not be obtained. This limitation highlights the need for future research to delve into the customization of Metaverse-supported learning environments to suit diverse student needs. It is imperative for future studies to not only obtain these data manually or with different software but also to explore adaptive instructional strategies that address individual learning styles and preferences. Additionally, incorporating advanced analytics and AI could offer deeper insights into student behaviors and preferences, further personalizing the learning experience. Hence, addressing these limitations and recommendations could substantially contribute to refining the efficacy and inclusivity of Metaverse-supported synchronous online flipped learning environments, particularly in catering to the diverse needs of learners and enhancing their overall educational experience.