Application of Flipped Classroom Teaching Mode Based on Rain Classroom App in Anesthesia Teaching

Tao Peng Department of Anesthesiology, The A liated Hospital of Southwest Medical University Xingchen Zhou Department of Anesthesiology, The A liated Hospital of Southwest Medical University Yingxu Chen Department of Anesthesiology, The A liated Hospital of Southwest Medical University Yaxian Huang Department of Anesthesiology, The A liated Hospital of Southwest Medical University Maohua Wang (  wangmaohua@swmu.edu.cn ) Department of Anesthesiology, The A liated Hospital of Southwest Medical University


Introduction
In teaching, we should establish the teaching concept of "people-oriented and student-oriented", guide and promote students to participate in classroom learning, let students think independently, and let students express their ideas in an open way [1]. This is the application of cognitive psychology in teaching, which emphasizes the student-centered teaching concept. Flipped classroom teaching mode highlights the dominant position of students. In this teaching mode, teachers send learning materials to students before class, and students can exibly self-study according to their own learning rhythm and acceptance ability; in class, they are committed to using knowledge for more active and in-depth learning by answering questions or discussion and analysis based on case situations [2].
Ausubel, a famous educational psychologist, thinks that meaningful learning is to connect new knowledge with original knowledge and bring new knowledge into learners' original cognitive structure. In the ipped classroom teaching mode, the teachers push the learning materials to the students for selfstudy before class, so that the students can establish a new knowledge system on the basis of the original knowledge, and build a new understanding of the existing knowledge through the exchange and discussion with teachers or other students in the classroom. According to Cunningham, an American cognitive psychologist, that is, "learning is a process of constructing internal psychological representation. Learners do not transfer knowledge from the outside world to memory, but build a new understanding based on the existing knowledge and experience through interaction with the outside world." Cognitive psychology attaches importance to the inherent cognitive nature of human beings, including curiosity, cognitive needs, achievement motivation, etc. the respect for psychological cognitive laws in teaching design can mobilize students' cognitive drive, improve their cognitive structure and improve their cognitive methods [3]. Traditional teaching pays more attention to the teaching of knowledge structure and logical structure of teaching materials, but ignores the cognitive structure in students' minds [3]. Flipped classroom introduces the most popular lecturing mode in the classroom by using a series of modern teaching methods such as group discussion method, so as to guide and promote students to participate in classroom learning, and stimulate students' critical thinking and learning the deep thinking of materials can improve the ability of explanation, reasoning and application of new knowledge, and it will have a positive impact on students' learning attitude, learning habits and later learning methods [3]. In the classroom, we can build a new understanding of existing knowledge through the exchange and discussion with teachers or other students. This interactive teaching mode conforms to the cognitive structure of students [4].
In ipped classroom knowledge application, students can play a leading role in explaining the practical application of a certain knowledge point to the whole class. Learning from the book of rites, learning from each other, teaching is one of the most e cient learning methods, which is in line with the cone of learning proposed by Edgar Dale, an American scholar and famous learning expert Learning), because in the process of teaching to others, you will nd your own lack of understanding of knowledge, and strive to overcome it, so that you can study knowledge more thoroughly and thoroughly, and nally learn more rmly. In order to enable students to master the knowledge of these important and di cult chapters, the teaching mode is introduced in the classroom discussion and knowledge application of ipped classroom, so that students can take the stage to explain to the whole class. However, due to the time limit of the class, only a small number of student representatives can take the stage to analyze and explain, which can not make all students stand on the platform to teach the application of knowledge points. In this teaching mode, most students can not get the best results in learning these important and di cult chapters, which is far less than those students who participate in the process of speaking on the stage, because Compared with the students who give lectures on stage, they lack enough enthusiasm, participation and opportunities for knowledge internalization. "Knowledge internalization" is the process that learners transform explicit knowledge into tacit knowledge, and it is a part of transforming new knowledge into learners' internal quality [5].
With the rapid development of "Internet", more and more front-line teachers integrate digital media, arti cial intelligence, big data and other information technology into classroom teaching. With the popularization of multimedia hardware and the rapid development of educational information in colleges and universities, multimedia has increasingly become a necessary means in teaching. With the further development of ipped classroom, the demand for additional technical support is increasing. As a new teaching technology, rain classroom integrates PowerPoint and we-chat, providing technical support for every teaching link from pre class to after class [7]. One of the important components of effective teaching is students' participation, which plays an important role in students' learning [8]. Rain classroom is based on the teaching concept of taking students as the main body, so that every student can actively participate in every learning link, which may better meet the needs of ipped classroom for technical support. Based on the ipped classroom teaching mode, we intend to explore the in uence of rain classroom application on students' participation, enthusiasm and teaching effect..

Study design and population inclusion
One hundred and twenty-two third-year students majoring in anesthesiology in the Clinical Medical College of Southwest Medical University were randomly divided into two groups, 61 in each group. One group was taught with ipped classroom teaching mode as the control group (FC group: ipped classroom group) and the other group was taught with ipped classroom software as the experimental group (FR group: ipped classroom + rain). The experimental study was conducted with the help of a senior associate professor and a teaching assistant. The whole experimental design is based on the speci cations of randomized controlled research and questionnaires are added. The speci c ow of the study is shown in Figure 1.

Course arrangement
The key and di cult content of "acid base electrolyte balance and blood gas analysis" is selected as the teaching content. A variety of novel learning activities in ipped classroom may cause students a feeling of uneasiness or loss, because they have not experienced these activities in the traditional classroom [9]. Therefore, the teaching staff will speci cally introduce the classroom structure and teaching concept of ipped classroom to all students in advance, and explain to learners the principle of using ipped classroom in medical education environment may be useful At the same time, introduce the function and operation of rain classroom technology and its advantages to the students of FR group. In order to encourage teamwork in ipped classroom, students in each group are further divided into small teams with ve students in each group.
Before class, the teacher prepared the teaching video of "six steps of blood gas analysis" course and put forward some related thinking questions. FC group sent the video to the student end through we-chat group online, and the FR group pushed the video to the student end through rain classroom software.
After watching the video, each team discusses problems and prepares PowerPoint presentation for class presentation and discussion; in class, student representatives of each group give a 10 minute speech to review the knowledge points of the teaching video, and then put forward the unsolved problems of the group for class discussion. Each of the remaining groups publishes their answers to the questions and discusses the answers for about 20 minutes. For some particularly challenging problems, the students discuss and solve them together with the teaching assistant teachers. Finally, the teacher makes an authoritative summary (including an overview of the key points of theoretical knowledge of the course, the analysis of di cult problems encountered in the process of students' discussion, and encouraging students to review relevant teaching materials after class), FC group is completed with the help of PowerPoint demonstration software, and FR group is completed with the help of rain classroom technology; after class, teachers assign homework, involving in the ipped classroom Students are required to complete and hand in their homework within three days. FC group completed this link with wechat and word documents, and FR group completed it through rain classroom technology. The teacher publishes the answers to the assignments online three days later and helps students solve challenging problems according to their requirements.

Data collection
Before the course begins, all students are required to complete prediction questions about acid-base electrolyte balance and blood gas analysis. At the end of the course, both groups of students were required to ll in an anonymous questionnaire to evaluate their views on the teaching mode of their respective courses (including nine items, covering both positive and negative aspects). Finally, students' learning gains and interests in acid-base electrolyte balance and blood gas analysis were assessed by themselves. The three-point Likert scale (-1, disagree, 0, neutral, 1, agree) was used to quantify students' views and self-assessment. The questionnaire is modi ed according to Paul Ramsden's curriculum experience questionnaire and Biggs' learning process questionnaire, and has been veri ed to be reliable and valid [10][11]. In addition, students need to report on the time spent in class preparation. In order to evaluate the students' learning of the course, a post test was conducted after the students completed all the courses. The test consists of multiple choice questions, multiple choice questions and discussion questions. We calculated the total score of each student for questions related to "acid-base electrolyte balance and blood gas analysis" and for questions related to "non-acid-base electrolyte balance and blood gas analysis". Independent sample t test was used to analyze the time spent in class preparation.
Students' interest in the teaching content "acid base electrolyte balance and blood gas analysis" can be quanti ed as: 1. Not interested; 2. Somewhat interested; 3. Very interested.

Results
A total of 122 students participated in the study, including 61 students in FC group and 61 students in FR group. The sex and age composition in the two groups were similar and no statistical signi cance, was shown in Table 1. The attendance rate in both groups was 100%. All students in both groups watched the video course. The response rate of questionnaire and theory test in both groups was 100%. However, among the questionnaires received, some questionnaires scored "-1" or "1" for all questions. For more objective analysis, these data were removed from the statistical analysis. A total of 119 reliable questionnaires were analyzed, including 59 from FC group (49.6%) and 60 from FR group (50.4%). In the theory test results of all the students, some objective questions all options are the same option, or subjective questions do not answer the test paper will be eliminated. A total of 117 reliable papers were analyzed, including 58 from FC group (49.6%) and 59 from FR group (50.4%). More students in the FR group believed that teaching staff could help them improve their learning motivation (P = 0.042) and understand course materials (P = 0.027), at the same time, the students in FR group were more satis ed with the teaching method of ipped classroom + rain classroom (P = 0.025), as shown in Table 2. However, there was no signi cant difference between the two groups in "preparing for the examination". The students in FC group and FR group spent considerable time in class preparation (2.95 ± 0.98 hours vs. 2.85 ± 0.89 hours, P = 0.562, effect dose = 0.105), as shown in Figure 2A. More students in FR group thought that teaching staff could improve their clinical thinking (P = 0.005), promote knowledge acquisition (P = 0.018) and self-opinion expression (P = 0.040). However, there was no difference in the two groups in terms of "communication skills" and "scienti c thinking", was shown in Table 3. In addition, 95% of the students in the FR group said that they were "somewhat interested" or "very interested" in the acid-base electrolyte balance and blood gas analysis, which was higher than that in the FC group (81.36%), was shown in Figure 2B. The difference of overall interest score in the two groups was statistically signi cant (P = 0.031, u = 1405.5 (z = -2.153), effect size = 0.361), and the FR group was higher than the FC group, was shown in Figure 2C.  Figure 2D.

Discussion
In the ipped classroom teaching mode, it is not necessary to ip all the contents [9], but only partially ip the key and di cult knowledge of the teaching content. For example, acid-base electrolyte balance and blood gas analysis, the key and di cult parts in medical teaching, can not only reduce the learning burden of students before class, but also enable students to concentrate on the key and di cult knowledge points for targeted learning and exploration. There is evidence that students also prefer to divide the curriculum into traditional classroom and ipped classroom [9]. In a study on engineering major, students pointed out that 30% of the ipped classroom and 70% of the traditional classroom are the best composition proportion [15]. In the teaching process, it is di cult for students to master the key and di cult knowledge points in each chapter e ciently, and some di cult points even perplex students and weaken their learning enthusiasm. Therefore, this study will focus on the key and di cult knowledge plate as the teaching content of the study, to explore the application of ipped classroom teaching mode based on rain classroom technology in the teaching of key and di cult content.
Compared with FC group, the students in fr group performed better (75.40 ± 11.82 vs. 80.07 ± 9.46, P = 0.020, effect dose = 0.437). It should be noted that, Compared with FC group, the students in fr group performed better (75.40 ± 11.82 vs. 80.07 ± 9.46, P = 0.020, effect dose = 0.437). It should be noted that, as shown in the pre-test, the acid-base electrolyte balance was comparable to the theoretical knowledge baseline of blood gas analysis in both groups before the study. These results are particularly encouraging to encourage educators to consider using rain classroom technology, as we have shown that it is very effective in helping students master and apply knowledge of acid-base electrolyte balance and blood gas analysis. From the perspective of "knowledge internalization", this paper analyzes and discusses the in uence of ipped classroom teaching mode and rain classroom technology on teaching effect. Students watch the teaching video before class and solve the related problems raised by the teacher before class, so as to have the students' rst knowledge internalization; in the classroom link, according to the feedback of students' watching the video before class, the teacher discusses and interacts with students in class to solve the problems that students don't understand The second knowledge internalization occurred, and students' knowledge internalization plays an important role in ipped classroom teaching effect [16][17]. The internalization of a concept, especially the internalization of complex and ill structured knowledge concepts that cannot be established spontaneously, is far from enough only through one internalization, and it can be mastered skillfully only after multiple internalization [18].as shown in the pre-test, the acid-base electrolyte balance was comparable to the theoretical knowledge baseline of blood gas analysis in both groups before the study. These results are particularly encouraging to encourage educators to consider using rain classroom technology, as we have shown that it is very effective in helping students master and apply knowledge of acid-base electrolyte balance and blood gas analysis. From the perspective of "knowledge internalization", this paper analyzes and discusses the in uence of ipped classroom teaching mode and rain classroom technology on teaching effect. Students watch the teaching video before class and solve the related problems raised by the teacher before class, so as to have the students' rst knowledge internalization; in the classroom link, according to the feedback of students' watching the video before class, the teacher discusses and interacts with students in class to solve the problems that students don't understand The second knowledge internalization occurred, and students' knowledge internalization plays an important role in ipped classroom teaching effect [16][17]. The internalization of a concept, especially the internalization of complex and ill structured knowledge concepts that cannot be established spontaneously, is far from enough only through one internalization, and it can be mastered skillfully only after multiple internalization [18].
Compared with the FR group, the FC group had lower high scores. Many of the students who got high scores were students who actively participated in the teaching. In the ipped classroom, only some students participate in the classroom speech, which improves the enthusiasm and participation of these students, and facilitates them to internalize their knowledge better. However, most of the students who did not participate in the speech lacked enough enthusiasm and opportunities for knowledge internalization. If these students who are not active enough to complete the task of self-study before class are not up to standard, lack of enthusiasm for interaction with teachers and students in class, and do not participate in the designated pre class or classroom activities, ipped classroom will not be able to support effective learning [19][20]. Rain classroom scienti cally covers every teaching link from before class to after class, providing complete and three-dimensional data and technical support for teachers and students [7]. The application of rain classroom technology in ipped classroom teaching mode can help to form a new knowledge structure and improve students' learning e ciency by decomposing the di culty of knowledge internalization and increasing the times of students' internalization. Compared with FC group, the use of rain classroom technology promoted the internalization of students' knowledge and improved the theoretical test scores of FR group. At the same time, the subjective evaluation of FR group on the improvement of learning ability was also higher. It highlights the advantages of rain Classroom: rstly, to improve students' interest in learning, enthusiasm and active learning ability, secondly, it helps to achieve personalized autonomous learning, thirdly, it helps to build a "relaxed and pleasant" classroom atmosphere.
Using rain class, teachers can push the preview materials with exercises, voice and MOOC video to students' mobile phones for self-study. Students' pre class learning situation can be fed back to the teacher, which plays a certain role in supervising and urging students' pre class self-study. At the same time, teachers can teach students according to their aptitude according to their learning conditions. In class, the functions of random roll call, real-time answer, bullet screen contribution, exercise push and red packet in class can realize the e cient interaction between teachers and students, which greatly improves the participation of all students Enthusiasm provides a perfect solution for the interaction between teachers and students in classroom teaching: real time answer in class, teachers can push exercises to the whole class in real time. On the one hand, it can improve students' concentration in class, and at the same time, it can also test students' mastery of knowledge points. The teacher can also cast all the students' answers on the screen for the whole class to browse. Students can compare their answers in the class to re ect on their own learning de ciencies. Bullet screen interaction and contribution: the teacher can select any time point to open the barrage function, all students can speak freely and actively express their personal opinions. The bullet screen content sent by students will be displayed on the large screen of lectures, and both teachers and students can browse. Therefore, the bullet screen function provides most students who have not been on stage to express their opinions and opinions to the whole class Space and opportunity. If you are worried that the opening of the barrage will affect the students' concentration in class, the teacher can turn off the function of the barrage in class and open it between classes, so that students can also activate their thinking during the break time. Students can also send their opinions or questions to the teacher in the form of contribution, and the content will not be directly displayed on the large screen. After receiving the contribution, the teacher can decide whether to put it on the lecture screen. Exercise push: teacher can push time limited (or unlimited) exercises to students at any time point before class, class and after class, as an evaluation test of students' learning situation. Students submit answers after answering questions, and teachers can check students' answers on the teacher's side and make corrections. Classroom red packets: teacher can reward students with excellent performance in class by giving them red envelopes. While activating the classroom atmosphere, they can fully attract and mobilize the attention of students and put them into classroom learning. After class, the rain classroom will send personalized reports of classroom teaching to teachers. Teachers can refer to the classroom reports to further understand the students' learning situation and make targeted suggestions students to solve doubts, nd out the missing.
Flipped classroom is a deeper and more open teaching mode, and it may need to update the evaluation system to better evaluate the effectiveness of ipped classroom [21]. The results showed that there was no signi cant difference between FC group and FR group (62.74 ± 10.41 vs. 65.81 ± 8.67, P = 0.085, effect amount = 0.321) (Figure 2(f)). When more complex evaluation indicators are included, for example, there are not only standardized multiple-choice questions, but also open subjective discussion questions; the evaluation level is not only the mastery of theoretical knowledge, but also includes learning ability, critical and creative thinking, students' reactions and opinions. The results are shown in Figure 2 (e). The nal conclusion is that the teaching effect of the experimental group is better than that of the control group and the teaching effect of ipped classroom can be signi cantly improved with the help of rain classroom technology. Students have changed from traditional passive acceptance learning to active autonomous learning, and the evaluation depth and representativeness of standardized multiple-choice questions are insu cient, such as the improvement of students' learning ability, especially the cognitive ability of higher-order thinking, the improvement of problem-solving ability, inquiry ability and critical creative thinking [22]. This may be the main reason why some studies [23][24] have concluded that ipped classroom has little or no improvement in teaching income compared with traditional classroom.
This study also has some limitations. First of all, the teaching content of this study is the key and di cult knowledge in medical education. Due to the particularity and complexity of medical education [25], when it is extended to other teaching elds, the teaching mode of ipped classroom + rain classroom may not achieve good results. It is expected that more research will make up for this blank in the future. Secondly, the scoring standard of argumentative questions in the after-school theoretical evaluation is to score according to the key points. The reviewers may attach their own subjective judgment when marking, which may lead to certain scoring errors. However, all our papers are graded by the same reviewer, so as to avoid different scoring standards of different people, and strictly follow each score point, speci c to each score detail, and reduce the error to the lowest.
To sum up, in the ipped classroom teaching of the key and di cult chapters of the teaching content, by using rain classroom software, compared with the simple use of ipped classroom teaching, more students can obtain greater teaching bene ts.