Simulation-Based Flipped Classroom in Surgical Suturing Technique: Faculty and Medical Students’ Experiences at Soroti University.

Introduction

In recent years, the landscape of medical education has been evolving in response to the increasing complexity of healthcare systems and the need for competent, practice-ready graduates. A major concern in low-resource settings like Uganda has been the limited clinical exposure and skill acquisition among undergraduate medical students, which affects their readiness for independent clinical practice upon graduation.^1,2 Traditional lecture-based teaching often falls short in equipping learners with the procedural competencies and clinical reasoning skills demanded in contemporary practice.³

Simulation-based education (SBE) has emerged globally as a powerful pedagogical approach that allows learners to acquire technical and non-technical skills in a safe, controlled environment.^4–6 When integrated with active learning strategies such as the flipped classroom, simulation becomes even more effective by fostering learner engagement, critical thinking, and self-directed learning.^7–9 The Simulation-Based Flipped Classroom (SBFC) model encourages students to prepare through pre-class content and apply knowledge during hands-on simulation sessions, aligning well with constructivist learning theory and adult learning principles.^10,11

Despite the growing adoption of the flipped classroom in high-income countries, there is limited evidence from sub-Saharan Africa on its feasibility and educational impact, particularly in simulation contexts.^12,13 In Uganda, medical education institutions are increasingly interested in reforming their curricula to enhance competency-based training; however, few studies have explored faculty and student experiences following implementation of SBFC methods.^14–17 Understanding these experiences is essential for contextual adaptation, faculty development, and curriculum improvement.

This study therefore sought to explore the experiences and perceptions of both students and faculty following participation in a simulation-based flipped classroom module at Soroti University. By addressing the literature gap, the study aimed to contribute to the understanding of how active, simulation-enhanced pedagogies can improve the quality of surgical skills training and the readiness of graduating doctors in Uganda.

Methods

This exploratory qualitative study was part of a wider quasi-experimental study that was evaluating the effectiveness and feasibility of simulation-based flipped instruction for surgical suturing skills at Soroti University in February of 2025. We included year III medical students in their second semester of junior clerkship who had no prior formal training or practice in suturing technique. Students with prior suturing skill experience, such as nurses, clinical officers, were excluded from participating in the research study but took part in the module for learning purposes. Students were exposed to a simulation-based flipped instruction module for 1 week, and at the end of the training, their perceptions, experiences, and those of their instructors were explored.
The flipped instruction involved providing students with pre-class learning materials one day before in-class learning. Students were then oriented about the flipped classroom approach and provided with learning materials, including 5-8-minutes instructional videos( 2 per session), 2 truncated textbook chapters, and 1 journal article, all shared via WhatsApp and email. Additionally, each student received a practice kit with suturing instruments and a banana for pre-class practice.

The in-class component was conducted over three days using pig skin in the skills lab. Each day began with a review of pre-class material, followed by a live demonstration projected to the class using a Moto G84 phone camera setup. Students were paired and rotated between roles as surgeon and assistant during supervised hands-on sessions. Instructors facilitated these sessions using guiding questions to stimulate discussion and correct misconceptions. At the end of each day, key learning points were summarized, and post-class tasks were assigned.

To ensure the reliability of the learning and assessment exercises, all instructors were taken through a training in the flipped classroom approach and on how to use the assessment tools by the principal investigator himself, who is an expert in health professions education.

At the end of the training, students were allocated to one of the 4 focus groups for discussion about their perceptions regarding the flipped simulation training. Audio recordings of this interaction were gathered for later transcription. Three in-depth interviews were conducted with the available surgeons who facilitated the training, and the conversations were audio-recorded for transcription.

From the focus group discussions and in-depth interviews, the researcher, working with the research assistants, transcribed the audio data. This helped in the analysis of the data for themes or categories, and developing conclusions based on personal and/or theoretical meaning extracted from the data. The transcripts from the recordings were compared to harmonize the data. The cleaned-up transcripts were open-coded using Qualicoder version 3.6 to help establish the dominant themes and the relationships between the themes. This process of open coding allowed identification of those themes that are essential to the understanding of the perceptions of students and instructors about the flipped classroom approach. Axial (color) coding of the text enabled the researcher and assistants to organize essential themes under each participant’s code into a codebook.

Ethical approval was sought from the Mbarara University Faculty of Medicine research and ethics committee. Administrative clearance was granted by Soroti University.

Results

We conducted four focus group discussions and three in-depth interviews with the students and instructors, respectively. Each focus group had 8 students and lasted 1 hour. The in-depth interviews involved three instructors who were involved in the training process, and they lasted 45 minutes each via a Zoom discussion.

The focus group discussions were conducted among year three medical students (n=30). Of these 20 (67%) were males, and their ages ranged from 22 to 34 years. Three surgeons participated in the in-depth interviews. Each had at least 3 years of teaching experience in surgery and at least 4 years of clinical practice as surgeons.

Perceptions of Flipped Simulation

Instructors’ Perception

Instructors viewed the flipped simulation approach as innovative and student-centered, though unfamiliar prior to this module. They acknowledged that it shifts responsibility to learners, with instructors acting as guides.

“It is a student-centered approach to learning, whereby the lecturer will prepare materials for studying. Maybe this can be in the form of recorded lectures, links to a video… You send them a link, you have these images, a pictorial presentation, so you prepare the materials, give them to the students for them to study on their own, and then when they finish studying them, you meet up, just for a recap, clarification, and participation of the students.” (IDI3)

“What I understand is that in a flipped class, I just learned about it recently in this training. It is a combination of kind of self-directed learning by the students where they are given material, they go with it at home, review it, and then they come to class, and you see what they can do. Then either you can correct them or you can guide them, instead of us teaching them the way we are used to teaching in a lecture.” (IDI1)

They noted it was well-suited for clinical skills education and encouraged peer-to-peer learning:

“For medical education, especially if you are teaching clinical skills, I think the flipped class is better than the traditional class that we always have. Because usually, when you’re teaching in the traditional class, we are used to having a class which is completely unaware of the topic, and in that case, you’re teaching them things they’ve never seen or heard.” (IDI1)

“I think in terms of students’ participation, it is more student-centered than teacher-centered, right? And I think because of that, the students take upon themselves the responsibility to learn. They own the learning process and they guide the learning process compared to the lecturing method, where it’s the traditional method where the students are very passive in the process, right?” (IDI3)

Students’ Perception

Students expressed excitement and satisfaction with the flipped simulation model. They highlighted the proactive and hands-on nature of the experience.

“I got more than what I expected. I’m satisfied, and at first I thought it was not going to be this much, but I feel like I’ve gained a lot and I appreciate it.” (FGD1-P6)

“Looking at the flipped classroom as a student, you are allowed to take the lead in the learning. You are provided with materials, so by the time you get to interact with the supervisor, the lecturer, or whatever, you at least have something you know and you are not starting from scratch, and you have an opportunity to engage in discussions that are going to help you in more learning you get.” (FGD2-P5)

“They give you the teaching material, you go back home, you first pick what you have learnt, what you have read, and which videos you have watched. Then they give you the practical materials to use, the sutures, the instruments, the gloves. You try it out at home. In case you fail or you are stuck somewhere, you come back, they correct you.” (FGD1-P5)

Learning Strategies

Students reported using pre-class time effectively for practice and peer-based discussions.

“I think it has had a good influence or a good effect on my learning because I picked up faster than the way I always pick up in class, and it is rare for me to forget what I’ve done twice. In case I didn’t understand, I would ask my partner.” (FGD1-P6)

“I liked this mode of learning because it was group-based, you work in pairs, so you get to know, like you get to relate, like you get to work with a colleague, and that’s any better skill in life.” (FGD3-P2)

“At least everyone was catered for. Each time you have not understood something, you would call them and then they attend to you.” (FGD1-P2)

“Considering that we were doing this exercise under supervision, it was important in that, in case you’re not sure of something, or in case there is a mistake that you’ve made, you can easily be corrected by the senior who is around.” (FGD3-P7)

Benefits of the Flipped Simulation

Active Learning

Participants appreciated the opportunity to engage deeply with hands-on learning.

“In a flipped classroom, I got a chance to have hands-on as many times as I wanted, with minimal interference. That is what I liked about it.” (FGD2-P3)

“What I liked about it was a hands-on experience, other than the other side, where, let’s say in theater, when you’re just observing, and things like, look like rocket science, as though we can’t flip our hands and all that.” (FGD3-P4)

It also encouraged open, two-way interaction between students and facilitators.

“And then the other is that it’s quite very interactive, right? Yeah, interactive. It’s very practical. The course providers are always available to the students, and they move around. It gives a chance for immediate feedback to the students. You get to know how much information the students have retained, and you read these or mistakes, you address them in a timely fashion.” (IDI3)

“It is interactive, and can I say user-friendly? As you learn a lot in a clear environment, like an acceptable environment, nothing is wrong.” (FGD2-P7)

Self-Motivation and Engagement

Students reported increased motivation and ownership of their learning process.

“This mode of learning has affected my learning, or motivated the learning of the course positively, in that we had our supervisors who encouraged us. Many times we want to go for things, but we at times fear or we have that fear, but when we had these experienced people on board, we were motivated by them.” (FGD4-P2)

“Really, other course units should follow up on the same as it builds self-esteem and helps us also to air out our views and gain correction on what we know. And also, some of us don’t like reading a lot. At least seeing those things practically at home motivates us and encourages us to do better and learn better skills.” (FGD1-P3)

“I also think that it would be better for other course units to be taught the same way, because you see when you’re doing hands-on, so you get motivated to read more, to love medicine, move and to look at higher goals in medicine, unlike when you’re in class, just reading and reading and listening and seeing nothing hands-on.” (FGD3-P1)

Skill Acquisition

The flipped simulation was seen as effective for bridging theory with practice and increasing confidence.

“You get to understand something to the depth, not just coming, and it is a unidirectional kind of learning. This is more like a tool where you can have an opportunity to probably also guide, because you have the resources, so you can read through, and there can be room for adjustments, probably depending on what you think. Yeah, so I think it is a very good one.” (FGD2-P5)

“My view is that this exercise, the flipped teaching modules, is important in that it is imparting that necessary skill in the student, and it is imparting that confidence that comes with the skill, in that if someone knows that they have the skill, they will be confident that they can do something using that skill they have acquired.” (FGD3-P7)

Suggestions for Improvement

Curriculum Integration

Both students and instructors recommended broader adoption of the SBFC approach across other course units, especially those with a practical focus. Participants believed that such integration would improve competence and long-term retention.

“I think it’s one of the best approaches I’ve ever seen, because it truly gives you a good experience on things that are being done practically, especially for the practical courses, we expect that at least they would adopt such learning modes, because by the time you finish the module, you feel you have learned something, and you’ve learned a lot, as compared to other modules that we have been using currently, where people just cram things and, you know, attend lectures and that’s all. I think it is a very good one for more practical interaction with your lecturers and with the things that you are always doing in the hospital.” (FGD3-P6)

“I have just realized that we can become better doctors tomorrow, if medicine is to be taught this way. And that is why I also request that if other departments could also catch up with the same spirit of teaching in this way, it would benefit us a lot.” (FGD1-P2)

Instructors suggested using the flipped classroom as a complementary strategy rather than a full replacement, to maximize its benefits while adapting to varied learning contexts.

Planning and Structuring

Participants emphasized the need for deliberate scheduling and time management, noting that the flipped classroom approach demands significant time investment from both students and instructors.

“Yeah, for example. The time duration it takes to teach a skill. I don’t know how we can handle that. Still, it’s a little bit hard for us to handle it without changing the entire system, the entire setup of the skill training, and the flipped classroom method. It is a good method of teaching if facilitated well. Still, I think for it to work very well, it would need quite a bit more resources, especially in terms of staffing in the university, and there should be critical thought through the planning and scheduling process.” (IDI2)

Resource Allocation

There was a strong call for institutional support in staffing and material provision. Increasing the number of facilitators was seen as essential to improve the student-to-instructor ratio and reduce supervision gaps.

“I feel like it may require more resources for the effective utilization of this approach. But for example, when you may be doing a practical on how to repair operations of the bowel. You may need to buy those samples and so many other things that may be required for the student to practice. And so it might turn out to be a bit costly for you to get the required resources.” (IDI2)

Standardization of Teaching Techniques

The variability in technique demonstrated by different instructors during in-class sessions was seen as a source of confusion. Students suggested that pre-session consensus meetings among instructors could help ensure a unified approach.

“For example, let me say the hand noting technique, like you find all the different supervisors have their different ways of doing a note. I feel if they had agreed on which technique we should deliver to the students, that would not confuse the students. I feel that would be a better way of making the student not have bias against which, maybe a lecturer, maybe some student, maybe like I feel that this lecture is better than this one. I should take that skill, so I feel that’s, yeah, that’s what can be done better.” (FGD1-P6)

Introducing Assessment

To enhance accountability and encourage preparation, both instructors and students proposed the introduction of assessment components linked to SBFC modules.

“One of the motivating things is like, you can tell the students about a test, for example, this topic may contribute to maybe your mark, which can encourage the students. They know that once I go back, before I do anything else, they are going to examine me on this.” (IDI1)

Discussion

From the qualitative results, both students and instructors viewed the flipped simulation model as a novel and learner-centered approach. Instructors appreciated the shift from traditional didactic teaching to a facilitative role, where students come to class prepared and actively participate in skill-building activities. This is consistent with the principles of flipped learning, which emphasize student autonomy, active engagement, and pre-class preparation to enhance in-class learning outcomes.^18,19 Instructors noted that flipped learning is particularly suited for skill-based learning, such as clinical procedures, where observation, practice, and feedback are crucial.

From the students’ perspective, the flipped simulation is a “fantastic” and “engaging” approach. They appreciated having access to learning materials ahead of time and felt that this empowered them to lead their learning. This aligns with earlier findings that flipped classrooms foster self-directed learning and allow learners to control the pace of content acquisition.^20,21 Although improvised, the pre-class practice with suturing materials allowed learners to build foundational understanding before formal class sessions, promoting more effective use of in-class time. It can then be generally said that the flexibility of accessing pre-class learning materials such as: pre-recorded videos, selected literature, etc., allowed students to learn at their own pace, aligning with self-regulated learning (SRL) theories. According to Zimmerman,²² SRL enables students to plan, monitor, and evaluate their learning behaviors facilitated by the asynchronous nature of flipped content. In our study, students valued the ability to rewind and review steps multiple times, a privilege not commonly afforded during traditional in-person demonstrations.

The major benefits identified included active learning, enhanced skill acquisition, high student engagement, and simplified instruction. The more pronounced hands-on nature of the flipped simulation ensured that learners had multiple opportunities to observe, practice, and refine their techniques. Students reported that this approach made it easier to transition from theoretical understanding to practical execution—a key goal in procedural skill training.²³ This is further reinforced by the cognitive load theory in the way that pre-class conceptual understanding of core principles separated from psychomotor practice reduces the working load, hence freeing up more working memory for skill acquisition.^24,25 This sequencing was evident in students’ descriptions of how conceptual clarity enhanced their ability to focus on hand movements, angles, and knot technique during simulations.²⁶

Flipped simulation also provided an interactive and low-pressure learning environment, an idea that has been identified in other studies as a key positive learning environment pillar.²⁷ This perception demonstrates the significance of student preparation before class, and its impact on their ability to engage their facilitators in academic discussions in which there is no judgment or reprimand but rather mentorship and nurturing. Students noted the value of immediate feedback and peer-to-peer learning, echoing earlier studies that highlight the role of social interaction and feedback in simulation-based education.^28,29 The collaborative nature of the training promoted mutual support, motivation, and a sense of ownership over learning, a core outcome desired in modern competency-based medical education (CBME) frameworks.

Instructors also acknowledged that flipping the classroom simplified instruction by allowing students to enter class with a foundational knowledge base. This freed up class time for targeted feedback, concept clarification, and skill reinforcement. This finding supports studies by O’Flaherty and Phillips (2015), who reported that flipped learning can improve faculty efficiency and reduce the need for repetitive, passive lectures.³⁰

One of the most striking outcomes was the students’ increased confidence in performing suturing skills. Learners expressed that repeated exposure to suturing techniques—both at home and in class—helped demystify procedures that previously seemed intimidating. This confirms earlier reports that flipped simulation improves psychomotor skills by offering repeated, low-stakes practice.^31,32 The multisensory nature of the flipped simulation—engaging sight, touch, and hearing—was also noted as an enhancer of comprehension and retention.

Furthermore, student narratives revealed that the flipped simulation promoted deep learning by encouraging critical reflection and repeated engagement with the content. As students were responsible for reviewing the materials, practicing independently, and participating in group-based skills sessions, this pedagogy effectively supported adult learning principles,³³ including self-direction, relevance, and experiential learning.

Despite the positive feedback, participants identified several significant challenges to implementation. The most prominent was time demand. Preparing, engaging with pre-class content, and attending practical sessions proved time-consuming for both students and instructors. This echoes similar challenges reported in the literature,^19,30 where the flipped model has been critiqued for increasing the preparatory workload. This moves hand in hand with its impact on other competing academic requirements, hence the potential for scheduling conflict in academic programs.

Resource constraints were another major issue. The number of available instructors was insufficient relative to the number of students, leading to limited individualization of supervision. This limited instructor-to-student ratio has been previously reported as a barrier in simulation-based learning environments.⁶ Well as the flipped class has been known to facilitate learning even where there is limited human resource coverage by depending much on student activity during pre-class learning, it should also be remembered that in-class demand for small group supervision requires the exact opposite: more instructors. In this study, the use of improvised materials, such as bananas and porcine skin, introduced a short-term remedy to logistical difficulties. While improvisation is often necessary in low-resource settings, material inconsistency can affect the fidelity and effectiveness of simulation³⁴ as reported by students.

Technological access also posed a barrier, as some students lacked stable internet connections or appropriate devices for accessing pre-class materials. Such challenges have been highlighted in global medical education literature as potential inequities that can hinder the effectiveness of flipped models, especially in low- and middle-income countries.³⁵

Instructor variability in surgical technique was another concern. Students were exposed to different methods by different instructors, leading to confusion and academic debates. While exposure to variations can enrich learning, excessive inconsistency may lead to uncertainty in early learners. This highlights the need for standardized instructional protocols and alignment among instructors in delivering procedural skills training.³⁶

Finally, individual student factors, such as lack of motivation or poor time management, were reported as limitations to effective engagement. The success of flipped learning hinges on student responsibility and pre-class preparation.³⁷ Students who skipped this phase struggled during the in-class sessions, emphasizing the importance of instilling self-regulated learning skills in medical training. In this perspective, several studies have emphasized the role of pre-class assessment quizzes to motivate learners towards self-regulation and pre-class engagement.⁹ This study underscores the potential of flipped simulation-based learning to improve clinical skill acquisition, especially in resource-constrained environments. It presents a promising approach for improving engagement, ownership, and competence among learners. However, its implementation must be supported with adequate planning, instructor training, resource investment, and technological infrastructure. To enhance consistency, educators should consider developing standardized, evidence-based instructional material and aligning faculty on key procedural steps. The study also suggests that flipped models can be adapted for other clinical skills beyond suturing, fostering a broader shift toward active, student-centered medical education.

Recommendations

Institutional Integration: Medical schools should consider formally integrating flipped simulation approaches into clinical skills curricula, particularly in disciplines such as surgery, obstetrics and gynecology, and internal medicine. Doing so can enhance engagement, autonomy, and performance.

Standardization of Instructional Content: Developing standardized instructional protocols and harmonizing teaching techniques among faculty can minimize confusion and support consistency in procedural skills training.

Faculty Development: Regular orientation and training workshops for instructors are essential to familiarize them with flipped learning principles, technology use, and student-centered facilitation strategies.

Investment in Resources: Institutions should prioritize the provision of adequate practice materials and increase the number of facilitators to maintain optimal student-to-instructor ratios. Improvisation may be necessary but should not compromise fidelity.

Incorporation of Formative Assessments: Pre-class quizzes or short assessments can motivate students to engage with materials and support the development of self-regulated learning behaviors.

Technology Support: Universities should improve access to affordable devices and stable internet to ensure equity in learning opportunities and access to flipped content.

Study Limitations

Due to logistical limitations, the study relied on improvised materials, which may not fully replicate the realism of high-fidelity simulation environments.

The intervention was focused on suturing skills only; different outcomes may emerge with other clinical procedures.

Suggestions for further research

Longitudinal Follow-Up: Exploring how students apply the skills learned via SBFC in clinical rotations and internships could provide insights into the long-term impact on competence and patient care.

Adaptation for Other Disciplines: Investigating the use of flipped simulations in other procedural areas (e.g., catheterization, delivery skills, basic life support) could extend the model’s utility across the medical curriculum.

Faculty Experience and Adaptation: Future qualitative inquiries could focus more deeply on instructors’ long-term adaptation, perceived workload, and pedagogical satisfaction following repeated SBFC implementations.

Conclusions

The findings reveal that the SBFC approach is a novel, engaging, and effective model for clinical skills training. Students appreciated the opportunity to engage with materials at their own pace before class, which facilitated active participation, skill mastery, and self-directed learning. Instructors, on the other hand, valued their transformation from content deliverers to learning facilitators—a shift aligned with pedagogical frameworks of this century. The flipped simulation approach promoted hands-on practice, peer interaction, and critical reflection, enhancing psychomotor competence, learner autonomy, and confidence. It created an inclusive, low-pressure learning environment that encouraged immediate feedback, mentorship, and experiential learning. However, implementation challenges such as time constraints, limited resources, technological barriers, and variability in instructional methods were noted. Despite these obstacles, the study affirms that SBFC holds considerable promise for transforming procedural skills education in low-resource settings and aligning medical training with competency-based and adult learning principles.