Nurse Education in Practice 26 (2017) 126e133

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Original research

Transitioning a bachelor of science in nursing program to blended

learning: Successes, challenges & outcomes
Laurie Posey*, Christine Pintz
The George Washington University School of Nursing, 2030 M Street, NW, Suite 300, Washington, DC, 20036, USA

a r t i c l e i n f o a b s t r a c t

Article history: To help address the challenges of providing undergraduate nursing education in an accelerated time
Received 22 September 2014 frame, the Teaching and Transforming through Technology (T3) project was funded to transition a
Received in revised form second-degree ABSN program to a blended learning format. The project has explored the use of blended
4 March 2016
learning to: enable flexible solutions to support teaching goals and address course challenges; provide
Accepted 17 October 2016
students with new types of independent learning activities outside of the traditional classroom; increase
opportunities for active learning in the classroom; and improve students' digital literacy and lifelong
Keywords:
learning skills. Program evaluation included quality reviews of the redesigned courses, surveys of student
Undergraduate nursing education
Blended learning
perceptions, pre- and post-program assessment of students' digital literacy and interviews with faculty
Hybrid course design about their experiences with the new teaching methods. Adopting an established quality framework to
Active learning guide course design and evaluation for quality contributed to the efficient and effective development of a
Online education high-quality undergraduate blended nursing program. Program outcomes and lessons learned are pre-
sented to inform future teaching innovation and research related to blended learning in undergraduate
nursing education.
© 2016 Elsevier Ltd. All rights reserved.

Students enrolled in Accelerated Bachelor of Science in Nursing
(ABSN) programs complete a challenging curriculum within a
compressed time frame. Instructors must make optimal use of
teaching and learning time to equip students with a broad base of
nursing knowledge and the clinical reasoning skills needed to
provide safe, effective care to people with diverse healthcare needs.
Blended teaching methods, which combine online and face-to-face
instruction with classroom and clinical experiences, expand the
nursing instructor's toolkit of teaching strategies and give them
flexibility to address curricular objectives in more innovative and
effective ways.
The Teaching and Transforming through Technology (T3) project
was funded to transition a second-degree ABSN program to
blended learning. The project explored the use of blended learning
to: (1) enable flexible solutions to address course goals and chal-
lenges; (2) provide students with new independent learning ac-
tivities outside of the traditional classroom; (3) increase
opportunities for active learning and critical thinking in the class-
room; and (4) improve students' digital literacy and lifelong
* Corresponding author.
E-mail addresses: posey@gwu.edu (L. Posey), cpintz@gwu.edu (C. Pintz).
learning skills. The nursing faculty took the lead in redesigning
their courses, with guidance from instructional design and multi-
media staff. The resulting program includes ten blended and five
fully online courses. This paper shares the outcomes of a program
evaluation that examined the quality of the blended courses, stu-
dents’ digital literacy skills before and after participating in the
program, and student and faculty perceptions of the blended
learning experience.
1. Background
Blended learning is emerging as a popular teaching approach in
nursing education. A comprehensive literature search revealed
forty-six papers published between 2004 and 2014 specifically
focused on blended learning in undergraduate nursing education.
The majority of these studies examined students’ perceptions and/
or performance related to the introduction of blended learning
strategies within individual courses. Only three studies reported
outcomes of blended learning implementation at the program level
(Davidson et al., 2011; Robinia et al., 2012; Houldson, 2009). Thus,
although many nursing educators have explored the effectiveness
of blended learning strategies, the number of fully blended nursing
programs appears to be limited.

http://dx.doi.org/10.1016/j.nepr.2016.10.006
1471-5953/© 2016 Elsevier Ltd. All rights reserved.
 L. Posey, C. Pintz / Nurse Education in Practice 26 (2017) 126e133
There is evidence to support broader adoption of blended ap-
proaches throughout the nursing curriculum. At the program level,
Davidson et al. (2011) found improved graduation rates after
transitioning a BSN program to a blended format. Graduates’ critical
thinking scores were comparable to traditional students at the
same school and higher than the national average. Seventy-five
percent of graduates rated their experience as very good or excel-
lent. Robinia et al. (2012) demonstrated improved satisfaction and
attrition rates, with no significant difference in certification pass
rates, after transitioning an undergraduate nursing certificate
program to a blended format. Similarly, Houldson (2009) compared
the final examination scores, certifying exam scores, and satisfac-
tion of students graduating from traditional and blended nursing
programs and found no significant differences.
When compared to traditional approaches, blended learning
appears to be equally and in some cases more effective that tradi-
tional methods in improving student learning and performance.
For example, nursing students in a blended group had significantly
higher levels of medication administration knowledge than nurses
in a face-to-face group, with no significant difference found in
medication administration self-efficacy and ability (Sung et al.,
2008). Several other studies have compared blended learning in-
terventions to traditional approaches and found no significant
differences in learner performance (Mehrdad et al., 2011; Kelly
et al., 2009; Parker et al., 2011). Research has also demonstrated
significant increases in learners' knowledge scores after completing
blended courses (Cho and Shin, 2014; Jang et al., 2006). In addition,
Hsu and Hseih (2011a) found that nursing students’ demonstrated
significantly higher self-reported reasoning, decision-making and
metacognition after completing a blended course.
Across the studies reviewed, student perceptions and satisfac-
tion with blended learning were positive (Donato et al., 2010; Hsu,
2012; Jang et al., 2006; Koch et al., 2010; Green et al., 2006; Lyons
and Evans, 2013; Mahoney et al., 2005; Salamanson and Lantz,
2005). For example, Mahoney et al. (2005) introduced online dis-
cussion activities into a traditional, face-to-face psychiatric nursing
course. When surveyed, a majority of students expressed a pref-
erence for blended learning. In a similar study, 81% of 123 under-
graduate nursing students believed the web-based portions of a
blended learning course enhanced their learning and 72%
expressed a desire for web-based components in all of their courses
(Koch et al., 2010).
The most commonly noted benefit of blended learning is flexi-
bility. Students appreciate convenient, on-demand access to online
materials and discussions, and the ability to study at their own pace
(Donato et al., 2010; Drozd & O'Donoghue, 2007; Ireland et al.,
2009; Koch et al., 2010). They also view supplemental online ma-
terials as helpful in preparing for class and for review purposes
(Green et al., 2006). These findings lend support for Hsu and Hseih's
(2011a) observation that blended learning contributes to learners'
metacognitive and self-regulatory development. Notably, the need
for independent learning has been identified as a concern among
students who also placed high value on instructors' facilitation of
learning (Rigby et al., 2012). Blended learning places more re-
sponsibility on the student, which can contribute to a perception of
increased workload (Hsu, 2012).
Students have also reported that online activities such as
asynchronous discussions are beneficial in fostering deeper
reflection, critical thinking, active learning and problem-solving
skills (Donato et al., 2010; Hsu and Hseih 2011a). This is sup-
ported by a study of learner activity within the online portions of a
blended course that demonstrated a link between active partici-
pation and learner performance (Ransdell and Gaillard-Kenney,
2009). Similarly, Hsu and Hseih (2011b) found frequency of on-
line dialogue and time spent on Internet to be predictors of learning
127
outcomes. In contrast, Green et al. (2006) did not find a relationship
between student performance and frequency of online module use.
Although many students value the online components of
blended learning, some have also expressed a desire to maintain
traditional, face-to-face lectures (Koch et al., 2010). Mehrdad et al.
(2011) compared nursing students’ views of online and lecture
methods within the same course, and found that student ratings for
the online approach were significantly higher for “capability” (i.e.,
the ability to use the tools and learn using the method) and
“independency” (i.e., the ability to self-direct their learning); and
significantly lower for “effectiveness” (i.e., degree to which the
method fostered learning) and “motivation” (i.e., eagerness to
learn). The authors noted that students were in their third semester
and had become accustomed to the lecture method, and recom-
mended careful design of online components to enhance learner
engagement and motivation. In another study, student ratings of
preference for hybrid vs. traditional formats were mixed, with
some students indicating a preference for both formats
(Salamonson and Lantz, 2005).
There is good evidence to support continued adoption of new
teaching approaches that combine online and face-to-face modal-
ities to augment lecture-style teaching, promote learner self-
direction, and increase opportunities for active learning in under-
graduate nursing education. Successful implementation of high
quality blended learning courses and programs requires careful
planning and instructional design to ensure learning effectiveness
and support students’ transition to new approaches to teaching and
learning. Sharing outcomes and lessons learned from the evalua-
tion of a newly transitioned blended nursing program can inform
future teaching innovations and research.
2. Research methods
In order to determine whether the T3 project led to program
improvements, the evaluation consisted of four components:
quality ratings by peer reviewers of the blended and online courses
according to Quality Matters (QM) standards (Quality Matters
Program, 2011); pre- and post-program assessment of students’
digital literacy skills using the iSkills™ Information and Commu-
nication Technology (ICT) literacy assessment (Educational Testing
Service, 2005); assessment of student perceptions of the blended
learning experience; and interviews with faculty to obtain their
perceptions about teaching in a blended format. All components of
the study involving human subjects were approved as exempt by
the University Institutional Review Board.
2.1. QM reviews
Peer reviews of the blended and online courses were conducted
using QM, a well-established rubric and process for assessing the
quality of the online and blended course design. The QM standards
were developed by Maryland Online, a consortium of post-
secondary institutions in the state of Maryland, U.S., through a
grant from the U.S. Department of Education's Fund for the
Improvement of Post Secondary Education. The standards were
derived from the literature, with input from experienced practi-
tioners. The reviews were conducted using the 2011e2013 edition
of the QM rubric, which included 41 standards organized in eight
categories: Course Overview and Introduction, Learning Objectives,
Assessment and Measurement, Instructional Materials, Learner
Interaction & Engagement, Course Technology, Learner Support
and Accessibility. Of the 41 specific standards, 21 were considered
essential and required in order for the course to achieve QM
certification.
The QM peer reviews were part of the overall program planning
128 L. Posey, C. Pintz / Nurse Education in Practice 26 (2017) 126e133
and course design process. Faculty were oriented to the rubric up
front and guided by an instructional designer to incorporate the
standards into the blended course designs. Standard syllabus and
course templates that included required QM components, such as
learner orientation and support information, were also developed.
Eight blended and five fully online courses were officially
reviewed according to QM guidelines. Because the QM standards
focus on online components, two courses that made limited use of
online learning were not reviewed. The remaining thirteen courses
were reviewed by three-person teams of QM-certified reviewers
that included a chair, a subject-matter expert and a reviewer from
outside of the institution. The reviews were administered online
through QM's course review management system.
2.2. Digital literacy assessment
Students completed an ICT literacy assessment from the
Educational Testing Service (ETS) called iSkills™ during their first
and last semesters of the program. The goal of this evaluation was
to determine whether the increased use of online technologies
throughout the blended program would have a positive impact on
students’ digital literacy. iSkills™ is an outcomes-based assessment
in which students complete a series of scenario-based questions
that demonstrate their ability to evaluate the adequacy of data;
create, adapt or communicate information using technology; and
integrate data from a variety of sources to achieve specified goals
(ETS, 2005). All of the seventy-one students enrolled in the
2011e2012 cohort and forty-eight students enrolled in the
2012e2013 cohort were asked to complete the exams. Of these,
sixty-four from the first cohort and thirty-two from the second
cohort consented to participate in the study and completed the
exams. Students completed the assessments in a proctored
computer-lab environment.
The iSkills™ assessment was developed by a team of specialists
who subjected the assessment to a variety of reviews at different
stages of development to produce a valid and reliable assessment of
ICT literacy. These reviews included small-scale usability studies
and larger scale field trials involving 6345 students and sixty-three
institutions. The estimated reliability (Cronbach alpha) of iSkills™
across various administrations was 0.88 (Katz, 2007).
2.3. Student perceptions
The first component of the student perception evaluation came
from an alumni survey sent to all students who graduated from the
program in 2013. The survey included an item that asked students
to rate different teaching modalities, (i.e., classroom instruction,
online instruction, simulation lab, clinical experiences and indi-
vidual mentoring from faculty) as very valuable, valuable, some-
what valuable or not valuable.
The second component of the student perception evaluation
focused on student experiences related to several new teaching
modalities that were introduced in some of the blended courses.
For the first activity, flipped classroom with role-play, students
reviewed online materials to learn about communication skills, and
then participated in scenario-based role-plays in the classroom. The
second activity, guided preparation for case-based learning, involved
carefully constructed online materials and activities followed by
instructor-facilitated problem-based learning in an open-classroom
environment. For the third activity, collaborative wiki with class
discussion, students worked together using a wiki to first build a
clinical case and then apply the nursing process to it. Groups then
shared their results in an interactive class discussion. The fourth
activity, interactive worksheet with class discussion, included an
online study guide with embedded links to different online
resources, followed by an active learning activity in the classroom.
Each of the blended learning activities was implemented within
a different course and involved three different cohorts of students.
One cohort of 54 students participated in the flipped classroom with
role-play activity. A second cohort of 44 students participated in the
collaborative wiki with class discussion activity. A third cohort of 34
students participated in the guided preparation for case-based
learning and interactive worksheet with class discussion activities.
All students were invited to complete a survey that asked them to
rate their experience with each activity. The survey asked students
to indicate their level of agreement on a 5 point Likert scale item,
where 1 ¼ strongly disagree and 5 ¼ strongly agree, for five
statements:
 The learning activity was engaging.
 The learning activity was an effective way for me to learn.
 The learning activity made good use of my personal study time.
 The learning activity made good use of my classroom time.
 The learning activity promoted interaction and collaboration.
These survey items were developed based on a review of the
literature related to blended learning, which emphasizes the
importance of optimizing the use of online and classroom time to
maximize learning (Garrison and Vaughan, 2008), and posits that
blended teaching strategies can promote learner engagement,
interaction and collaboration (McLaughlin et al., 2013; Pluta et al.,
2013). The survey was intended to be formative, gathering infor-
mation about how well each blended strategy achieved these
educational benefits to inform faculty practice. It was not reviewed
by experts or pilot tested. This formative portion of the evaluation
took place during course implementation, prior to the Quality
Matters reviews.
2.4. Faculty perceptions
The instructors who participated in the interviews were
selected based on their involvement in the design and imple-
mentation of the four different blended strategies that were
formatively evaluated for this study. Six faculty members were
interviewed by phone and were asked to describe their observa-
tions and experiences with redesigning their courses to integrate
the new blended learning approaches. Participants were all female,
ranging in age from 35 to 73. Participants included 3 senior faculty
members, with 16e50 years of teaching experience, and 3 less
experienced educators who had been teaching for 5e6 years. All
participants were experienced clinicians, with 13e40 years of
clinical experience. All of the instructors who were asked to
participate agreed to do so. Faculty perceptions of blended learning
were analyzed using a descriptive qualitative method (Neergaard
et al., 2009) to identify themes related to each of the structured
interview questions. Transcripts were reviewed and faculty per-
ceptions were categorized by themes that emerged across these
categories while synthesizing faculty comments.
3. Results
3.1. QM reviews
Twelve of the thirteen courses reviewed met the standards to
achieve QM certification. One of these courses required a formal
amendment process in order to achieve recognition. The one course
that did not meet the standards was subsequently removed from
the ABSN curriculum for reasons unrelated to the QM review, and
therefore was not amended. Table 1 lists the courses that were
converted to blended learning, the scores achieved by each course,
 L. Posey, C. Pintz / Nurse Education in Practice 26 (2017) 126e133 129

Table 1
QM™ course review outcomes.

Course name Format Review outcome Score* Date

Transition to the nursing profession Blended Met Standards 1st Review 93 7/31/13
Health assessment Blended Met Standards 1st Review 92 8/6/13
Adult/aging acute & chronic illness Blended Met Standards 1st Review 92 8/15/13
Adv adult medical-surgical nursing Blended Met Standards 1st Review 93 4/30/14
Maternity and women's healthcare Blended Met Standards w/Amendment 85 1/11/13
Psychiatric mental-health nursing Blended Met Standards 1st Review 95 10/22/13
Epidemiology & community health Blended Met Standards 1st Review 95 6/6/14
Children and families Blended Met Standards 1st Review 92 4/17/14
Patient safety & health care quality Online Met Standards 1st Review 93 2/15/13
Theoretical foundations in nursing Online Did Not Meet Standards 68 N/A
Nursing leadership Online Met Standards 1st Review 95 2/6/13
Health information and technology Online Met Standards 1st Review 93 6/29/14
Research methods for health Prof. I Online Met Standards 1st Review 93 6/11/13

*Total possible points ¼ 95.

whether the QM standards were met, and the date that each course
achieved formal QM recognition. Of the courses that met standards,
three courses achieved perfect scores of 95 out of a possible 95
points; four achieved 93 points; 3 achieved 92 points; and one
achieved 85 points. The course that did not meet standards ach-
ieved 68 points. A total of 81 points was needed to achieve
certification.
3.2. Digital literacy assessment
Student pre- and post-test scores on the iSkills™ assessments
were estimated using paired-samples T-tests. For the first cohort of
64 students, mean scores decreased from pre-test (M ¼ 274.7,
SD ¼ 78.92) to post-test (M ¼ 263.9, SD ¼ 84.15), t ¼ 1.455, df ¼ 63,
p ¼ 0.15. For the second cohort of 32 students, mean scores
increased from pre-test (M ¼ 285.31, SD ¼ 66.04) to post-test
(M ¼ 296.88, SD ¼ 72.58), t ¼ -.97, df ¼ 31, p ¼ .34. The results of
these analyses were not statistically significant.
collaboration (M ¼ 4.22, SD ¼ 0.60), and lowest for good use of
personal study time (M ¼ 4.01, SD ¼ 0.65). The overall mean ratings
for the other categories were as follows: learner engagement
(M ¼ 4.16, SD ¼ 0.63), learning effectiveness (M ¼ 4.15, SD ¼ 0.60),
and use of classroom time (M ¼ 4.09, SD ¼ 0.69). There was little
difference in the overall ratings among the activities, with mean
ratings of 4.22 for the flipped classroom with role-play activity, 4.19
for the guided preparation for case-based learning activity, 4.12 for
the collaborative wiki with class discussion activity and 3.95 for the
interactive worksheet with class discussion activity. Fig. 1 illustrates
students’ perceptions related to the effectiveness of each learning
activity.
3.4. Faculty perceptions
There were several themes that emerged from the analysis of
the interviews.

3.3. Student perceptions 3.4.1. Increased opportunity for active learning

All of the student survey responses were analyzed using
descriptive statistics. The graduate survey was sent to 48 students
and had a 75% response rate (N ¼ 36). All of the students found the
classroom instruction very valuable or valuable, while 67% of stu-
dent found the online instruction valuable or somewhat valuable.
The majority of the students found clinical experiences, simulation
and individual faculty mentoring very valuable. Table 2 depicts the
percentage of students who rated each instructional modality as
very valuable, valuable, somewhat valuable or not valuable.
Response rates for the second set of surveys measuring student
satisfaction with specific blended learning activities are summa-
rized in Table 3. The mean student ratings related to each survey
item for each blended learning activity are presented in Table 4.
Overall, students rated all of the activities favorably for all of the
different items. For the question related to learning effectiveness,
the overall mean rating was 4.15, Students' combined ratings of the
blended activities were highest for promoting interactivity and
One theme was the increased opportunity for active learning
within the face-to-face component of the class. In addition to
freeing up classroom time, preparing students with foundational
knowledge in advance of class set the stage for learning experiences
that prepared them for nursing practice. As one faculty member
noted:
One of the biggest benefits is that students come to class pre-
pared to engage. When you have students that are prepared, it
enables richer dialogue because students know what they are
talking about e or if they are off base, you have the opportunity
to clarify misperceptions. It opens the door to moving away
from passive, lecture-based teaching to new pedagogical
methods.
Ensuring that students come to class prepared to participate in
these active learning experiences was also a commonly noted
challenge. As one faculty member noted:

Table 2
Students' perceived value of different instructional modalities (N ¼ 36).

Instructional modality Very valuable Valuable Somewhat valuable Not valuable

Classroom instruction 57% 43% 0% 0%

Online instruction 0% 37% 30% 33%
Clinical experiences 77% 20% 3% 0%
Simulation lab 53% 30% 17% 0%
Individual mentoring from faculty 60% 27% 7% 7%
130 L. Posey, C. Pintz / Nurse Education in Practice 26 (2017) 126e133

Table 3
Student response rates for blended learning activity surveys.

Strategy Total students Completed surveys Response rate

Flipped classroom with role play 54 37 69%

Collaborative wiki with class discussion 44 23 52%
Guided preparation for case-based learning 34 27 79%
Interactive worksheets with Class discussion 34 26 76%

Table 4
Students perceptions of blended learning activities.a

The learning activity… Flipped classroom with Guided preparation for case- Collaborative wiki with class Interactive study guide with class Combined
role- play (N ¼ 37) based learning (N ¼ 27) discussion (N ¼ 23) discussion (N ¼ 26) (N ¼ 113)

Was engaging. M ¼ 4.24 M ¼ 4.37 M ¼ 4.22 M ¼ 3.81 M ¼ 4.16

SD ¼ 0.60 SD ¼ 0.63 SD ¼ 0.67 SD ¼ 0.49 SD ¼ 0.63
Was an effective way to M ¼ 4.24 M ¼ 4.19 M ¼ 4.22 M ¼ 3.92 M ¼ 4.15
learn. SD ¼ 0.55 SD ¼ 0.74 SD ¼ 0.67 SD ¼ 0.39 SD ¼ 0.60
Made good use of my M ¼ 4.00 M ¼ 4.00 M ¼ 3.96 M ¼ 4.08 M ¼ 4.01
personal study time. SD ¼ 0.75 SD ¼ 0.62 SD ¼ 0.64 SD ¼ 0.56 SD ¼ 0.65
Made good use of M ¼ 4.19 M ¼ 4.07 M ¼ 4.04 M ¼ 4.04 M ¼ 4.09
classroom time. SD ¼ 0.66 SD ¼ 0.73 SD ¼ 0.70 SD ¼ 0.72 SD ¼ 0.69
Promoted interactivity & M ¼ 4.41 M ¼ 4.30 M ¼ 4.17 M ¼ 3.92 M ¼ 4.22
collaboration. SD ¼ 0.55 SD ¼ 0.72 SD ¼ 0.57 SD ¼ 0.48 SD ¼ 0.60
a
Scale: 1¼Strongly Disagree to 5¼Strongly Agree.

the case studies. One faculty member observed:

Students had an opportunity to practice, make mistakes, and
learn from their instructors as well as other students.

Another faculty member stressed the importance of real-time

interaction between faculty and students in moving students to-
ward deeper levels of learning. In her opinion:
The instructor's presence is most valuable in guiding, modeling
& scaffolding higher-order learning in real time/face-to-face
environment.

She described the faculty role this way:

Freeing classroom time for case-based learning allowed for
ongoing, real-time assessment of learning challenges related to
problems core conceptual understanding; weak areas where
more than one student is struggling showed up.
Fig. 1. Perceived learning effectiveness of blended learning activities.

Another strategy used was role play, which provided an op-

portunity to practice communication techniques and gain under-
You need to emphasize importance of coming prepared to class
standing of the patient's situation.
ahead of time; for some students it boils down to coming un-
prepared and being embarrassed. Putting them in the role of the patient raised their empathy
more than if they were just sitting there taking notes. e expe-
rienced what it might feel like to be in the situation of not un-
One of the more common active pedagogical methods adopted
derstanding what on earth was going on.
was case based learning. Several of faculty members commented
on the value of challenging students to apply new knowledge and
skills to real-world situations. In describing the benefit of this
3.4.2. Instructor’s role
approach, one of the more experienced faculty members stressed
A second theme focused on the importance of the instructor's
the importance of case study selection, stating:
role in preparing materials and planning the blended learning
Authentic case-study examples provided the foundation for experience. As one faculty member stated:
successful active learning. Cases were real world e all situations
Successful implementation of blended learning strategies re-
that they are likely to confront e hopefully students will be able
quires careful preparation by the instructor and is more time
to make real application of it in the clinical setting.
consuming than preparing a traditional lecture.

Several of the faculty emphasized the value of interaction

Another faculty member commented on the importance of
among faculty and peers that occurred while working together on
allowing adequate time for this new level of up-front planning:
 L. Posey, C. Pintz / Nurse Education in Practice 26 (2017) 126e133
Everything takes much longer than you think: securing an
innovative classroom setting, selecting the right online mate-
rials, recording lectures, and careful planning of classroom ac-
tivities that will maintain students' interest for two hours.
Faculty also recognized how more thoughtful planning
contributed to a positive learning experience. For example, one of
the faculty members who took extra steps to secure an open-
classroom setting noticed marked improvement in learner
engagement:
Student engagement and attention was very strong, primarily
due to the innovative classroom environment. It was harder for
students to hide or be lost, and there was more generalized
participation. Lecture was interspersed with questions and
discussion, which had a positive influence on student attention.
3.4.3. Learner motivation and participation
A third theme focused on learner motivation and participation
during the online, self-directed portions of the blended experience.
One faculty member pointed out the value of the blended approach
in building students’ independent study skills, stating:
New concepts challenged students to do independent research
and developed lifelong learning and nursing skills.
Faculty also noted that there was learner resistance to the new,
blended format.
Some students look at self-directed learning as faculty not doing
their job.
Faculty also reported that students appreciated the online
components:
Online materials are better than straight reading e some stu-
dents reported learning better from narrated lectures because
they are audiovisual learners. One student felt like lecturer was
with her the whole time (listening to lectures online).
4. Discussion
This program evaluation revealed both benefits and challenges
associated with transitioning a traditionally face-to-face ABSN
program to a blended format. Establishing the QM quality frame-
work early on, as a basis for course design and evaluation,
contributed to an efficient and effective transition process that ul-
timately led to QM recognition of all but one of the blended courses.
In addition to quality assurance, early adoption of the QM standards
led to the establishment of a consistent syllabus and template for
the online portion of the courses. The nursing faculty, most of who
had never taught online before, had a checklist of elements to
consider when revising their courses. With guidance from
instructional designers and support from multimedia staff, faculty
members were able to take the lead in designing and developing
the blended courses. The opportunity and decision to approach the
redesign of all courses in the program in a systematic and holistic
manner resulted in a high-quality blended program. Other authors
have reported similar success in using the QM framework to guide
course design (Bogle et al., 2009). To ensure a holistically high-
quality blended learning program, these authors recommend
complementing QM, which focuses purely on design, with the
Community of Inquiry (COI) framework, which addresses the
131
processes of teaching and learning. The COI framework emphasizes
the interaction among cognitive presence, social presence and
teaching presence in creating an effective learning community
(Garrison et al., 2001). Although our project did not apply the COI
framework systematically, the prominence of active learning ex-
periences characterized by high degrees of critical thinking and
faculty and student interaction, as evidenced by the student sur-
veys and faculty interviews, are consistent with this model.
It is important to note that the QM standards, although intended
specifically for the review of the online portions of the blended
courses, are grounded in solid principles of instructional design. For
example, course and lesson-level learning objectives, learning ac-
tivities and assessments must be aligned in order for a course to
achieve QM recognition. Thus, the QM-based redesign and quality
assurance process went beyond the assessment of online course
components and provided for a fresh look at the curricular integrity
of each course in the program. The review process also allowed
faculty to receive constructive feedback and the opportunity to
improve their courses.
The iSkills™ assessment of students' ICT literacy skills before
and after participating in the program was inconclusive and did not
support the premise that the increased exposure to technology
afforded by participation in a blended program would improve
students' digital literacy skills. This finding may be related to the
age of our students who were probably technology literate when
they entered the program. iSkills™ categorizes scores into three
levels: developing ICT literacy (score range100e220), foundational
ICT literacy (score range 230e310), and advanced ICT literacy (score
range 320e500) (Educational Testing Service, 2016). Students’
mean scores were at the high end of the foundational level on both
the pre- and post-tests for both cohorts. It is evident that students
entered the program with a moderately high level of ICT literacy.
This is an important finding because it indicates that our students
had the requisite technology skills to be successful in the blended
learning program, and left the program prepared to use technology
effectively in the workplace and for lifelong learning.
The results of the student perception surveys highlight the
importance of educating nursing students using a mix of instruc-
tional modalities. While fewer graduates of our program perceived
the online components of the blended program to be as valuable as
other forms of in-person instruction, they did rate specific blended
learning activities positively. Given that students rated the specific
active-learning oriented blended activities highly, and that a high
percentage of our graduates rated the classroom, simulation lab
and clinical experiences as valuable or highly valuable, it is likely
that they valued more active learning opportunities with clear
relevance to clinical practice. This premise is supported by a study
of student satisfaction with a “flipped classroom” approach, in
which graduate-level nursing students completed prework and
came to class prepared to participate in case-based collaborative
learning experiences (Critz and Knight, 2013). In this study, 85% of
students agreed that the classroom activities were either worth-
while or very worthwhile.
Eliciting faculty observations and experiences allowed them to
reflect on the impact of new teaching approaches and to examine
the benefits and challenges of using blended learning. Although
only six faculty members were interviewed, their experiences are
consistent with and support common themes in the blended
learning literature. This study confirmed the supposition that
moving didactic content online can free up valuable classroom time
for more active and problem-based teaching approaches, in which
students benefit from real-time interaction with faculty as well as
their peers. This is consistent with the findings of Mason et al.
(2013), who reported that a blended approach allowed them to
cover more content and increased opportunities for active,
132 L. Posey, C. Pintz / Nurse Education in Practice 26 (2017) 126e133
cooperative and collaborative learning without placing adding to
students’ overall workload.
Faculty agreed that these kinds of learning activities require
careful planning, including the development of problems or sce-
narios that enable students to apply new knowledge to real-world
practice situations. The use of authentic scenarios and problems as
a basis for active learning experiences appears to be an important
characteristic of effective blended teaching strategies. This finding
is supported by other studies on blended learning (Jokinen and
Mikkonen, 2013, McGowan et al., 2014). Within this context, the
instructors’ presence in facilitating higher-order learning and
identifying the need for remediation was viewed as more valuable
than lecturing. Effective facilitation of blended learning activities
depends upon skilled educators who create a safe environment for
students to practice new skills, and who are willing and able to
effectively adapt to an unpredictable and evolving teaching and
learning experience. McGowan and colleagues (2014) found that a
successful blended experience needed three components: students
prepared for class, pre-work done for class that supports learning in
the face to face portion of the class and the live class experience
fosters student engagement and active learning.
The shift to more active, learner-centered approaches also pla-
ces more responsibility on the students, some of whom may be
resistant and perceive this as additional work. Hsu (2012) found
that blended learning increases workload because of the active
learning components, which may lead to lower levels of satisfac-
tion. This is consistent with faculty observations that some students
perceived the self-directed online work as the instructor not doing
his or her job. Instructors can help to optimize student engagement
in blended learning by communicating the purpose and value of the
learning activities, creating high-quality online materials, carefully
guiding students’ use of these materials, and weaving didactic
content through the in-class learning activities to reinforce the
relevance of didactic content to professional practice. McLaughlin
and colleagues (2014) found that students were more engaged
when encouraged by instructors, that it was necessary to be pre-
pared for class and the teaching strategies in the flipped classroom
enabled them to learn and apply the course material. Providing a
variety of carefully planned and facilitated blended activities can
help to increase student attention in the classroom, foster inde-
pendent learning and meet diverse learning needs and preferences.
5. Conclusions
Transitioning a nursing education program from a traditional
classroom to a blended learning approach can be challenging.
Designing and developing high-quality blended learning courses
requires careful planning, time and resources. Students who are
accustomed to a traditional format may resist taking more re-
sponsibility for their own learning. Nevertheless, there is evidence
to indicate that blended learning, especially active learning ap-
proaches, add value to the educational experience. A holistic design
approach grounded in best practices for quality can result in suc-
cessful and effective blended nursing education programs.
Acknowledgements
This study was supported by funds from the Division of Nursing
(DN), Bureaus of Health Professions (BHPr), Health Resources and
Services Administration (HRSA), Department of Health and Human
Services (HHS) under grant number D11HP22190. The information
or content and conclusions are those of the authors and should not
be construed as the official position or policy of, nor should any
endorsements be inferred by the Division of Nursing, BHPr, HRSA,
HHS or the U.S. Government.
The authors would also like to acknowledge the faculty whose
blended teaching experiences are features in this paper: Karen
Dawn, MSN, BSN; Carol Lang, DHS, MS; Whitney Shanley, MSN, RN;
Jacqueline Wavelet, MSN, ACNS-BC, CNL; Gretchen Wiersma, RN,
MN, CNP; and Stephanie Wright, PhD, NP.
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