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Nurse Education in Practice 13 (2013) 524e528

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

Teachers’ experiences of teaching in a blended learning environment

Pirkko Jokinen*, Irma Mikkonen 1

Savonia University of Applied Sciences, School of Health Care, P.O. Box 1028, FI-70111 Kuopio, Finland

a r t i c l e i n f o

Article history:Accepted 19 March 2013

Keywords:Blended learningLearning technologyNurse education

* Corresponding author. Tel.: þ358 44 785 6466.E-mail addresses: pirkko.jokinen@savonia.fi (P.

savonia.fi (I. Mikkonen).1 Tel.: þ358 44 785 6469.

1471-5953/$ e see front matter � 2013 Elsevier Ltd.http://dx.doi.org/10.1016/j.nepr.2013.03.014

a b s t r a c t

This paper considers teachers’ experiences of teaching undergraduate nursing students in a blendedlearning environment. The basic idea of the study programmewas to support students to reflect on theoryand practice, and provide with access to expert and professional knowledge in real-life problem-solvingand decision making. Learning was organised to support learning in and about work: students workedfull-time and this provided excellent opportunities for learning both in practice, online and face-to-facesessions. The aim of the study was to describe teachers’ experiences of planning and implementingteaching and learning in a blended-learning-based adult nursing programme.

The research method was qualitative, and the data were collected by three focus group interviews,each with four to six participants. The data were analysed using qualitative content analysis.

The results show that the blended learning environment constructed by the combination of face-to-facelearning and learning in practicewith technology-mediated learning creates challenges thatmust be takeninto considerationwhen planning and implementing blended teaching and learning. However, it providesgood opportunities to enhance students’ learning in and about work. This is because such programmessupport student motivation through the presence of “real-life” and their relevance to the students’ ownplaces of work. Nevertheless, teachers require knowledge of different pedagogical approaches; they needprofessional development support in redesigning teaching and learning.

� 2013 Elsevier Ltd. All rights reserved.

Introduction

Health care practice has been transformed by changes in science,technology, and the nature and settings of nursing practice. Theemphasis on client-centeredness has also had a role in this trans-formation. The demands of complex practice require better-educated nursing professionals. There is a need for competentnurses who have the knowledge, skills and abilities that enablethem to work effectively. The four features that describe a compe-tent nurse are: professional practice, critical thinking and analysis,the provision and coordination of care, and collaborative and ther-apeutic practice. In addition, a competent nurse has to be ready forlife-long, and often self-directed, learning (Benner et al., 2010).

Changes in nursing practice have implications for nursing educa-tion. Educational organisations have to respond to challenges in thesociety and work environments. Such challenges may comprise, forexample, a shortage of nurses, an increase in the number of adultnursing students entering education, as well as taking into accountlearners’ versatile needs. Life-long learning and multiple approaches

Jokinen), irma.mikkonen@

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are required to meet these challenges. Furthermore, the practice-education gap constitutes a challenge that forces educational organi-sations and working life to find new ways to educate nursing pro-fessionals. New understanding of the nature of the curriculum andpedagogy, and changes in the pathways to nursing competency areneeded. A blended learning approach might be a useful way to meetthe challenge. Garrison and Vaughan (2008, 148) define blendedlearning as “the organic integration of thoughtfully selected andcomplementary face-to-face andonlineapproaches and technologies”.

Savonia University of Applied Sciences in Finland launched acompetency- and practice-based nursing education programme inthe autumn of 2010. The curriculum is based on the blendedlearning approach, and the purpose is to develop nursing students’situated knowledge, skills and ethical consciousness. In the pro-gramme, blended learning environment was constructed bycombining face-to-face learning and learning in practice withtechnology-mediated learning. The basic idea of the curriculum isto invite the students for dialogue between theory and practice, andprovide access to expert and professional knowledge, skills andattitudes in real-world problem solving. For example, the studentsare triggered to use context-specific theoretical and practicalknowledge together with professionals in solving patient relatedproblems; it is suggested that this helps the students to gain deeperunderstanding of the situation, to get an insight to expert and

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professional knowledge, and promotes the integration of theoryand practice. The education is part of the EU-funded project: SaWee To become a competent nurse in networks and nets, 2010e2013.The aims of the project are to develop an innovative educationmodel for adult nursing learners in collaboration with health carepersonnel, and to construct a model which combines nursing stu-dents’ learning with development of health care practices. A total of45 adult full-time working undergraduate students started theprogramme. The programme includes approximately 30 contactdays per year, and the main portion of the study is implemented atwork, supported by eLearning.

As a framework for the curriculum, the blended learningapproach enables the students to be exposed to a variety of learningexperiences. A blended learning environment involves, for example,face-to-face and online lectures, simulations, work-shops, self-directed learning and online discussions and learning. New inter-active technological equipment, such as desktop videoconferencingsystems, combined with the blended learning environment mightpromote students’ social presence and interaction in learning (Kligerand Pfeiffer, 2011). As advantages of blended learning have beenmentioned flexibility (Graham, 2006; Ocak, 2010), freedom of timerestrictions (Ocak, 2010), pedagogic richness and cost-effectiveness(Graham, 2006). One of the many challenges in all education is howto increase students’ autonomy as learners; how to maximize theirself-direction, content choice and becoming central to their ownlearning process (Reynard, 2007; Rigby et al., 2012). There is evi-dence that blended learning may increase learner autonomy(Reynard, 2007) and encourage life-long learning (Ireland et al.,2009; Rigby et al., 2012). These are both factors that have beenviewed as essential skills of a competent nurse (Benner et al., 2010).

The review of literature concerning blended learning reveals thatthere are many issues that teachers have to take into considerationwhen creating blended learning. In particular, the teachers mustthink the pedagogical implications through carefully, and make newdesigns for instruction and course delivery (Mccown, 2010;Mohannaet al., 2008; Reynard, 2007). They must choose the methods that areappropriate to the aims of the course (Mccown, 2010). Ocak (2010)has categorized factors of potential barriers to the use of blendedteaching into three groups: instructional processes; communityconcerns; and technical issues. Instructional processes e includingthe complexity of the blended learning environment, a lack of timefor preparation and planning the teaching, challenges in encouragingstudents to use the online section of the course and time manage-ment e were the most commonly mentioned reasons for not usingblended teaching. Community concerns, that is, a lack of institutionalsupport and the demands of changes in the teacher’s role, mightprevent a teacher from putting blended teaching into operation.Potential barriers impeding the embracing of blended learning couldalso be linked with teachers’ and students’ discomfort with tech-nology, insufficient technical support and inadequate hardware.However, well-organized technical resources promote the students’engagement in the learning process (Kliger and Pfeiffer, 2011; Rigbyet al., 2012), and increase teachers’ involvement in programmingblended teaching and learning (Reynard, 2007).

The purpose of this article is to raise discussion about the use ofa blended learning approach in nurse education from the teachers’perspective. The combination of face-to-face, online and practice-based learning creates challenges that have to be taken intoconsideration when planning and implementing blended teachingand learning.

Aim of the study

This study was designed to obtain an insight into how teachersrespond to the use of blended learning in nurse education. The aim

of the study was to describe teachers’ experiences of planning andimplementing teaching and learning in a blended-learning-basedadult undergraduate nursing programme.

Method

Data collection, informants and analysis

The research method was qualitative, and the data werecollected by focus group interviews. A focus group is a form ofmoderated group interview that stimulates communication andinteraction between research participants in order to generate data(Kitzinger, 1995; Krueger, 1994). The benefits of the method havebeen seen in that that it provides an opportunity to collect dataquickly and simultaneously from several people. Nonetheless, in asuccessful focus group, the participants are encouraged to talk toone another: participants ask questions, exchange opinions andattitudes, comment on each others’ experiences and points of view,and explore and clarify their views. (Kitzinger, 1995; Krueger, 1994;Shaha et al., 2011.) When the group dynamics work well, themoderator may remain in the background: the moderator’s role ismainly to stimulate a lively debate, and maintain confidentiality(Shaha et al., 2011). For the most part, this method has been usedfor exploring peoples’ experiences (Kitzinger, 1995; Krueger, 1994).

In this study, a total of three focus groups, each with four to sixparticipants, were conducted. The participants were the teacherswho had been engaged in the teaching and learning process of thenursing student group during the first study year. The themeinterview process was employed. The themes in the interviewswere: the common design of the course; teaching approaches inthe blended learning context; designing assessment of learningoutcomes, thoughts on technology in teaching; and experiences ofteaching in this nurse education programme. The interviews werescheduled and the participants were informed about the themes ofthe interviews beforehand. The interviews lasted approximately90 min and there were always two researchers present: one as amoderator and the other as a facilitator. Themoderator’s rolewas toensure that the discussion in the group ran smoothly, and thefacilitator’s role was to observe, and ask more detailed questionswhen necessary. The participants and researchers were teachersin the same organisation and knew each other previously. Thefocus group interviews were recorded and transcribed by theresearchers.

The data were analysed using qualitative content analysis(Elo and Kyngäs, 2008). Firstly, the transcript data were arrangedaccording to the themes of interviews. Secondly, within each themethe analysis proceeded inductively through the categorisationprocess into themes which describe teachers’ experiences ofteaching in blended learning environment.

Ethical and reliability considerations

The researchers obtained permission from the research orga-nisation before commencing the research. Ethical approval was notrequired as this research was part of the EU-founded SaWe-projectevaluation. The project itself and evaluation within it have beenaccepted as one of the education development projects at SavoniaUniversity of Applied Sciences. Prior to the focus groups, eachparticipant was provided with both a written and verbal explana-tion of the interview and the research. Participants gave their oralconsent to being interviewed and audiotaped. Before each inter-view, the participants were informed that they were allowed torefuse to answer any question, and that they were free to withdrawfrom the research at any time. It is important to remind participantsof secrecy in focus group interviews: the confidentiality of all the

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information shared in the groupwas discussed before the interview(Kitzinger, 1995; Krueger, 1994).

In this study, the researchers were doing research on their ownwork environment which was an issue that required specialattention. The situation has both advantages and disadvantages(Bonner and Tohurst, 2002; Field, 1991). In this study, advantagewas that the researchers and informants were familiar with eachothere it was easy to gain acceptance, trust and co-operation in theinterviews. As the researchers worked in the organisation theyknew the culture, daily language and local conditions very well. Thedisadvantage of the “insider situation” might be that it poses athreat to the trustworthiness of the study (Bonner and Tohurst,2002; Field, 1991). However, personal bias was avoided by carefulcollegial peer-reflection of two researchers: the colleague was usedin all phases of the study to increase the objectivity of the processby examining critically assumptions and actions in relation to datacollection and analysis.

Results

Nine themes emerged from the data to describe teachers’ viewsabout planning and implementing teaching in a blended-learning-based adult nursing programme. These were: collaborative plan-ning; integration; student group; face-to-face teaching; onlinelearning; learning activities; teaching and learning methods;learning in and about work; and confirming competences.

Collaborative planning was perceived as necessary in the teach-ers’ experiences about planning and teaching in a blended learningbased programme. The teachers’ attitude towards joint planningwas mainly positive: they experienced that collaborative planningsupported the integration of learning content. In addition, theteachers thought that the joint planning supported the develop-ment of teachers’ expertise as well as the development of teachingand learning. Moreover, the teachers perceived that joint planningenhanced the transfer of learning from one situation to another.However, the teachers experienced collaborative planning as time-consuming and arduous; moreover they felt that it was not easy tomove from solo-planning and working to collaborative planningand working e working alone is so deeply rooted.

“Actually I have never had the chance to experience so strongly thatI belong to this group.”

“We started to plan this course in very close collaboration witheach other.”

Integration in planning and teaching was in close relation to theprevious theme of collaborative planning. Integration emergedfrom the teachers’ experiences on several levels: integrating cour-ses, subjects, learning tasks, and integrating learning activities inpractice. When planning blended learning, the teachers integratedthree different courses, for example, into one wider theme, as wellas smaller learning assignments into one wider assignment. Theyalso planned learning assignments from the viewpoint of workingpractice in order for the assignments to be directly applicable towork. The teachers found it important to ensure that learning ob-jectives would be achieved by integrated learning assignments;according to teachers, when learning assignments are integratedinto wider assignments instead of several smaller learning tasks,the students will achieve a more holistic picture of care-relatedissues, enabling expertise to be developed. The teachers pre-sented both successful and unsuccessful experiences of integration;they felt that the introduction and assigning of learning tasks wereparticularly important.

“It was a comprehensive unit e it is an entirety in my own mind, Ihope that the students experienced it in the same way.”

“Specific basic issues were included e integrating different issueswas principally quite natural.”

Student group played a significant role in the teachers’ experi-ences about blended learning. The teachers experienced that agroup of mature, adult students with previous health care educa-tion and work experience has great potential for learning. Thestudents were divided into permanent participatory learninggroups (7e8 students per group). The teachers experienced thatthis supported learning because the students among each grouprepresented different kinds of work places (mental health, acute,long term and elderly care), which enabled the emergence ofdifferent viewpoints. On the other hand, however, teachers felt thatpermanent group allocation could prevent learning due to thecertain learned roles in the group. The teachers experienced thatthe student group was very challenging from the viewpoint ofplanning teaching and learning as well as carrying out teaching: thechallenges were caused by the size of the group (45 students) andits heterogeneity with regard to the students’ age, work experienceand previous education. As all of the students were mature withwork experience (some of them even with more than ten years), inthe teachers’ experience, the students appeared to be very work-oriented, and abstract thinking was a challenge for them.

“In my opinion, the group of 45 students is big. It is crying out oneextra cycle of energy when you think about the big size of the groupe and how would you include some participatory component inyour teaching. It is quite a tough thing, this 45 people.”

“The group was very heterogeneous e on the one hand, the groupincluded students whose skills were very good, and on the other,some students’ skills were very poor.”

The number of face-to-face teaching sessions was far lower thanin traditional programmes, and teachers experienced this as verychallenging. The teachers felt that, because of less face-to-facesessions, there was a sense of rush; they emphasised the signifi-cance of finding the core issues of the subject to be discussed duringthe face-to-face sessions as well as the importance of giving clearinstructions for learning activities to the students. Deciding uponthe issues to be considered during the face-to-face sessions andconstituting appropriate content to be learned online was a chal-lenge for the teachers.

“The questions here concern what should be learned online andwhat face-to-face learning includes; I chose the themes for face-to-face learning by thinking about what previous experience hasshown to be the most difficult content.”

“It is important to give the students good instructions.”

The success of online learning was not a truism. In the university,the official recommendation is to use online learning in teaching andall teachers have basic online teaching and learning education.However, the level of earlier use of technology-mediated learningvaried among the teachers: some had a lot of experience whereasthere were teachers who had only delivered material via internet. Inthis programme, the teachers realised that usingmaterial in an onlinecourse differs from using material in face-to-face sessions. Someteachers used the online environment only as a depository forlearningmaterial; teachers alsoprofessed their disappointment aboutthe students’ ignorance of the online material or presence online.Moreover, teachers discussed the teacher’s role in online learning e

when and how the teacher should participate in online discussions.

“I found it very challenging to include learning material in Moodle;it was very challenging and could not be done the same was asbefore.”

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“Now, we teachers also study and learn new issues and technolo-gies all the time, aiming continually to make better use of thesedifferent technologies and online tools.”

The teachers experienced that planning learning activities andassignments for the blended learning course presumed a differentapproach from traditional face-to-face learning. According to theteachers, the planning of learning activities and assignments wasdirected by clinical practice guidelines or nursing process: theteachers considered it important for the assignments to be relatedto nursing practice, and for the students to be able to utilize theirwork experience. They perceived that the ultimate goal in assign-ments, in addition to the students’ learning, was to develop thework community. Moreover, the teachers considered it importantfor students to justify by theory their views in the assignments.However, the teachers’ experience was that fairly often the as-signments were superficial and lacking justification and in-depthdiscussion. The teachers also experienced that the students didnot succeed in the integrative assignments.

“In my opinion, now there was a clear change e both teachers andstudents realised that issues may be learned inmany different wayse I think that many eyes were opened when people realised thereare places other than the classroom where you can learn.”

“It was difficult for the students to understand that these assign-ments are not separate assignments related only to classroomstudy, instead they were related to work and their practice.”

The teachers experienced that when the pedagogical approach isblended learning, they have to change teaching and learningmethodse it is not appropriate to use the same methods as in face-to-faceteaching when using a blended learning approach. Nevertheless,the teachers encountered challenges when starting to apply newapproaches and methods. The teachers experienced that the stu-dentswere reluctant to usenew learningmethods; theywereused totraditional teacher-led studying. The teachers felt that both theteachers and the students were puzzled by the new pedagogicalapproaches. However, the teachers described that the more thestudents have to work close to the extreme limits of their skills, themore they learn, and that learning always includes uncertainty andeven distress. Moreover, the teachers expressed that, at the initialstages of theprogram, both theyand the studentsdid not understandhow much it is possible to learn outside the classroom, and conse-quently, the teachers were not able to facilitate that learning. Theteachers felt that the size of the group placed limits on the teachingand learning methods. They experienced that seminars were oneefficient learning method; the seminars provided the students withthe opportunities to show their expertise and to share knowledge.

“I have been wondering how it could be possible to pull oneself freefrom these previous (methods), more than I have now done: tosome extent I have already gone in that direction, but it would beimportant to support students to produce more ideas and to listento their voice more.”

“You had to think about what are now ‘must know’ eissues hereand what is something else.”

Learning was organised so that learning in and about workplayed an important role in programme. The teachers’ experiencesabout learning in and about work varied. Some teachers expressedthat the area of work was emphasised in the students’ learning,while some described that they did not takework into account at allin their teaching. There were opinions that being at work restrictsstudying, however, there were also opinions that because studentsare working full-time, there are excellent opportunities for learningand studying. The teachers considered that the topics of the

assignments were often work related, and the implementation ofthe assignments were planned in collaboration at work places; thestudents prepared their learning assignments in collaborationwiththeir classmates and colleagues in work places, and this enhancedshared learning and the development of work community. More-over, many of the students arranged teaching and learning sessionsat their work places. The teachers concluded that an educationprogramme, in which learning in and about work is essential, en-ables the highlighting of challenging issues of practice as a focus oflearning.

“In a way, learning at work was a big question mark; what it meansand how to implement and support it.”

“In my mind it is a difficult question e I am not good at recognisingwhat is a critical point on which I should focus when giving as-signments for work; students come from totally different worlds ofwork; it would be important to develop the work community aswell.”

Confirming competences was experienced as important by theteachers, especially because the amount of face-to-face learningwas low. The teachers used versatile methods in confirming com-petences, for example, tests and exams; multiple-choice questiontests; skills tests; online tests; peer-reviews; group exams; and self-assessment. The importance of students’ mastering the basic con-cepts and core issues as well as having theoretical knowledge andjustification skills were emphasised by the teachers.

“I have a rather uncertain feeling about learning e I think that ineach small group there were students who learned a lot, but Iwonder if they all participated in group work and whether I haveany means to conform learning e that each student has achievedthe goals.”

“Applying theoretical knowledge inworking or actinge I think that asimulation session is a goodway to verify the student’s competence.”

Discussion

The results contribute to an understanding of the teachers’ ex-periences of planning and teaching in the nursing education pro-gramme based on a blended learning approach. The teachers in thisstudy experienced the blended learning approach positively;however, they found it to be very challenging from the viewpoint ofplanning and design. If the teachers had no previous experience ofcollaborative planning and blended learning, it was evident that,although they were willing to change their teaching towardsstudent-centeredness, they quite easily chose a traditional, evenbehaviouristic approach for their teaching. Moreover, in blendedlearning approach it is necessary to use technology more than inface-to-face teaching and that is why it is necessary to facilitate ashift in culture between both teacher and student in utilisingtechnology (Johnson et al., 2010).

According to the current study, careful planning is an importantprerequisite to ensure that combination of face-to-face learningand learning in practice with technology-mediated learning activ-ities support achieving the learning outcomes of diverse students.This finding is supported by previous studies of Glocowska et al.(2011) as well as Mohanna et al. (2008). Moreover, the teachersin this study experienced that the large number of students and theheterogeneity of the group were challenges in using student-centred learning approaches. According to previous studies(Glocowska et al., 2011; Johnson et al., 2010), it is important to planboth online learning activities and face-to-face sessions carefully inorder them to be relevant and engaging for often a heterogeneousgroup of students. Moreover, while planning blended learning, it is

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important to include a variety of learning activities, not onlyreading materials, in online environment to meet the needs ofdifferent learners (Strickland et al., 2012). According to this study, ablended learning approach triggers teachers to plan versatilelearning methods and materials in order to meet students’ indi-vidual needs.

The results of this research revealed that online learning was achallenge for teachers. Although all of themhad some experience ofusing learning technology. For some, reducing the face-to-faceteaching was the most challenging issue. This has been recog-nised also by Mohanna et al. (2008). Teachers also professed theirdisappointment about the students’ ignorance of the online ma-terial or presence online. However, according to the previousresearch (Ocak, 2010) teachers’ perception of student involvementmotivated them to establish more effective learning experiences.Mccown (2010) states, that the students will more likely to engagewith online learning, if the inputs are varied. It is evident thatblended learning requires teachers’ active role in enhancinglearning (Ireland et al., 2009), more creative teaching methods andconstant reflection on meaningful teaching methods (Ocak, 2010).

In accordance with the findings of Kamaruzaman andKhodabandelou (2009), this study revealed that it is especiallychallenging for educators to enhance student learning withoutbeing continuously present. However, students in a previous study(Smyth et al., 2012) felt that the flexibility of blended learningfostered a sense of autonomy and supported them to take moreresponsibility for their learning (Rigby et al., 2012; Smyth et al.,2012). Consequently, it is important for teachers to understandthat in a blended learning they function as facilitators and it is theirduty to create an online setting where they enable students tocollaborate with each other (Smyth et al., 2012) as well as supportthem to take responsibility for their learning.

In this programme, learning in and about work was a crucialpart of blended learning environment. The teachers experiencedthat a close connection with practice enabled to highlight practiceas a focus of learning and enhanced the integration of theory andpractice. However, the teachers described that theory-practiceintegration was not easy because some students’ level of abstractthinking was low and they did not use theory to justify their con-clusions. Also Corlett et al. (2003) argue that creating the integra-tion of theory and practice is a demanding task in education.

The teachers experienced that it was fascinating and educatingto work together: joint planning in a blended learning coursesupported the development of their wide expertise as teachers.However, it is evident that teachers need time for joint planningand exploring how the different learning settings can be broughttogether for students in order to support their learning and pro-fessional development. Moreover, teachers require knowledge ofdifferent pedagogical approaches; they need professional devel-opment support in redesigning teaching and learning. These find-ings are similar to Reynard’s (2007) and Mohanna’s et al. (2008)studies.

Conclusion

This study aimed to investigate the teachers’ experiences inplanning and teaching in a course based on a blended learningapproach. There is a lot of research of students’ experiences aboutblended learning, as well as experiential articles about teachers’experiences in planning and teaching in blended learning courses,however, there is less research about teachers’ experiences.Consequently, this study adds to the teacher voice in this field. Onenotable finding that was not reported in previous research is that inaddition to face-to-face and online learning, the blended learning

approach may also include learning in and about work. In thisstudy, the teachers experienced that when the course includeslearning in work places, it enables the highlighting of relevant is-sues in teaching and learning during face-to-face sessions as well.Consequently, the integration of theory and practice will beenhanced as well as having appropriate content as a focus from theviewpoint of practice, thus leading to studentmotivation and betterlearning results. Moreover, there are also benefits for work places;collaboration between students, work place staff and educatorsenables the development of work places.

The integration of face-to-face learning, online learning andlearning in and about work provides opportunities to enhancelearning in blended-learning programmes. This is because suchprograms support student motivation through the presence of“real-life” and their relevance to the students’ own places of work.

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