Introduction
In reviewing the literature, it is clear that blended learning offers many benefits: for students, but also for the institutions that offer this teaching modality. There are different models of blended learning in which the learner spends various blocks of time learning online and in a brick-and-mortar classroom. Used properly, it allows for deeper learning of the material. Students enjoy the flexibility of taking part of their courses online, but with the added benefit of face-to-face interaction with the instructor and other students in the classroom. Blended classrooms are meant to engage and motivate students, and the research supports this finding. However, if a blended learning model is to be adopted successfully, it is important to investigate and learn from others who have integrated technology in a learning environment. This literature review discusses what blended learning is, how it can benefit our students, and potential pitfalls in its implementation.
The Four Basic Models of Blended Learning
Blended learning is defined as a “formal education program in which a student learns: at least in part through online learning, with some element of student control over time, place, path, and/or pace, at least in part in a supervised brick-and-mortar location away from home; and the modalities along each student’s learning path within a course or subject are connected to provide an integrated learning experience” (Christensen, 2015). Blended learning integrates both face-to-face and online teaching modalities, creating a cohesive learning experience. These hybrid approaches can foster independent learning and collaboration, as well as facilitate better communication among students and between students and instructors (Horizon Report, 2016). Christensen divides blended learning into four main categories: Rotation, Flex, A La Carte, and Enriched Virtual. The Rotation model includes four sub-models: Station Rotation, Lab Rotation, Flipped Classroom, and Individual Rotation (Christensen, 2015).
The Rotation model is where students rotate through learning modalities on a fixed schedule, at the discretion of the instructor. It includes an online component. Learning modalities may include group assignments, full-class instruction, traditional paper-and- pencil assignments, tutoring. It mostly takes place in the brick and mortar classroom, except for homework. The flipped classroom approach is a well-known subcategory of the rotational model, where learners participate in online learning and receive the primary content off-site. They then attend class where they participate in teacher-guided learning activities, practice, and projects (Christensen, 2015).
The Flex model describes a course in which online learning is the “backbone”, and students have a customized schedule among learning modalities. Students learn mostly on campus, except for homework. The teacher is on-site and provides support as needed (Christensen, 2015).
The A La Carte model is a mixture of online and brick-and-mortar classes. The student will take some classes completely online which accompanies his or her experiences at the school or facility. This differs from taking courses completely online because a full-time online schedule is not considered a “whole school experience” (Christensen, 2015).
Finally, in the Enriched Virtual model, most of the learning occurs online, on the student’s schedule. It differs from online classes because there are some required face-to-face meetings with the instructor of the course (Christensen, 2015).
How Students Learn
Before analyzing different methods and technologies used in teaching, it is vital to have a solid understanding of how students learn. In How Learning Works, Ambrose, Bridges, DiPietro, Lovett, and Norman (2010) list seven research-based principles for effective teaching. One of the principles is how prior knowledge can help or hinder learning. When previous knowledge of a topic is inactive, insufficient, inappropriate, or incorrect, it hinders learning. On the other hand, when activated, sufficient, appropriate, and correct, it helps learning. They explain how teachers often overestimate students’ prior knowledge, thus building new knowledge on a shaky foundation (Ambrose et al, 2010, pg. 12)
Students participating in a blended learning environment have the advantage of learning the foundational knowledge at their own pace, online. This allows for deeper learning to take place while in the classroom. In 2005, one study at Pennsylvania State University Berk’s College, a chemistry class was conducted as a blended course. Realizing that students needed certain foundational knowledge to understand more advanced topics and participate in critical thinking, the faculty built online guides with resources for the students. The end result of this blended design increased student engagement, retention, and nearly doubled pass rates (Amaral & Shank, 2010).
Another important factor in learning is engagement and motivation. Motivation is key in learning outcomes. If students do not find the course material interesting or relevant, they might see little value in mastering the subject matter, or engaging in behaviors that facilitate deeper learning (Ambrose et al, 2010, pg. 69).
Blended learning does not imply that educators should not teach and emphasize certain core knowledge, skills, and dispositions in students, but that to successfully accomplish these goals, schools should be “intrinsically motivating” (Horn & Staker, 2014).
A study at the University of Massachusetts followed the 5-year results of conducting a chemistry class in the traditional way vs. a blended format. The research found that the blended format increased student engagement. This led to more active learning in class and resulted in a net test score increase of 12% over the traditional classroom model. A review of 20 studies, funded by the Bill & Melinda Gates Foundation, showed similar results, indicating that blended learning increases student engagement, motivation, and ultimately student success (Horizon Report, 2016, pg. 18).
Experience shows that blended classrooms enhance student learning and retention; it further engages the students using digital learning materials such as podcasts, interactive multimedia tutorials, and videos (Amaral & Shank, 2010).
Other Benefits of Blended Learning
A critical component of blended learning is reduced seat time. Students are free to pursue their education on their own schedules, which is a very attractive draw for many adult learners (Morrison, 2013). Colleges and Universities are increasingly offering online courses for students to address financial and time constraints, and issues of balancing work and family obligations. In fact, 32% of students surveyed in a study by JISC indicated that technology influenced University choice (Horizon Report, 2016, pg. 18). Morrison (2013) explains that “blended learning develops a skill set for students that otherwise would not be possible in exclusive face-to-face instruction. Skills include digital citizenship, information management skills, self-directed learning, and web research and collaboration skills.”
Finally, a benefit for the learning institution is the ability to manage facility resources more efficiently and allows for the teaching of many more students in a term (Morrison, 2013).
Teaching a Blended Class
In 2010, Resta insisted that we need to prepare teachers to teach in online and blended learning environments. Online courses and blended courses have grown exponentially in recent years and is projected to continue well into the future. Unfortunately, few teachers are learning to teach online classes. “Twenty-first century educators must get training and experience in online and blended learning environments as part of their educator development programs so that they master the skills to teach in such environments” (Resta, 2010).
Teachers must understand what students are trying to accomplish and what experiences are needed to help them accomplish those goals. Then, the teacher must assemble the right resources and integrate them in the right way to deliver those experiences (Horn & Staker, 2014). Done well, this learning style preserves the benefits of the old way (traditional classroom), and provides new benefits: personalization, access, equity, and cost control (Horn &Staker, 2014). This is particularly important to adult learners who have specific goals, but feel limited by the traditional classroom due to work schedules or other obligations.
Applications for Healthcare 
One of the most critical elements of a healthcare program is to teach students interpersonal communication skills and interprofessional collaboration. Good communication skills with patients and other healthcare professionals is stressed in all types of programs to ensure that patients understand their health conditions, treatment options, and the risks and benefits of those options. It is also vital that healthcare professionals from different disciplines work together to ensure optimal patient care and reduce the possibility of errors that may result due to lack of communication between professionals regarding the care of a patient. A study was published using a course at East Tennessee State University that uses a blended learning model specifically for increasing communication skills of healthcare providers with their patients and other providers. It is a 2-credit course, titled Communication Skills for Health Professionals. The course combines online learning modules with 3-hour face-to-face group sessions. The students who take this course come from the medical, nursing, pharmacy, and psychology disciplines. At the time of the study, the students taking the course were medical and pharmacy students. The lessons include topics such as rapport building, active listening, and interprofessional communication skills. The research concluded that the blended model was very successful in teaching these skills, as evidenced by pre- and post-skill assessments. Some limitations noted in the article are the fact that the study was limited to only one learning institution, and the focus was on oral communication; written communication was not assessed (Hess, Hagemeier, Blackwelder, Reid, Ansari & Branham, 2016). I would also include the fact that this course was not compared with similar all online or all face-to-face courses as a major limitation, even though the blended course was deemed successful.
In another study undertaken in Universities in Uganda, Sweden, and South Africa, the blended learning model was piloted in healthcare fields including clinical research, pharmacology, obstetrics, epidemiology, and health systems research. The courses included structured learning material, recordings of synced sessions, guides to self-directed activities and communication tools online. In the classroom, synchronous learning occurred in the form of lecture, discussions, demonstrations, and labs. At the end of the study, 94% of the students surveyed said they would recommend the blended course to someone else. They generally felt supported during and between the synchronous sessions, collaborated with each other, engaged in active learning (individualized assignments), maintained high expectations for learning, and felt that the blended model showed respect for diverse talents and ways of learning (Protsiv, Rosales-Klintz, Bwanga, Zwarenstein & Atkins, 2016).
Lessons from Failures
One of the problems with incorporating technology such as with a blended model, is when the focus is on the technology, and not in the paradigm shift that needs to occur with learning. A huge improvement that occurs with a blended model is the ability to move students toward the higher levels of Bloom’s taxonomy; the students can learn the bulk of the foundational knowledge and its applications at home, then work on more project-based activities in the classroom that result in deeper learning at the analysis, evaluation, and creation levels. An example of focusing on technology was discussed in “ICT in Innovative Schools”. A Greek teacher mentioned that the children are more excited to type a paper on the computer, which is great because the kids are more engaged, but it is simply swapping one mode of doing something with another. This type of change doesn’t result in the paradigm shift needed in education. Another example would be having students take an online multiple-choice test. No deeper learning is occurring solely with the addition of technology. The focus must be on the learning, using technology as an adjunct. In the same article, the authors noted a different strategy used in Finland and Japan, where the focus was based on learning how to take responsibility for their own learning (ICT in Innovative Schools, n.d.). The focus on technology can seem progressive but can be the same old teaching methods, just dressed up. Consider: “One of the most popular headlines these days is about school systems celebrating the adoption of 1-to-1 programs. But the fact that a district has a 1-to1 program tells us nothing about what kind of teaching and learning is happening in schools” (Fagnani, 2014).
Another potential failure in implementing blended learning would be a lack of preparedness in following guidelines prescribed by our IT department or software company for the online portion of the class. Whatever software we would use (Blackboard, Moodle, etc.) would require that protocols are followed and training is provided. A glaring failure of this was the Los Angeles iPad initiative in which Apple’s deployment guidelines were not followed, leading to a “hack” of the iPads (Chambers, 2014).
Professional development is also key. In her article, “Rolling out Blended Learning”, Fagnini (2014), stresses using instructors who are familiar with technology to slowly start implementing blended learning in their classrooms. Some instructors will be hesitant to pilot a blended course due to lack of technology skills. The more knowledgeable instructors can help the others when they are ready to try a blended model for their classes.
This highlights the important success factor of teacher collaboration. Often, teachers feel that their work is in the classroom, and not in collaborating with other teachers. This was one of the problems faced by an Oakland, CA school where over half their students were failing English. Once strong leadership stepped in, teacher collaboration was promoted, and a blended learning model helped those students excel. In fact, two years later, nineteen percent of those students scored as “advanced” in English. Prior to this, that number was zero (Roscoria, 2012).
Conclusion
After reviewing the literature, the blended learning approach seems promising. The research has shown that it can help students learn their material more deeply, and can engage and motivate learners. It has been shown in several studies that students’ test scores are ultimately better in a blended learning environment vs. a traditional classroom. It extends flexibility to the working adult and/or parent who may not have a schedule that permits him or her to attend classes in a traditional setting. Blended learning can save resources for the school, and allow for more students to be reached in a given term, but it also allows for face-to-face interaction with the teacher that some students may need or want.
I would like to read more about the different models of blended learning and the pros and cons of each; this would give me a better understanding of what would work best in a career college setting, where a large amount of the learning is hands-on in a lab or clinic setting. It seems that blended learning would work very well for didactic courses, especially considering that adult learners come from a wide range of experiences and foundational knowledge. As more colleges and universities adopt this style of teaching, it will become a standard that many students will benefit from- and even expect.
Before piloting a blended course, it is important to learn from the mistakes of others and avoid making those same mistakes. The most important factor is to keep the focus on the learning, and to strive for learning at the higher levels of Bloom’s Taxonomy. When the focus is on the technology, the learning is simply a dressed-up version (and more expensive) of the same style of learning that was employed previously. Following IT’s instructions and the instructions of our chosen software will be critical to avoid mistakes such as in the Los Angeles iPad initiative. Blended learning has so many advantages, it is clearly worth initiating. I am confident that utilizing a blended format for a health care program, such as dental hygiene, will benefit our students and the future patients they will serve.
References
Amaral, K.E. & Shank, J. (2010). Enhancing Student Learning and Retention with Blended Learning Class Guides. Educause. Retrieved from http://er.educause.edu/articles/2010/12/enhancing-student-learning-and-retention-with-blended-learning-class-guides
Ambrose, S., Bridges, M., DiPietro, M., Lovett, M., & Norman, M. (2010). How Learning Works. 7 Research-Based Principles for Smart Teaching. San Francisco, CA: Jossey-Bass.
Chambers, B. (2014). L.A. cancels iPads-in-the-schools program: a failure of vision, not technology | Macworld [Web log post]. Retrieved from http://www.macworld.com/article/2599988/lausd-ipad-cancellation-is-a-failure-of-vision-not-technology.html
Christensen, C. (2015). Blended Learning Definitions. Clayton Christensen Institute for Disruptive Innovation. Retrieved from http://www.christenseninstitute.org/blended-learning-definitions-and-models/
Fagnani, S. (2014). Rolling out blended learning. District Administration, 50(8), 69
Hess, R., Hagemeier, N. E., Blackwelder, R., Rose, D., Ansari, N., & Branham, T. (2016). Teaching Communication Skills to Medical and Pharmacy Students Through a Blended Learning Course. American Journal Of Pharmaceutical Education, 80(4), 1-10.
Horizon Report. (2015). Higher Education Edition. Retrieved from http://cdn.nmc.org/media/2015-nmc-horizon-report-HE-EN.pdf
Horizon Report. (2016). Higher Education Edition. Retrieved from http://cdn.nmc.org/media/2016-nmc-horizon-report-he-EN.pdf
Horn, M. & Staker, H. (2014). Blended Learning is About More than Technology. Retrieved from http://www.edweek.org/ew/articles/2014/12/10/blended-learning-is-about-more-than-technology.html
ICT in Innovative Schools. (n.d.). Retrieved from http://www.oecd.org/site/schoolingfortomorrowknowledgebase/themes/ict/41187025.pdf
Morrison, D. (2013). Is Blended Learning the Best of Both Worlds? Retrieved from https://onlinelearninginsights.wordpress.com/2013/01/17/is-blended-learning-the-best-of-both-worlds/
O’Byrne, W. I., & Pytash, K. E. (2015). Hybrid and Blended Learning. Journal Of Adolescent & Adult Literacy, 59(2), 137-140. doi:10.1002/jaal.463
Protsiv, M., Rosales-Klintz, S., Bwanga, F., Zwarenstein, M., & Atkins, S. (2016). Blended learning across universities in a South-North-South collaboration: a case study. Health Research Policy & Systems, 141-12. doi:10.1186/s12961-016-0136-x
Resta, P., & Carroll, T. (2010). The Summary Report of the Invitational Summit on Redefining Teacher Education for Digital-age Learners. Retrieved from http://redefinete. achered.org/sites/default/files/SummitReport.pdf?q=summitreport
Roscorla, T. (2012, July 11). Collaboration, Leadership Key in Oakland, Calif., School Turnaround. Converge.
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