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. I will also explore the potential benefit of increased collaboration among students taking blended courses, particularly for the flex model of blended learning. The research clearly demonstrates that blended learners tend to have higher rates of satisfaction, engagement, and mastery of the material. Of particular interest to me is the question of whether a flex model of blended learning increases collaboration among students.
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). According to the Horizon Report (2016), 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. Christensen (2015) 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).
Christensen (2015) explains that 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. He states that learning modalities may include group assignments, full-class instruction, traditional paper-and- pencil assignments, and 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) describes the Flex model as 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) further explains the A La Carte model as 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”.
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
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.
Amaral and Shank (2010) published a study at Pennsylvania State University Berk’s College, where a chemistry class was conducted as a blended course. In this study, students participating in a blended learning environment have the advantage of learning the foundational knowledge at their own pace, online. 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 result of this blended design increased student engagement, retention, and nearly doubled pass rates.
Ambrose et al (2010) stressed another important factor in learning: 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.
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).
The Horizon Report (2016) described a study at the University of Massachusetts that 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. Also, included in the Horizon Report was a review of 20 studies, funded by the Bill & Melinda Gates Foundation, which showed similar results, indicating that blended learning increases student engagement, motivation, and ultimately student success.
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
Morrison (2013) mentioned that 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. The Horizon Report (2016) stated that 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. These 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
Resta (2010) 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).
Horn and Staker (2014) insist that 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. Done well, this learning style preserves the benefits of the old way (traditional classroom), and provides new benefits: personalization, access, equity, and cost control. 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.
Lessons from Failures
An example of focusing on technology was discussed in “ICT in Innovative Schools” (n.d.): 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. In contrast, 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.). Fagnini (2014) emphasizes that 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).
Chambers (2014) stresses the importance of following protocols and providing training for instructors. 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).
In her article, “Rolling out Blended Learning”, Fagnini (2014), encourages 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.
Roscorio (2012) 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. Roscorio noted that 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.
Applications for Science and Healthcare 
Hess, Hagemeier, Blackwelder, Reid, Ansari, and Branham (2016) published a study 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.
Protsiv, Rosales-Klintz, Bwanga, Zwarenstein, and Atkins (2016) undertook studies in universities in Uganda, Sweden, and South Africa. At these universities, 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.
Eachempati, Kumar, and Sumanth (2016) aimed to show that blended learning can be successfully implemented in a dental pharmacology class. Student survey results were positive for: merits of blended learning, skills in writing prescriptions for oral diseases, dosages of drugs, and their identification of their own strengths and weaknesses in understanding the material. Some of the comments noted that it was difficult to concentrate during lecture courses, lecture courses can be boring and exhaustive, the blended course was more flexible, gave them the ability to repeat content as needed, and was more fun and interesting.
Pereira, Pleguezuelos, Meri, Molina-Ros, Molina-Tomas, and Masdeu (2007) conducted a study to compare learning outcomes for an anatomy class at Pompeu Fabra University in Barcelona, Spain using a blended instructional model vs. a traditional face-to-face learning model. The topic of learning in this study was the locomotor system (musculoskeletal). In the blended course, students learned theoretical material online and attended 3 live seminars for support and problem-solving activities. The other students learned about the locomotor system the traditional way, through lecture. Test score results were surprisingly higher for the blended learners: 87.9% vs. 71.4% for the traditional learners. Satisfaction scores were similar for both groups, but learning outcomes for blended learners far exceeded those in the traditional group.
According to Stockwell, Stockwell, Cennamo, and Jiang (2015), blended learning improves science education. This study compared blended learning with traditional lecture learning in an undergraduate biochemistry course. They examined four modes of learning: video, textbook, lecture, and problem-solving. The same instructor taught the blended courses and the lecture courses. In the blended versions, students watched videos on the class content prior to attending class; in the classroom, students either listened to lecture or engaged in student problem-solving in class. In the non-blended version of the class, students were assigned textbook chapters to read before class, then attended lecture where problems were explained by the instructor or engaged in student problem-solving. All four versions of the class achieved similar satisfaction ratings, but there were differences in attendance and grasp of the material. Students who took the blended version had higher attendance than those in the traditional lecture class. They also performed better on exams. Specifically, the best combination was a blended course in which students watched a video before class, then engaged in student problem-solving in the classroom. The conclusion was that the videos increased student engagement and understanding of difficult subject material, and the student-problem solving in class facilitated active learning, thereby increasing understanding of the material.
Collaboration
According to Chen and Chiou (2014), blended learning increases collaboration among students. In their study, hybrid learning was assessed in a Taiwan university’s child development course for learning outcomes, course satisfaction, and sense of community. Learning outcomes, satisfaction, and sense of community were all higher in the blended course.
Johnson (2013) examined the effects of blended learning and collaboration:
“Taking time to predesign a course, set up processes for student groups for communication and coordination, and clarifying assignments and expectations greatly facilitates cooperative learning as it allows students to assign responsibilities, tasks and deadlines to individual members. A critical component to the cooperative learning process is students receiving feedback amongst their group and receiving feedback to the instructor about the progress of the teams. Ensuring that students can communicate with each other about the progress of a project and with the instructor will greatly impact a successful completion of an online project.”
The importance of reflection papers in class and discussions online were emphasized in Johnson’s research. These exercises aid in increasing collaboration, a highly desirable skill that is sought by employers (Johnson, 2013).
Similarly, Hyo-Jeong and Bonk (2010), found that blended learning (part online and part face-to-face) offers the advantage of greater access to resources, online tools that support discussion, and fostering of collaboration online after building a sense of community in their face-to-face meetings. Their study emphasized the importance of good design that encourages collaboration via discussions and the use of collaborative tools such as Google docs in blended courses.
Conclusion
After reviewing the literature, the blended learning approach seems promising, especially for science-based courses such as those found in dental hygiene. 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 each term, but it also allows for face-to-face interaction with the teacher that some students may need or want.
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.
Blended learning, when implemented correctly, can help foster collaboration among students by making available online discussion forums and tools such as Google docs that can be worked on together, but also asynchronously, at their convenience. The face-to-face meetings build a sense of community that transcends into the online environment.
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. 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. 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. If blended learning can encourage collaboration, it will hopefully continue its impact on peer collaboration past the school years and into the professional setting. 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
Chen, B. H., & Chiou, H. (2014). Learning style, sense of community and learning effectiveness in hybrid learning environment. Interactive Learning Environments, 22(4), 485-496. doi:10.1080/10494820.2012.680971
Christensen, C. (2015). Blended Learning Definitions. Clayton Christensen Institute for Disruptive Innovation. Retrieved from http://www.christenseninstitute.org/blended-learning-definitions-and-models/
Eachempati, P., Kumar, K. K., & Sumanth, K. N. (2016). Blended learning for reinforcing dental pharmacology in the clinical years: A qualitative analysis. Indian Journal of Pharmacology, 48S25-S28. doi:10.4103/0253-7613.193315
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.
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Roscorla, T. (2012, July 11). Collaboration, Leadership Key in Oakland, Calif., School Turnaround. Converge.
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