Nursing Education Perspectives

The Impact of Blended Teaching on

Knowledge, Satisfaction, and Self-Directed
Learning in Nursing Undergraduates: A
Randomized, Controlled Trial
Marie-Pierre Gagnon, Johanne Gagnon, Marie Desmartis, and Merlin Njoya

doi: 10.5480/10-459

Abstract
aim This study aimed to assess the effectiveness of a blended-teaching intervention using Internet-based tutorials coupled
with traditional lectures in an introduction to research undergraduate nursing course. Effects of the intervention were compared
with conventional, face-to-face classroom teaching on three outcomes: knowledge, satisfaction, and self-learning readiness.
method A two-group, randomized, controlled design was used, involving 112 participants. Descriptive statistics and analysis
of covariance (ANCOVA) were performed.
results The teaching method was found to have no direct impact on knowledge acquisition, satisfaction, and self-learning
readiness. However, motivation and teaching method had an interaction effect on knowledge acquisition by students. Among
less motivated students, those in the intervention group performed better than those who received traditional training.
conclusion These findings suggest that this blended-teaching method could better suit some students, depending on their
degree of motivation and level of self-directed learning readiness.

Recent work in the educational sciences and
advances in information and communications
technology (ICT) have contributed to the
transformation of learning environments.
Although computer-based learning in
nursing dates back to the 1960s (Lewis,
Davies, Jenkins, & Tait, 2001), the advent of
the Internet in the 1990s led to a greater use
of online education for health professionals
(Cook et al., 2008). The potential of the
Internet as an instructional tool for the health
professions was rapidly recognized (Curran,
Lockyer, Sargeant, & Fleet, 2006; Friedman,
1996; Lam-Antoniades, Ratnapalan, & Tait,
2009; Wutoh, Boren, & Balas, 2004).
E-learning has many advantages,
including increased accessibility to
educational materials (at a time and place
chosen by learners), personalized instruction
(to tailor education to individual learners’
needs), and standardization of content (Cook
et al., 2008; Ruiz, Mintzer, & Leipzig, 2006).
This study aimed to assess the effectiveness of
a blended learning strategy in an introductory
research course for nursing undergraduates.
We sought to compare the effects of an
intervention combining self-directed,
Internet-based learning and conventional,
face-to-face classroom teaching on three
outcomes: students’ knowledge, satisfaction,
and self-directed learning.
LITERATURE REVIEW
As Internet-based learning (IBL) became
increasingly popular in nursing education,
concerns about its effectiveness stimulated
a growing body of research. Thus, a number
of nursing studies have compared the effects
of computer-based learning and conventional
teaching methods on knowledge acquisition
(Lewis et al., 2001). A comprehensive review
by Cook et al. (2008) summarized the evidence
on the effectiveness of IBL in the health
professions. In two systematic reviews (which
included 201 studies), Cook and colleagues
compared the effects of IBL to no intervention
and to non-Internet interventions and found
positive effects associated with IBL when
compared with no intervention. Compared
with non-Internet learning methods, effects
were inconsistent across the studies and
generally small, a finding that may be due
to different learning contexts and objectives
or to different methods of implementing an
Internet-based course.
In a recent systematic review, Cook,
Garside, Levinson, Dupras, and Montori

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(2010) portrayed instructional approaches
used in IBL and found a wide range of
approaches. The configuration of courses
(e.g., tutorial, asynchronous discussion,
live conferencing) and the instructional
methods (e.g., practice exercises, cognitive
interactivity) encompassed by this term
varied considerably. These authors suggest
that future research should focus on how
we can use IBL effectively in comparing
different strategies for implementation. Cook
et al. (2008) suggest that research should use
outcome measures that are responsive to the
intervention and sensitive to change.
With e-learning, the delivery and receipt
of course content may be asynchronous,
shifting the educational model from a passive,
teacher-centered one to one that is active and
learner-centered (Ruiz et al., 2006). Self-
directed learning (SDL), a central element in
e-learning, is seen as a promising method for
continuing education in medicine (Murad &
Varkey, 2008) and in nursing (Fisher, King,
& Tague, 2001). A literature review by Murad
and Varkey demonstrated that SDL has been
used in the education of a variety of health
care professionals, but there is little evidence
showing the efficacy of individual aspects
of SDL (Jennings, 2007). Most studies
have focused on evaluating the learner’s
acceptability and satisfaction with SDL rather
than on its impact on learning outcomes.
Some authors have explored the concept
of self-directed learning readiness (SDLR),
defined by Wiley in 1983 (as cited in Fisher
et al., 2001) as “the degree [to which] the
individual possesses the attitudes, abilities
and personality characteristics necessary
for self-directed learning.” Other scales
have been developed to measure SDLR in
educational and nursing research. One of the
most widely used, the Self-Directed Learning
Readiness Scale, developed in 1977, has
been criticized for several reasons (cost and
poor reliability among them) (Field, 1989;
Fisher et al.). Other scales, such as the Oddi
Continuing Learning Inventory (Oddi, 1986)
and Ryan’s questionnaire (Ryan, 1993), have
shown little evidence of validity (Murad &
Varkey, 2008).
378 november/december 2013
Nursing Education Perspectives
Fisher et al. (2001) developed the Self-
Directed Learning Readiness Scale for
Nursing Education (SDLRSNE), which
contains 40 items to assess the three
underlying factors of SDLR in nursing
students. Recently, Fisher and King (2010)
reexamined the factor structure of the
SDLRSNE subscales; their findings support
the tool’s validity.
METHOD
The study employed a two-group, randomized,
controlled design with participants recruited
from a population of first-year nursing
undergraduates at Laval University in the
Province of Quebec, Canada. Students in the
intervention group had blended instruction
with Internet-based tutorials and in-class
sessions; students in the control group
had conventional, face-to-face classroom
teaching. All students who registered for
the mandatory course, “Introduction to the
Research Process,” during the winter 2009
semester were eligible for inclusion. Approval
for the study was obtained from the Ethics
in Human Experimentation Committee of
Laval University.
The study was based on three hypotheses:
a) that students in both groups would obtain
comparable examination scores, b) that level
of satisfaction with the course would be
similar in both groups, and c) that between
the beginning and the end of the course, the
level of SDLR would rise more significantly
in students in the intervention group.
Recruitment and Stratified Randomization
Before the semester began, students were
stratified according to age, gender, study
program (A = initial bachelor’s in nursing,
B = bachelor’s in nursing after a nursing
diploma, and C = combined nursing diploma
and bachelor’s in nursing), and location of
prior studies (Province of Quebec versus
other). Of the 131 students randomized,
nine withdrew prior to the first class (seven
in the control group, two in the intervention
group), and three from each group changed
groups and were therefore excluded from the
analyses. A computerized random number
generator was used to assign students to one
of two groups: 65 to the intervention group
(Wednesday evening class) and 66 to the
control group (Thursday afternoon class). A
list with students’ names and group was sent
to the registration service at the Faculty of
Nursing, which was responsible for providing
schedule information to the students.
During the first class, information
about the study was provided by the two
professors who taught the course, including
an explanation of the purpose and design and
what participation in this study entailed. The
professors then left the classroom to avoid any
undue pressure to participate in the study; a
research assistant remained in the classroom.
Students who agreed to participate were
asked to sign a consent form. Students could
refuse to participate or could change groups;
these students were automatically excluded
from the study. A total of 116 students were
eligible for inclusion (60 in the intervention
group, 56 in the control group). Of these,
112 students (56 in each group) consented to
participate in the study.
Teaching Interventions
The research course aims to introduce
students to the various steps of research and
to train them in critical reading of scientific
articles. Course content and evaluation
methods were the same for both groups.
After the first class, students in the
intervention group were given access to 11
interactive, Internet-based modules for self-
study. These modules were combined with
five traditional classroom sessions. The online
modules were adapted from similar modules
used with medical students and medical
residents (Cauchon, Labrecque, Baillargeon,
Légaré, & Frémont, 2002). Content was
adapted to suit nursing undergraduates and
was based on the same material taught to the
control group.
The control group was instructed
using traditional methods in 13 classroom
sessions. The course offered an overview
of the research process, with an emphasis
on nursing research. Teaching methods
included PowerPoint-assisted lectures, class
discussion, small-group exercises, readings,
and quizzes. The evaluation methods were

identical for both groups and included four
separate group projects as well as two in-class
exams. Group projects were not considered
in the data collection as it would not have
been possible to distinguish individual
contributions. To diminish the potential
impact of a particular instructor’s influence,
the two professors took turns teaching each
group.
Data Collection
The impact of the teaching methods was
measured by examining three outcomes:
students’ knowledge, satisfaction, and
SDLR. Knowledge was assessed by students’
scores on the midterm and final exams,
which consisted of multiple-choice questions
and a few open-ended questions. Exams
were graded by an assistant blinded to the
research project.
Student satisfaction was evaluated
through a standardized satisfaction
questionnaire developed by Laval University.
This questionnaire uses 21 structured items
to measure satisfaction, as well as one item
that measures motivation (in three degrees:
unmotivated, more or less motivated, and
motivated) and two items identifying the
student’s profile: type of curriculum (initial
bachelor’s in nursing or bachelor’s in nursing
after a nursing diploma) and class attendance.
The 21 items measuring satisfaction were
four-point Likert-type statements (1 = totally
agree; 4 = totally disagree) with a fifth stating
not applicable. This instrument is mandatory
for the evaluation of all courses at the
university. The evaluation questionnaire was
distributed in the classroom and completed
by students during the last class, just before
the final exam.
The SDLRSNE, designed to measure
SDLR in nursing students (Fisher & King,
2010; Fisher et al., 2001), was developed and
validated in three stages: a comprehensive
literature search, a Delphi study, and a
pilot study of items on a sample of 201
undergraduate nursing students (Fisher et
al.). The final scale consists of 40 items in
three subscales: self-management, desire for
learning, and self-control. Several studies
have demonstrated the reliability and the
Impact of Blended Teaching
internal consistency of the SDLRSNE
across various samples (Bridges, Bierema, &
Valentine, 2007; Newman, 2004; Smedley,
2007). Fisher and King found support for the
factorial validity of the tool; 11 of the 40 items
had to be removed, as they failed to provide
a good fit with the subscales. Despite the
limitations of the study, especially its small
sample size, the authors recommended the
use of the 40-item SDLRSNE until further
research into the instrument is conducted.
Translation of the SDLRSNE
We translated this instrument into French
because we planned to use it with French-
speaking students. To do so, we followed
the steps proposed by Vallerand (1989) for
transcultural validation. A French language
version of the scale had been previously
developed by other researchers at Laval
University. We translated this version back
into English in order to identify translation
errors and correct them, back into French
to ensure the correspondence of the two
versions, and then into French again. We
conducted a pretest among students to
measure the tool’s ease of comprehension
and the length of time taken to complete the
questionnaire.
We evaluated SDLR using the 40 items
of the SDLRSNE on a five-point Likert
scale, with scores representing strongly
disagree, disagree, uncertain, agree, and
strongly agree. Two demographic items (age,
gender) completed the questionnaire. It was
distributed to students in the classroom
during the first and last classes.
Data Analysis
Data were analyzed by taking into account the
control variables described above (students’
gender, age, academic background, location
of prior studies). Descriptive analyses were
carried out first. The effect of the control
variables on the three outcomes was also
explored. Because the level of SDLR could
both influence learning outcomes and be
influenced by them, an analysis of covariance
(ANCOVA) was performed to measure the
association between teaching strategy and
postintervention SDLR (controlling for
preintervention SDLR and other covariates).
On the satisfaction measure, results were
compared between groups using ANCOVA.
Knowledge acquisition was measured by the
scores students received on two exams, and
these were analyzed using repeated measures
analysis of variance. All analyses were
performed using the SAS statistical package
(SAS Institute, 2005).
Results
The 112 students (56 in each group)
completed the first SDLRSNE questionnaire
at the end of the first class. Final exams were
completed by 52 students in the intervention
group and 50 in the control group. The
analyses are thus based on 102 participants.
As expected, no significant differences in
demographics between the two groups were
found. (See Table 1.)
Instrument Properties
Both the satisfaction and SDLRSNE scales
used for assessing outcomes showed high
internal consistency, with Cronbach’s alphas
of .83 and .94 for satisfaction and SDLR,
respectively. Furthermore, the temporal
stability (also known as the test–retest
reliability) of the SDLRSNE was acceptable
(intraclass correlation: .67).
knowledge Students in the two groups
did not differ in their global results on
both exams. For the global result, however,
an interaction effect was seen between the
students’ level of motivation and the teaching
method. Unmotivated students in the
intervention group performed significantly
better than unmotivated students in the
control group (17.2 ± .9 vs. 14.5 ± .6, p = .01).
When the two exam scores were considered
separately, a significant difference was found
between groups for the first exam at mid-
semester — the intervention group performed
significantly better than the control group —
but this difference was not observed for the
second exam. (See Table 2.)
satisfaction As shown in Table 2,
there was no significant difference between
groups regarding course satisfaction (the
control group was slightly more satisfied,
but not significantly). The only variable with
a significant positive effect on satisfaction
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 Nursing Education Perspectives

was motivation (p = .0005): for both groups,

Table 1: Characteristics of Participants students who were more motivated tended to
show greater satisfaction.
Intervention Group Control Group Total
(n = 52) (n = 50) (N = 102) sdlr There was no difference in the SDLR

score between the two groups. However,

Agea 23.43 ± 5.99 21.75 ± 4.6 22.59 ± 5.38 after adjusting for motivation, which was
incorporated in the model as a covariate, a
Gender b
Female 47 (84%) 51 (91%) 98 (87.5%)
significant difference on the SDLR score
was found postintervention (Table 3). This
Male 9 (16%) 5 (9%) 14 (12.5%)
difference depended on the SDLR score at
Study program b baseline. To explore the effect of teaching
A 36 (64%) 31 (55%) 67 (60%) method on SDLR, students in the two groups
B 3 (6%) 0 3 (3%) were assigned to three categories according
to their SDLR score at baseline: low, medium,
C 13 (23%) 20 (36%) 33 (29%)
and high. Among students with a low SDLR
Missing 4 (7%) 5 (9%) 9 (8%)
score at baseline, the control group improved
Originb significantly more than the intervention
Quebec 52 (93%) 52 (93%) 104 (93%) group (3.5 ± .3 vs. 1.9 ± .6, p = .01). Among
Other 4 (7%) 4 (7%) 8 (7%) those with a medium SDLR score at
baseline, those in the control group showed
a
Mean (± standard deviation); b n (%)
Note, A = initial bachelor’s in nursing, B = bachelor’s in nursing after a nursing diploma, significantly improved SDLR scores than
C = combined nursing diploma and bachelor’s those in the intervention group (3.8 ± .2 vs.
3 ± .3; p = .01). Conversely, among students
with a high SDLR score at baseline, the
Table 2: Difference Between Groups on Knowledge and on intervention group improved significantly,
Satisfaction compared with the control group (4.8 ± .2 vs.
4.3 ± .1; p = .02).
Intervention Group Control Group
Mean (SD) Mean (SD) p value (t-test)
(n = 52) (n = 50) * DISCUSSION
The results show that teaching method had
Exam 1a 19.6 (± 1.9) 19.0 (± 2.7) 0.0260 no direct impact on knowledge acquisition,
Exam 2b 13.3 (± 2.2) 13.6 (± 2.2) 0.6843 satisfaction, and SDLR. Thus, our two first
Satisfaction c
78.3 (± 11.9) 79.5 (±12.2) 0.6775 hypotheses were confirmed. However,
motivation and teaching method had an
a
Mean (± standard deviation); b n (%) interaction effect on knowledge acquisition.
Note, A = initial bachelor’s in nursing, B = bachelor’s in nursing after a nursing diploma,
C = combined nursing diploma and bachelor’s Students who were less motivated in the
intervention group performed better than
their counterparts in the control group,
and motivation was positively associated
Table 3: Difference Between Groups on Self-Directed with satisfaction in both groups. These
Learning Readiness (SDLR), Controlling for Baseline Scores findings are consistent with the literature
and Motivation on motivation and learning (Schiefele,
1991). Motivation influences what people
SDLR level Intervention group Control group p value learn, but also the intensity and duration
at baseline (n = 52) (n = 50) Difference (t-test)
of learning (Bandura, 1991). However, Siler
Low 1.91 3.53 1.62 0.0136 and VanLehn (2009) found that computer-
mediated learning did not change motivation,
Medium 2.99 3.81 0.82 0.0151
and Sankaran and Bui (2001) found that
High 4.79 4.28 -0.51 0.0235
students with similar motivation performed
equally well irrespective of teaching method

380 november/december 2013


(online or class lecture). Our study suggests
that less motivated students might benefit
from e-learning, although we used only a
single item to assess motivation.
Furthermore, contrary to our third
hypothesis, the teaching method was not
directly associated with students’ SDLR score.
Indeed, we found that motivation influenced
the relationship between teaching method
and SDLR. When controlling for motivation,
students with a higher SDLR score at baseline
significantly improved their score in the
intervention group, whereas students with
a lower SDLR score at baseline significantly
improved their score in the control group.
These findings are consistent with the review
by Jennings (2007) that concluded that SDL
is not suitable for every learner.
This study presents a pragmatic evaluation
of an innovative teaching strategy based on
online self-learning tutorials coupled with a
few in-class sessions. The results add to the
knowledge of the effectiveness of different
forms of e-learning for students in the
health professions (Cook et al., 2008), but
also provide evidence to support the use of
blended teaching methods, as suggested by
Ruiz et al. (2006). This study’s findings could
be transferable to similar student populations,
but more research is needed to evaluate the
effects of a blended-teaching method on
other nursing student populations.
This research also contributes to the
knowledge of e-learning in the nursing
curriculum by providing an example
of ICT use as well as a specific method
for the evaluation of an Internet-based
teaching technique. This research has
resulted in a French language adaptation
of the SDLRSNE, which seems to be a
promising tool for the assessment of learning
readiness in nursing students. Given the new
developments regarding this scale (Fisher &
King, 2010), it would be important to test the
revised version of the scale in future studies.
LIMITATIONS
Despite efforts to limit biases in this
study, it was conducted with real teachers
and students, and some biases may have
Impact of Blended Teaching
influenced the results. First, students
were not blinded to the intervention and,
given that both groups studied at the same
institution and in the same program, a
possible contamination may have occurred.
The e-learning modules were only accessible
to the students in the intervention group
who had a username and password, but it
is possible that some students in the control
group could have accessed it through their
classmates.
Second, the classes for both groups were
offered at different times of day (an afternoon
class for the control group and an evening
class for the intervention group). This may
have affected certain aspects of this study,
such as motivation, although students in the
intervention group could access the Internet
learning modules at any time.
Third, co-teaching could have influenced
the results of the study as a co-intervention.
However, this influence was the same
for both study groups, and co-teaching is
common for undergraduate nursing courses
at our institution.
Fourth, students in the control group
had to buy the course notes at the beginning
of the semester, while students in the
intervention group had electronic access to
the course notes and were invited to print
them themselves. Some students found it
unfair that the intervention group did not
have to buy their notes and raised this issue
when the study was explained to them during
the first class. Nonetheless, no difference
was seen between groups on student
satisfaction, which leads us to conclude that
this element did not affect outcomes. The
instrument used for measuring satisfaction
was a generic scale used in the evaluation
of all of our university’s courses. To assess
satisfaction, it might have been fruitful to
use instruments developed specifically for
e-learning (Wang, 2003). Finally, because
we based our assessment of motivation
on a single item, results from this variable
should be interpreted with caution. Future
studies should use a validated instrument for
assessing motivation because of its potential
relationship with e-learning success.
CONCLUSIONS
The findings of this randomized, controlled
study conducted in an educational setting
indicate that a blended-teaching method,
one combining Internet-based tutorials and
in-class sessions, is comparable to traditional
teaching in an introductory research course
for nursing undergraduates. This study
also suggests that blended-teaching better
suits some students, depending on their
degree of motivation and their SDLR. For
faculty planning an e-learning course, these
findings may be useful in choosing the best
teaching method to suit students’ needs and
learning styles.
About the Authors
Marie-Pierre Gagnon, PhD, and Johanne
Gagnon, PhD, are professors at the Faculty
of Nursing of Laval University and at the
Quebec University Hospital Research
Centre. Marie Desmartis, MA, is research
assistant at the Quebec University Hospital
Research Centre. At the time of the study,
Merlin Njoya, MSc, was biostatistician at the
Quebec University Hospital Research Centre.
The authors acknowledge the contributions
of Professor M. Fisher for giving permission
to use the SDLR instrument she developed,
and of Dr. M. Lacasse and her collaborators
for access to the French language version of
the SDLR instrument. We are also grateful
to the colleagues and students that helped
us with the translation and validation of
this instrument. A special thanks to Mr. S.
Turcotte, biostatistician, for his help with
the data analysis. This study did not receive
external funding. Marie-Pierre Gagnon
holds a New Investigator Career Grant
from the Canadian Institutes of Health
Research (grant #200609MSH-167016-
HAS-CFBA-111141). Write to Marie-Pierre.
Gagnon@fsi.ulaval.ca for more information.
Key Words
Computer-Based Learning – Nursing
Education – Randomized Controlled Design
– Self-Directed Learning Readiness –
Satisfaction
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 Nursing Education Perspectives
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