JNSD Journal for Nurses in Staff Development & Volume 28, Number 4, 186Y190 & Copyright B 2012 Wolters
012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Blended Versus Lecture Learning
Outcomes for Staff Development
Heidi Sherman, MSN, RN-BC ƒ Linda Comer, PhD, RN, CNE ƒ
Lorene Putnam, EdD, RN, CNE ƒ Helen Freeman, MSN, RN-C
Critical care pharmacology education is crucial to safe
patient care for nurses orienting to specialized areas. Although
traditionally taught as a classroom lecture, it is important to
consider effectiveness of alternative methods for education.
This study provided experimentally derived evidence
regarding effectiveness of blended versus traditional lecture
for critical care pharmacology education. Regardless of
learner demographics, the findings determined no significant
differences in cognitive learning outcomes or learner
satisfaction between blended versus lecture formats.
C
ritical care pharmacology is a complex course re-
quiring a significant amount of drug information
content. Inexperience and lack of drug knowl-
edge by new graduates or experienced nurses entering
critical care increase the risks for medication errors
(Camire, Moyen, & Stelfox, 2009). Learning must occur ef-
ficiently to prepare the nurse to work in a critical care
unit, and lecture has been a traditional method for deliv-
ering this content.
Provision of critical care pharmacology in the most ef-
fective learning format ultimately improves patient safety
and care. It is important to research the most effective
methods of providing this education rather than relying
on the traditional method of lecture. The purpose of this
experimental research study was to identify learning out-
comes and student satisfaction associated with blended
versus traditional lecture classroom learning of critical care
pharmacology nursing continuing education.
Heidi Sherman, MSN, RN-BC, is Education Specialist II, Nursing Practice,
Education and Research, Mission Hospital, Asheville, North Carolina.
Linda Comer, PhD, RN, CNE, is Associate Director for Graduate Nursing
Programs, School of Nursing, Western Carolina University, Candler,
North Carolina.
Lorene Putnam, EdD, RN, CNE, is Dean, School of Nursing and Health
Sciences, Union College, Barbourville, Kentucky.
Helen Freeman, MSN, RN-C, is Web Development Manager, Chamberlain
College of Nursing, Arlington, Virginia.
The authors have disclosed that they have no significant relationship with,
or financial interest in, any commercial companies pertaining to this article.
ADDRESS FOR CORRESPONDENCE: Heidi Sherman, MSN, RN-BC,
Mission Hospital, 509 Biltmore Avenue, Asheville, NC 28801 (e-mail:
heidi.sherman@msj.org).
DOI: 10.1097/NND.0b013e31825dfb71
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Garrison and Kanuka (2004) described blended learn-
ing as ‘‘the thoughtful integration of classroom face-to-
face learning experiences with online learning experiences’’
(p. 95). Studies indicated that blended learning is an effec-
tive alternative education method with similar or better
outcomes compared with lecture (Adams & Timmins, 2006;
Sheen, Chang, Chen, Chao, & Tseng, 2008; Sung, Kwon, &
Ryu, 2008). However, according to O’Neil, Fisher, and
Newbold (2008), it was also important to design and de-
velop content appropriate for online learning.
Study Hypotheses
1. There will be no significant difference in cognitive
learning outcomes or learning satisfaction between
nurses receiving critical care pharmacology educa-
tion via blended versus lecture format.
2. There will be no significant relationship between
demographics and outcomes for blended versus
lecture education.
BACKGROUND
McCartney and Morin (2005) described a gap in evidence-
based teaching due to lack of experimental research relat-
ing to general nursing education topics. There are, however,
several studies relating to the use of blended learning
as an effective method for educating nursing students
(Bata-Jones & Avery, 2004; Ireland et al., 2009; Sung
et al., 2008).
Research regarding blended learning identified advan-
tages compared with traditional lecture. Most qualitative
studies reported increased student satisfaction as a com-
mon finding, whether in nursing or other related healthcare
fields (Adams & Timmins, 2006; Ireland et al., 2009; So,
2009). Benefits included scheduling flexibility (Ireland
et al., 2009; So, 2009), increased time for higher learning
activities and discussions ( Jeffries, Wolf, & Linde, 2003),
as well as more time for practical or ‘‘hands-on’’ nursing
education (Sung et al., 2008). In addition, self-paced learn-
ing allowed the student to accommodate for previous
experience ( Jeffries, 2001) and decreased frustration with
the course pace often associated with a lecture format
(McCain, 2008). Thus, the online format more readily al-
lowed the student to individualize education based on
personal needs.
July/August 2012
 Furthermore, studies of blended learning identified its
cost-effectiveness (McCain, 2008). Berke and Wiseman
(2003) found that e-learning programs saved 20%Y60%
in time compared with traditional classroom learning.
A study by Jeffries (2001) noted a time decrease from
3 hours for lecture learning to 2 hours for blended edu-
cation, whereas McCain’s (2008) study found a decrease
in time between lecture and blended learning from 8 hours
to 1.5Y2 hours.
However, studies also described advantages of face-
to-face interaction that cannot be provided by e-learning.
Learners may prefer the face-to-face interaction and tra-
ditional student role associated with lecture. So (2009)
described face-to-face discussion as important for shar-
ing ideas, working collaboratively, and answering ques-
tions without delay (McCain, 2008). The instructor also
benefited from face-to-face discussion because of being
able to monitor visual cues to students’ understanding of
educational content (Johnson, 2008).
Disadvantages of e-learning associated with a blended
format include computer skill deficiencies or insufficient
knowledge of software requiring time and support from
the instructor (Morrow, Phillips, & Bethune, 2007). These
problems and issues associated with technical difficulties
can be a source of tremendous frustration for students
(Sheen et al., 2008).
The vast majority of studies found blended learning
for healthcare education provided equivalent or better
learning outcomes than traditional lecture (Adams &
Timmins, 2006; Bata-Jones & Avery, 2004; Ray & Berger,
2010; Sheen et al., 2008). Several studies identified stu-
dent self-selection of the learning format as a possible
limitation, allowing students with an inherent preference
for computers to skew study results. Furthermore, most
experimental studies used small sample sizes, limiting
ability to generalize findings.
Research relating to blended learning frequently de-
scribed the critically important aspect of course design
for success of the education (Adams & Timmins, 2006;
So, 2009). The quality of content and the ability of the in-
structor also influence the lecture format. It is important
to know what material is effective in an online format
versus that which lends itself to face-to-face lecture (So,
2009). Therefore, content and presentation issues must
be carefully considered when preparing all education.
METHODS
Design
This study was a randomized controlled trial to provide
evidence regarding effectiveness of blended versus lec-
ture format for cognitive learning in the nursing staff de-
velopment (hospital) setting. Staff registered nurses (RNs)
or new graduate nurses planning to work in critical care
Journal For Nurses in Staff Development
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
were approached during orientation. New nurses assigned
to work in critical care areas were recruited regardless of
prior experience or knowledge. A large Western North
Carolina community hospital with multiple critical care
areas was the location for research.
All participants provided consent to participate in the
study. The study was approved by hospital and univer-
sity institutional review boards. Participation was clearly
described as voluntary with no adverse consequences for
nonparticipation.
Seventy participants were randomized into an experi-
mental group to receive education in a blended format
or a control group to attend a traditional lecture. All par-
ticipants completed a pretest and a survey of demo-
graphics before education. The blended study group
was assigned 4.5 hours of interactive critical care phar-
macology learning modules delivered via the hospital’s
learning management system and a 2-hour discussion
session following module completion. The control group
attended the traditional 6.5-hour lecture offered to nurses
new to critical care.
Following education, participants completed a written
critical care pharmacology test. Tests were blinded and
proctored, and an experienced RN educator corrected
exams using a grading rubric. Upon test completion, nurses
were invited to participate in a focus group to discuss sat-
isfaction with education and to determine total number of
hours to complete the education.
Instruments
The study used instruments to measure demographics,
cognitive learning, and education effectiveness. Initially,
basic demographic data including age, gender, RN prep-
aration, prior online education experience, and experi-
ence in health care were collected from each participant.
The 46-item posttest was used to assess all critical care
nurses employed in the hospital during orientation. The
instrument consisted of multiple choice, true/false, short
essay, and calculation questions. A KuderYRichardson
20 of 0.70 was determined for test reliability. Test content
was validated through expert review by four critical care
nurse educator experts.
With the reliability and validity of the posttest estab-
lished, a pretest was compiled using 10 questions from
the pharmacology posttest. All subjects completed this
brief multiple-choice pretest.
The critical care pharmacology educational class ob-
jectives were evaluated by both groups using a Likert-
scale tool. Each objective for online modules, discussion
session, and lecture was ranked immediately upon com-
pletion of the education. The researcher prepared all on-
line self-study materials and led discussions, critical care
pharmacology lectures, and focus groups. Self-study mod-
ules were created using the interactive online authoring
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tool, Articulate. Critical care nurse educators tested the TABLE 1 Demographics of Blended and
online education to ensure that there were no technical
issues with accessing or completing modules. Detailed in- Lecture Participants
structions for technical support and access of computers Blended, Lecture,
were created for blended learning participants. Demographics n (SD) n (SD) p
Gender
Data Collection
Male 6 (17.1%) 5 (15.2%) 1.00
Following the educational intervention, participants were
given 2Y3 weeks to study material before taking the post- Female 29 (82.9%) 28 (84.9%)
test. Once corrected, tests were reviewed with responses
compiled in Excel spreadsheets to track demographics Age (M in years) 32.6 34.8 .33
and pretest and posttest results. Experience
Participants provided feedback and information through
focus groups after completion of the posttest. These ses- New grad 20 (57.2%) 15 (45.4%) .47
sions were poorly attended, so randomly chosen partici- Experience as RN 5.5 6.7 .57
pants were approached on the units during downtime to (M in years)
request additional feedback. Information was gathered
from a total of 11 participants. Education

Associate degree 20 (57.1%) 22 (66.7%) .53

Data Analysis
Demographics were compiled and compared using Fisher’s
exact test or pooled t test. Pretest and posttest results were
analyzed for central tendencies (means) with standard de-
viation and were compared between groups using paired
t-test analysis. Finally, pooled t tests compared demo-
graphics with posttest scores for analysis. A threshold
p value of .05 was used for the study.
RESULTS
The original sample size designated for the study was 70;
however, the number of participants completing the study
was 68. Two subjects dropped from the lecture learning
group: one resigned employment with the hospital, and
the other did not complete the posttest in the designated
time frame.
Demographics of the groups are noted in Table 1.
Male/female ratios were comparable, and average partic-
ipant age was 33.7 years. New graduates comprised 51.5%
of the study population, whereas experienced RNs had an
average of 6.1 years of experience. The analysis of partic-
ipant nursing degrees revealed 61.8% with an associate’s
degree, 1.5% with a diploma, 36.8% with a BSN, and none
with an MSN. Finally, 75% of participants reported pre-
vious experience with online learning.
Pretest scores between groups were compared to de-
termine participant baseline knowledge (see Table 2).
Average pretest scores were 62.6 for the blended group
and 60.9 for the lecture learning group, with a resulting
p value of .68.
The results of posttest scores indicated similar out-
comes between groups (see Table 3). Comparing the
posttest scores, a p value of .34 was determined by t-test
analysis. When adjusted for initial pretest scores, a p value
of .58 indicated no significant differences between groups.
Diploma 1 (2.9%) 0
BSN 14 (40%) 11 (33.3%)
Online education 38 (80%) 23 (69.7%) .41
experience
Finally, the overall change in scores from pretest to posttest
resulted in nearly identical values.
Further analysis compared learning groups to assess
the affect of demographic differences on posttest scores.
In each category measured, no statistically significant dif-
ferences were found (see Table 4). Nurses with experience
actually scored lower (88.6) than the new graduates (89.5),
possibly a reflection of experienced nurses’ confidence in
prior knowledge or lack of recent test-taking experience.
A closer comparison of experience determined no signif-
icant difference (p = .23) between nurses with 0Y3 years
in nursing versus those with 4 or more years of experi-
ence. Age also was apparently not a factor in test score
results. Participants with ages of 30 years old or younger
scored an average of 89.6 on the posttest, whereas nurses
older than 30 years scored 87.5.
Nurses with a BSN scored 90.2 on the posttest com-
pared with those with an associate degree in nursing,
who scored an average of 88.2. Again, the p value of
.19 did not find significance in these differences. Finally,
although most participants indicated prior experience
with online learning, those with previous online experi-
ence scored an average of 89.6 whereas those with no
computer learning experience scored 87.4 (p = .19). There-
fore, gender, age, nursing experience, educational prep-
aration, or online learning experience of participants did
not influence the effectiveness of the learning method and
posttest score.

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TABLE 2 Pretest Result Blended Versus TABLE 4 Overall Demographic and Posttest
Lecture Comparison Result Comparison
Pretest Blended Lecture p Posttest
M (SD) 62.6 (15.59) 60.9 (17.56) .68 Demographic Score % SD p
Gender
Range 30Y90 20Y100
Male 90.4 6.17 .46

A compilation of Likert-scale evaluations indicated Female 88.8 5.99

some differences in participant responses to effectiveness New graduate
of education (see Table 5). The discussion group received
the highest percentage of ‘‘excellent’’ responses to the Yes 89.5 6.31 .51
education (97.1%), followed by the computerized learn- No 88.6 5.71
ing modules (91.4%) and lecture (87.9%). Although there
were differences, these did not reach statistical significance RN years of experience
with a p value of .36.
0Y3 89.6 6.07 .23
Satisfaction with the method of education was dis-
cussed with focus group participants. Blended learning 4+ 87.5 5.64
participants responded very positively, indicating that
Age
the format was beneficial allowing for self-pacing and
flexibility, interaction, and repeated access to information. 30 or younger 90.1 5.66 .19
The discussion sessions were considered valuable for
clarification and to answer questions. 31 or older 88.2 6.20
Responses from lecture learners were also positive Education
but less detailed than those of blended learners. Advan-
tages of lecture primarily related to interaction accorded Associate degree 88.2 6.01 .19
by the format: the ability to ask questions and interact Bachelor’s degree 90.2 5.95
with the instructor.
Finally, blended learning participants were asked the Online experience
number of hours to complete computer modules. Time Yes 89.6 5.85 .19
completion responses ranged from 1 to 8 hours. Analysis
determined a mean of 3.3 hours; less than the 4.5 hours No 87.4 6.29
was allocated for module completion. When added to
the 2-hour discussion time, total blended learning format
comes and both formats equally improve cognitive knowl-
required an average of 5.3 hours as compared with the
edge of critical care pharmacology. These findings are
6.5-hour lecture.
consistent with previous studies indicating no differences
in cognitive outcomes from blended versus traditional
DISCUSSION formats (Adams & Timmins, 2006; Sheen et al., 2008; Sung
Study results indicate that education offered in either a et al., 2008). A common perception persists that comput-
blended or lecture format achieves similar learning out- erized education is more difficult for older learners; this

TABLE 3 Posttest Result Blended Versus TABLE 5 Participant Evaluation of

Lecture Comparison Class Effectiveness
Post-test Blended Lecture p Class ‘‘Fair’’ or
Effectiveness ‘‘Excellent’’ ‘‘Good’’ ‘‘Poor’’ Total
M (SD) 89.7 (5.16) 88.3 (6.79) .34
Lecture 29 (87.9%) 4 (12.1%) 0 33
Range 78Y98 76Y99 (100%)

Mean adjusted for 89.7 88.3 .58 Computer 32 (91.4%) 3 (8.6%) 0 35

pretest scores (100%)

Change in score 27.2 T 6.65 27.4 T 18.09 .96 Discussion 34 (97.1%) 1 (2.9%) 0 35
pretest to posttest (SD) (100%)

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did not hold true in this study. In addition, results deter-
mined no significant differences in posttest scores asso-
ciated with participants’ age, gender, education, nursing
experience, or computer learning experience.
Study findings also determined that experience with
computer online learning was not a factor in posttest
scores. Technical problems with computers have been
identified as a significant barrier to satisfaction and learn-
ing in studies of computerized education (Sheen et al.,
2008). Therefore, to assist participants without prior on-
line experience, significant steps were taken to address
technical issues before assigning online education, in-
cluding an extensive trial of the modules to address po-
tential problems.
Focus group sessions found nurses participating in
blended learning described advantages of self-pacing,
flexibility, and interactivity as favorable aspects of this for-
mat. Online learning also provides the opportunity to
return/reinforce education at any time. Flexibility is partic-
ularly important for nursing staff working weekends or
nights and decreases the need for staff coverage to attend
lectures. In addition, the interactivity of modules requires
the participant to concentrate and participate in the edu-
cation, a key principle of adult education. By comparison,
lecture learning was also well received, with participants
describing advantages of discussion and interaction with
the instructor. Because this is the predominant format used
in hospital education, it was familiar and comfortable to
most learners.
Blended and lecture formats revealed a difference in
time to complete the education. Lecture learners received
6.5 hours of education in one class day, whereas blended
learners reported a mean time of 5.3 hours taken. This dif-
ference indicates 1.2 hours less to complete the blended
learning components compared with lecture and could be
an economic benefit to the institution.
A few study participants, particularly those older and
with less online experience, requested a change from
blended to lecture learning, whereas some younger learn-
ers indicated they would prefer blended. Because of the
study design, these requests were not accommodated.
However, according to study results, outcomes of learn-
ing were equivalent regardless of the learner’s preference.
Limitations
A sample size of 70 limited the ability to generalize study
conclusions and did not provide sufficient data to ensure
that these findings will occur in other situations and set-
tings. Furthermore, learner satisfaction results may have
been affected by low attendance at focus groups.
The use of posttest questions for the study pretest may
threaten internal validity. In addition, the ability to create
effective computerized learning modules or to present
lectures capably may influence outcomes in other set-
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tings. Finally, the specific topic of critical care pharmacol-
ogy may lend itself to blended learning whereas other
content may not.
CONCLUSIONS
The ultimate goal of nursing education is to ensure and
enhance safe nursing practice. Effective methods to im-
prove learning as a basis for safe practice subsequently
affect patient care. Results of this study provide data to
support effective provision of cognitive learning.
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