1. Buxton, Theresa PhD, RN, CNE
  2. Buxton, Jeffrey MBA
  3. Jackson, Alma PhD, RN, COHN-S

Article Content

Much has been written recently about hybrid, blended, and flipped learning strategies. Hybrid is classified as replacing at least 20% of campus-based meetings with online instruction, and hybrid plus replaces up to 80% of the course with online instruction.1,21,2 The term blended is used to describe programs that contain hybrid classes. Flipped classroom instruction assigns student learning activities before class in preparation for collaborative learning and mastery of content during class time.3,43,4


RN-BSN Program Changes

In fall 2012, an established campus-based RN-BSN program was converted into both a hybrid and flipped classroom design for 9 of 10 core nursing classes. Faculty teaching outreach classes traveled weekly in 8-week terms to their location, either on campus or at a local hospital site, to teach class at the students' workplace. The university also has a campus-based program in which students traveled to campus 1 night per week during the 8-week term. Hybrid classroom strategies were selected by the faculty to solve the problems with distance and commuting. Flipped classroom methods were selected to enhance student engagement during the times they met face-to-face and online. The overall objective was to incorporate the best of both learning environments. The role of faculty would be to act as facilitator, coach, and navigator. As students met face-to-face, they were able to work on project assignments, solve problems with their peers or the faculty, and actively apply what they learned in their class preparation. To enhance the student's learning and engagement with course material, a variety of technology and course tools were used. This included tools within the Learning Management System (LMS) such as dropbox, gradebook, and discussion forums. Other tools outside the LMS, including blogging, using flipped videos, creating infograms, and using photovoice, among other modalities, were integrated with various assignments.


Course Development

The process of converting the campus and outreach RN-BSN program began by asking the following questions: Do students taking a hybrid and flipped program format perceive enhanced learning, increased flexibility of time in their work/lives, and improved technology skills? Do faculty teaching in a hybrid and flipped classroom program format perceive benefits in providing this form of instruction, increased flexibility of their time, and increased proficiency in their technology skills? A review of the literature confirmed student or faculty satisfaction with various forms of hybrid instruction,5-75-75-7 although many studies were conducted on individual courses rather than entire programs such as ours. Finding the answers to our program questions would allow us to (a) provide an innovative enhanced learning product that met the needs of the school, students, and faculty; (b) decrease the number of face to-face sessions, thereby decreasing travel time; and (c) infuse technology to enhance learning and increase the flexibility of time experienced by both students and faculty.


Classroom Structure

Initially, the approach was to structure the 8-week courses so that they all had the same schedule of meeting face-to-face during weeks 1, 3, 6, and 8, with the remaining classes meeting online in the opposite weeks. The rationale was that students and faculty preferred the predictability and consistency of when and where class would be meeting. Attention was given specifically to assignments and timing for flipped classroom formats. Students would be actively engaged with the material such as project assignments during face-to-face classes and continue their engagement when they met online.



Student Survey

The pilot consisted of 64 students who completed the RN-BSN program. After institutional review board approval was obtained, these students received a letter of informed consent. Faculty were asked to place a copy of that letter into their course announcements section along with a link to the end-of-program survey. Follow-up e-mails were sent to faculty asking them to encourage students to complete the survey. Despite additional reminder letters, the final number of participants was 14.


The student survey contained 15 questions asking students to compare their previous face-to-face classroom experiences with the hybrid and flipped program experience. The questions in both the student and faculty surveys were reviewed for content validity by an expert panel involved in course development and were approved by the Quality and Evaluation Council. Using Likert Scales, students were asked questions about their level of skill with technology, amount of engagement during the courses, flexibility of time, and amount of preparation time before attending class. They also were asked open-ended questions about the perceived advantages and disadvantages of taking courses in a hybrid and flipped program format, as well as satisfaction with the program's format.


Faculty Survey

There were 15 full-time and affiliate faculty who taught the 6 cohorts of students in the RN-BSN hybrid and flipped program. A total of 12 faculty responded to the 13-question survey with both qualitative and quantitative questions. They were asked to identify past teaching experiences; their current rank; various tools, skills, and experiences needed for hybrid and flipped instruction; and their satisfaction with teaching a hybrid and flipped course and to rate the level of support received during the course. Open-ended questions were asked about their perspective of the differences between face-to-face and hybrid and flipped instruction and rate the level of improvement in students and their own technology skills.



Student Data

Data were analyzed using SPSS PASW Statistics GradPack 18. All of the students indicated that this was their first experience with taking hybrid and flipped classes. Students reported an average skill level of 2.91 (1 = unskilled and 5 = highly skilled) with using technology before starting the program. At completion of the program, however, students rated their skill level at 4.5, which was a significant increase (t = 5.397, df = 13, P < .01). When asked to compare their previous experience of learning in traditional face-to-face classes versus the hybrid/flipped program, 78.6 % believed they were more engaged in the learning process.


Students rated their overall satisfaction with the RN-BSN hybrid/flipped program in 3 areas. They had high satisfaction with the overall hybrid and flipped format (mean [SD], 1.2 [0.4]), enhanced learning (mean [SD], 1.4 [0.6]), and satisfaction with their technical skills (mean [SD], 1.4 [0.6]), measured on a 5-point Likert scale of 1 = highly satisfied to 5 = highly dissatisfied. In addition, students were asked open-ended questions about the advantages and disadvantages of the RN-BSN program in a hybrid format. The single most identified advantage of the program was flexibility of time. The ability to balance school, family, and employment obligations was essential for many students to be successful.


Faculty Data

Of the faculty respondents, 83% had previous face-to-face teaching experience, 25% had taught online, 8% reported teaching in a hybrid format, and 25% identified other teaching experiences such as in clinical courses. Faculty were satisfied with this format (mean [SD], 1.33 [0.47]) and the support given (mean [SD], 1.08 [0.28]) and are likely to use the hybrid and flipped format again (mean [SD], 1.0 [0.00]). Faculty comments included the following: "Hybrid and flipped courses offered a variety of methods of learning for students. They prepare students for the needs of our changing health care environment. They expand students' technical skills and build written communication balanced with oral communication skills." Another faculty member reported that this format was the "best of both worlds for teaching. It gets away from the sage on the stage and allows for teaching students in new ways to support their learning while also preparing for the real world of technology in nursing."


Faculty were asked to identify skills, techniques, tools, and previous experiences that were essential when teaching a hybrid course. The most common faculty response included the need for computer skills, time management, communication, and facilitation skills. Techniques identified were flexibility, openness to learning and doing things a new way, and Socratic questioning. Faculty listed tools such as problem solving, being a self-directed learner, and the need for advanced computing skills as key resources for students. Essential experiences identified by faculty included previous experience teaching in both a face-to-face and online classroom environment.



Overall, this case study supports the continued use of providing the RN-BSN program in a hybrid and flipped format. Both students and faculty were satisfied with the enhanced learning, increased flexibility, and improved technology skills. On the negative side, however, educators mentioned the need to learn a new system and technical issues with teaching in this new environment. Similar sentiments were expressed by some students. The unfamiliarity of the technology can be initially daunting, and support needs to be provided for faculty and students to be comfortable using the technology as they gain confidence and competence. However, the initial discomfort can be overcome with time and guidance so that learning improves as proficiency increases. One main advantage of hybrid and flipped classrooms is the ability to integrate technology with learning.




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