Nursing Undergraduate Students’ Experiences and Perceptions of Blended Learning in Pediatric Nursing: A Mixed Methods Study

Abstract

Introduction

Blended learning is a teaching approach that integrates online self-learning and classroom teaching. It emphasizes students’ self-directed learning, actively engaging, as well as communication and collaboration. Blended learning develops the qualities in nursing undergraduate students with problem-solving ability, clinical thinking, and communication skills as nurses have. Currently, learners’ experience has become an important factor in determining the success of blended learning.

Aim

To learn about the experiences and perceptions of undergraduate nursing students regarding blending learning in pediatric nursing.

Methods

A mixed methods design beginning with a quantitative data collection and analysis phase to inform the subsequent qualitative phase was utilized. This study was conducted among undergraduate nursing students at one university in China. In the quantitative study phase, a convenience sample of 59 students completed the online survey while the qualitative study phase included nine students recruited by purposive sampling. The qualitative data were collected using individual semistructured in-depth interviews. Audio data were transcribed and subjected to thematic analysis. The findings from those two phases were integrated into the final analysis.

Results

The majority (89.8%) of students reported satisfaction with blended learning. Among various teaching methods, case-based learning (CBL) was the most preferred (98.3%). Regarding the qualitative data, students reported positive experiences with blended learning including well-organized course structure, resourceful course content, and high teacher quality. They stated that blended learning improved the learning outcomes such as improving problem-solving ability and developing clinical thinking. They also provided suggestions for achieving better learning outcomes, including providing stressful learning activities, optimizing online course design, and improving the quality of group learning.

Conclusions

The blended learning model of pediatric nursing based on the Community of Inquiry framework provides a positive learning experience for nursing undergraduate students. However, ongoing assessment and improvement of the blended learning process are also needed.

Keywords

blended learning pediatric nursing education undergraduate nursing

Introduction

Blended learning is an educational strategy that combines traditional classroom activities with online activities in a flipped environment, where the responsibility of the teaching process is transferred to the students, who have direct access to the lessons’ content before entering the physical classroom (Zhong et al., 2022). In recent years, blended learning has emerged as a promising teaching strategy in nursing education. Previous research has focused on exploring the effects of blended learning compared to other teaching models via qualitative, quantitative, or mixed methods (Berga et al., 2021; McCutcheon, Lohan et al., 2015; McCutcheon, O'Halloran et al., 2018). A systematic review showed that blended learning is more effective than traditional lecture-based classes in improving learners’ knowledge, skill performance, and learning satisfaction (Du et al., 2022). Blended learning emphasizes students’ ability to learn independently, actively engage, as well as communicate, and collaborate to create a positive interactive teaching and learning system. Previous studies showed that blended learning promoted outside-the-class learning, active learning, team interactions, reflection, and problem-solving ability of undergraduate nursing students (Alshawish et al., 2021; Hee & Hae, 2021). This new instructional strategy also conserves nursing education resources and promotes the development of nursing education in a balanced manner (Du et al., 2022). Currently, an increasing number of scholars have proposed that research on blended learning is needed to identify best practices for its application in nursing education and how to maximize the efficacy of blended learning, and to analyze key influencing factors (Leidl et al., 2020). The focus on the learner's learning experience has become a key emphasis in the development of blended learning.

Review of Literature

Learning experience refers to the subjective experiences and feelings that learners feel about the school, curriculum, teachers, learners themselves, and other aspects during the learning process in school (Deng, 2015). Learner experience is an important basis for evaluating the quality of the course and the efficacy of instruction. When learners’ perceptions of the learning experience and teaching effectiveness are higher than their initial expectations, they will gain satisfaction in their course learning (Anh-Nguyet et al., 2017). Therefore, the current focus of blended learning research is on determining how to optimize the course design of blended learning from the perspective of the learner experience to improve the course's quality and teaching effectiveness.

The traditional lecture-based classroom has been used in pediatric nursing, which is teacher-centered, and where learners develop knowledge in a predetermined manner (Horsfall et al., 2012). This pediatric nursing teaching model is plagued by insufficient student learning initiative, weak participation, and low learning efficiency, resulting in unsatisfactory student learning outcomes such as poor knowledge mastery and inadequate ability to apply learned knowledge and skills to clinical practice. In response to these weaknesses, our school has conducted blended learning guided by the Community of Inquiry theoretical framework (Garrison et al., 2000), as shown in Figure 1.

Figure 1.

The community of inquiry framework.

The Community of Inquiry framework is an important pedagogical theory in both online learning and blended learning. It is guided by constructivist theory and focuses on how students construct knowledge effectively. The theory has three core dimensions, including cognitive presence, social presence, and teaching presence (Garrison et al., 2000). Akyol et al. (2009) found that all three dimensions were related to learning experiences.

Cognitive Presence is the extent to which learners are able to construct and confirm meaning through sustained reflection and discourse (Garrison et al., 2001). It triggers students to enter a learning state by designating a problem or task in which they explore relevant information or knowledge to determine a solution to a problem by analyzing and integrating different perspectives and understandings, and ultimately solving the problem. Archibald (2010) states that in comparison to open-ended discussions, students’ inquiry activities in case-based discussions are more able to reach the solution stage. Using the Community of Inquiry framework as the theoretical lens, multiple learning tasks are assigned in pediatric nursing blended learning, such as topic discussions and presentation, quizzes, drama play, and case studies, to motivate students to enter the learning process through problem solving.

Teaching presence refers to the design, facilitation, and instruction of learners’ cognitive and social processes to achieve personally meaningful and educationally valuable learning outcomes, and includes three subcategories: design and management, facilitated dialogue, and direct instruction (Anderson et al., 2001). Quality inquiry community activities provide students with challenging tasks. The design and assessment of these tasks should be based on authentic settings and should be conducted to provide clear descriptions and structured prompts. In view of this, in the blended learning of pediatric nursing, real clinical cases or cases that occur around students are adapted and applied to case-based learning (CBL), guiding students to use what they have learned to solve problems, thereby constructing and acquiring new knowledge and skills. Topics for thematic discussions in online learning and flipped classrooms (FCs) are closely related to life.

Social presence is “the ability of participants to identify with the community (e.g., course of study), communicate purposefully in a trusting environment, and develop inter-personal relationships by way of projecting their individual personalities” (Garrison et al., 2004). Social presence encourages interpersonal interaction, which in turn is the basis for critical thinking and higher-level learning. Therefore, a variety of interactive teaching methods are used in both online and offline pediatric nursing teaching, such as questioning, role play, and scenario-based simulation.

The Community of Inquiry framework advocates supporting collaborative learning and critical reflective dialogue, leading to deep and meaningful online and blended learning (Garrison et al., 2001). In light of this, multiple collaborative group learning tasks are assigned in the FC of pediatric nursing, to enable students to gain a holistic understanding of knowledge through discussion and collaboration to complete the learning tasks.

In summary, for educators concerned with the effectiveness of students constructing knowledge, the Community of Inquiry framework offers a theoretical lens for blended learning. Based on this theory, we designed blended learning in pediatric nursing. This study aims to investigate the learning experience of nursing undergraduates under blended learning of pediatric nursing, to deeply explore their perceptions of the blended learning model of pediatric nursing, and to summarize their opinions on further improvement of the model.

Methods

Design

This study employed a mixed methods approach that was designed to combine a quantitative descriptive approach triangulated with qualitative research. The explanatory sequential design was conducted, beginning with a quantitative data collection and analysis phase to inform the subsequent qualitative phase. This study design helps to gain a more comprehensive understanding of issues with the consideration of the voices of participants (Guetterman et al., 2015). This design was considered to be the most appropriate way of achieving the study aims. The qualitative and quantitative results are integrated in the discussion. The Good Reporting of a Mixed Methods Study guideline (O’Cathain et al., 2008) was used in reporting this study. This study was approved by the Peking University Institutional Review Board [IRB00001052-22143].

Context

The blending learning of pediatric nursing integrates the flexibility and availability of online learning and offline classrooms with diverse teaching strategies to increase interaction between instructors and students. Theory classes consist of a 4-hr FC, 4-hr CBL, 12-hr online classroom, and 34-hr traditional lecture-based classroom. Formative and summative evaluations are performed. Formative evaluation is based on the following performances: 15% participation in CBL and FC (two group assignments plus individual participation in discussions); 10% completion of online videos; 15% clinical performance and 60% final exam score. Blended learning was implemented by the full-time faculty from the School of Nursing and senior clinical faculty from the affiliated hospitals. Two graduate students assisted in teaching.

Research Questions

What are the learning experiences of blended learning among nursing undergraduates?

What are the perceptions of blended learning among nursing undergraduates?

What are the nursing undergraduates’ opinions on further improvement of blended learning?

Participants

The sample for this descriptive research was selected using convenience sampling and cluster sampling methods. A total of 82 students who had studied pediatric nursing in 2022 were invited to participate in the study by the first author in a face-to-face interview. Eventually, 59 students completed the questionnaire and the remaining 23 refused to participate in the survey. The inclusion criteria were as follows: (a) full participation in the blended learning pediatric nursing course in 2022; (b) undergraduate nursing students. Participants diagnosed by a physician with mental, emotional, or cognitive disorders were excluded because their ability to objectively report their experiences and perceptions may be compromised.

The sample for the qualitative research was chosen by purposive sampling. Semistructured interviews were conducted among the participants two weeks after the course. Inclusion criteria: (a) full participation in blended learning of pediatric nursing; (b) normal expression skills and willingness to express their true feelings. Exclusion criteria: (a) mental, emotional, or cognitive impairment diagnosed by a physician; (b) repeating students. The sample size was based on information saturation and no new themes emerged. To ensure the richness of the cases, differences existing in class, gender, and learning performance points were considered in the sampling. Characteristics considered for recruitment included class, gender, and grade point average (GPA). The sample size was determined by data saturation (Cleary et al., 2014). That is, once no new information was obtained, data collection ceased.

Instruments

Questionnaire Survey

The questionnaire consists of two parts. The first part contains the general information of students, such as gender, previous grades, preference for blended learning, and satisfaction with teacher literacy and different teaching methods (FC, CBL, online class, traditional lecture-based class). The second part is the learning experience evaluation questionnaire, which refers to the “Online Course Learning Experience Scale” (Zhang & Li, 2021) and is adapted to the characteristics of this course with six dimensions (26 items). The six dimensions are content and resources (three items), course structure and organization (five items), functional and technical environment (four items), learning support and services (seven items), course knowledge and ability (four items), and evaluation method (three items). The questionnaire uses a 5-point Likert scale (strongly disagree to strongly agree) to quantify students’ learning experiences and subjective judgments during the blended learning process. The scores of each item are summed to obtain a total score, ranging from 26 to 130 points, with higher scores indicating a better experience. Six nursing education experts were consulted to review the validity of the questionnaire. The content validity index (CVI) of the questionnaire was 0.923. The exploratory factor analysis identified a six-factor structure, as had been anticipated, with a cumulative contribution of 77.97% for the six factors. The internal consistency coefficient of the questionnaire was 0.968, and the internal consistency coefficient of each dimension ranged between 0.812 and 0.914.

Semistructured Interviews

The original version of the interview guide was scrutinized by two nursing education experts to confirm the suitability of the questions. The interview guide was pretested on two students to ensure the acceptability of the questions. The pretest data were not included in the study. The following questions were asked: What is your learning experience and what do you think why you have such kind of experience? What are your thoughts and suggestions on teachers’ teaching literacy? What are your ideas and suggestions for teaching resources? What are your ideas and suggestions for teaching content? What are your ideas and suggestions for instructional design and organization of instructional activities? What are your ideas and suggestions for the learning atmosphere? What are your ideas and suggestions for teacher-student communication and feedback? How do you think the blended learning of pediatric nursing has affected your learning? What do you think needs to be improved in blended learning of pediatric nursing?

Data Collection

Questionnaire Survey

The online questionnaire link was sent to the students one week after the end of the course. The questionnaire was established on the Questionnaire Star platform and sent to respondents via a WeChat class group. The purpose and significance of the study were explained in the questionnaire instructions, students who wish to participate in this study are required to first complete the online informed consent form before starting to fill in the questionnaire.

Semistructured Individual Interviews

A semistructured individual interview was conducted by the first author (YYY) in her office using a phenomenological research method. She is a trained qualitative researcher with previous experience in this field. She has been engaged in the instruction of pediatric nursing for a considerable period of time and has been involved in the implementation of blended learning reforms. Consequently, she is particularly interested in the student experience within this teaching model. The purpose and methods of this study were explained to the interviewees before the interview, and their consent was obtained before signing the informed consent form. The whole interview was recorded, and notes were taken. The privacy of the study subjects was fully protected during the study, and all data were processed anonymously. Interviews were conducted in a quiet and undisturbed room and lasted approximately 45–60 min. The interview summary was completed on the day of the interview, and a verbatim transcription of the interview was completed within 1 week. Data saturation was discussed among the authors.

Data Analysis

Descriptive data were reported to show participants’ demographics and satisfaction with different teaching methods. One-way ANOVA and independent sample t test were performed to compare the learning experience questionnaire scores of participants with different demographics on the quantitative data using SPSS24.0.

Thematic analysis was used in the analysis of the qualitative data. Key themes were collaboratively identified employing Colaizzi's phenomenological analysis (Colaizzi, 1978). The recording obtained from the interview was transcribed verbatim by two researchers within 24 hr. Two researchers read the data and transcripts independently. Each data set or transcript was coded to identify meaningful sentences. Then, the themes were generated. If there were differences in themes, the researchers discussed them until a consensus was reached.

Results

Quantitative Findings of the Study

A total of 82 questionnaires were distributed, and 59 were recovered as valid, with an effective recovery rate of 71.95%. Demographics and level of satisfaction with blended learning are shown in Table 1.

Table 1.

Demographics and Level of Satisfaction With the Blended Learning (n = 59).

	n	%
Sex
Male	26	44.1
Female	33	55.9
GPA rank
Top 20%	14	23.7
20% to 40%	15	25.4
40% to 60%	14	23.7
60% to 80%	10	16.9
Bottom 20%	6	10.2
Attitudes on blended learning
Completely inclined	24	40.7
Partially inclined	35	59.3
Not inclined	0	0
Level of satisfaction
Very satisfied	19	32.2
Satisfied	34	57.6
Average	6	10.2
None dissatisfied	0	0

Note. GPA = grade point average.

Learning Experience Questionnaire Scores

The mean score of the learning experience was 110.53 ± 11.96, and the mean scores of the entries for each dimension are shown in Table 2. Independent samples t test analysis showed no statistically significant difference in learning experience scores between male and female students (t = −0.934, p > .05). One-way ANOVA did not identify significant differences among students with different GPAs (F = 0.647, p > .05).

Table 2.

Learning Experience Scores for Blended Learning (n = 59).

	Min.	Max.	M	SD
Total score	78	130	110.53	11.96
Mean score of entries in each dimension
Course structure and organization	2.80	5.00	4.33	0.54
Function and technical environment	2.25	5.00	4.38	0.58
Learning support and services	2.86	5.00	4.14	0.59
Course knowledge and ability	3.00	5.00	4.11	0.48
Evaluation method	3.00	5.00	4.28	0.52
Contents and resources	3.00	5.00	4.37	0.59

Note. M = mean; SD = standard deviation; Min. = Minimum; Max. = Maximum.

Students’ Satisfaction With Different Teaching Methods

Nursing students had the highest satisfaction with CBL at 98.4%, while satisfaction with online courses was the lowest at 79.7%, as shown in Table 3.

Table 3.

Satisfaction of Nursing Students With Different Teaching Methods (n = 59).

	Very satisfied		Satisfied		Average		Dissatisfied
	n	%	n	%	n	%	n	%
Case-based learning	29	49.2	29	49.2	1	1.7	-	-
Traditional lecture class	28	47.5	28	47.5	3	5.1	-	-
Flipped classroom	24	40.7	29	49.2	5	8.5	1	1.7
Online class	25	42.4	22	37.3	11	18.6	1	1.7

Qualitative Findings of the Study

A total of nine nursing students were interviewed from six different classes, including three male and six female students. Two were ranked in the top 20% of the GPA, three in the top 20% to 40%; two in the top 40% to 60%; one in the 60% to 80%; and one in the bottom 20%. The three themes and five subthemes emerging from the analysis are shown in Table 4.

Table 4.

Themes and Subthemes.

Themes	Subthemes
Positive experience with the course	Well-organized course structure
	Resourceful course content
	High teacher quality
Improvement in learning outcome	Improvement in problem-solving ability
	Positive changes in clinical thinking
Improvement needs to achieve better learning outcomes	Providing stressful learning activities
	Optimizing the design of online courses
	Improving the quality of group learning

Theme 1: Positive Learning Experiences

The qualitative study revealed positive learning experiences of students with the blended learning of pediatric nursing. They were satisfied with the course structure, content, and resources, as well as teacher quality.

Subtheme 1: Well-Organized Course Structure

Students felt that the proportion of online and offline classes was appropriate. The teaching methods, including online learning, flipped classrooms, case-based learning, and traditional lecture-based classes, were diverse and engaging, fostering the development of various abilities without imposing undue pressure on students. Indicative quotes are demonstrated as follows.

I think the overall arrangement is quite appropriate, and the students don’t feel too much pressure. (S1)

The goals of the course are relatively clear. The key points are clear. So, we can have a clearer learning mindset for what we’ve learned. (S3)

Subtheme 2: Resourceful Course Content

Participants stated that the course content exceeded the scope of textbook knowledge. In addition to the textbook, teachers provided Supplementary Learning Materials. Seminars were also conducted for students to review literature, report, and discuss, thereby expanding their knowledge boundaries.

We can master the knowledge in the classroom better. The knowledge outside the classroom has been slightly expanded, which is very good. It expands our horizons, but does not increase the learning pressure. (S4)

Subtheme 3: High Teacher Quality

Students expressed their satisfaction with the teacher's quality. They felt that the teacher's teaching style reflected the literacy of pediatric health professionals. Their teaching ability and level of expertise as teachers were high.

I think the teacher's teaching level is very good. Kind, patient, just like a pediatric healthcare provider. The speed and tone of speech are also better controlled during lectures. So, we can easily understand and master what we have to learn in the class … Enjoy the class. (S6)

Theme 2: Improvement in Learning Outcome

Student perceived that blended learning increased their engagement in the classroom and improved learning outcomes. Specifically, it improved students’ problem-solving ability and had a positive impact on developing clinical thinking.

Subtheme 1: Improvement in Problem-Solving Ability

Students reported that blended learning promoted their ability to think deeply and analyze problems, improved problem-solving skills, and facilitated greater participation in class.

I think that if you truly want to learn knowledge, you need this kind of discussion class. A series of questions can make you constantly think about how to deal with and solve them instead of passively listening to the teacher. (S4)

Students might have varying opinions on a particular topic. Through this exchange of ideas, they could surpass their cognitive limitations and acquire knowledge from one another.

I feel it is a kind of collision of thinking, and we can learn from each other. (S3)

Blended learning was perceived to promote active learning and offer students increased opportunities to find solutions independently.

The few questions assigned in the flipped classroom require us to consult the literature and give answers. It actually teaches us a way to know where to find the learning materials or literature we need, which helps us improve our ability to solve problems. (S1)

Subtheme 2: Positive Changes in Clinical Thinking

Many students spoke highly of CBL, claiming that it enables students to combine textbook knowledge with clinical scenarios, exercises thinking, and enhances understanding and deeper memorization of the knowledge. Their statements contributing to these findings are given below.

We especially like it when the teacher gives a case and then leads us to analyse it step by step. It can also consolidate the knowledge from the book and then understand where the key points are. The thinking of the analysis is well remembered. (S5)

Case analysis makes it easier for us to memorize knowledge and think more clearly. (S2)

They also expressed their preference for case analysis in traditional lecture-based classrooms, and reported that it helps students experience real clinical situations and the roles of doctors and nurses.

I hope the CBL can also be integrated into the theoretical class. The teacher analysed a case from the beginning to the end in the class “Neonatal Asphyxia”. Every time we talked about a part of the content, we analysed what the situation was in the context of the case so that we felt as if we were working in the clinic with this patient, and as nurses or doctors, we were thinking about how to deal with this problem. (S3)

Theme 3: Improvement Needs to Achieve Better Learning Outcomes

Although students reported positive learning experiences with blended learning, they provided suggestions for further improving its effectiveness based on their learning experience with pediatric nursing and other courses, such as providing stressful learning activities, optimizing the design of online courses, and improving the quality of group learning.

Subtheme 1: Providing Stressful Learning Activities

Students believed that blended learning contained many independent learning activities, and requires setting strict supervision or task assessment to prevent students from not studying seriously due to inertia, so they hoped to provide more stressful learning activities.

Our generation has been receiving this compulsory education model since elementary school, and we are accustomed to it. Everyone has inertia. In fact, in the learning process, it is necessary to give him a certain amount of pressure, or this kind of mandatory restraint, so that he can enter the learning state. (S3)

They also made some specific suggestions for stressful learning activities. They were most inclined to add quizzes to the learning. These quizzes could be administered in both online learning and traditional lecture-based classrooms, either before, during, or after class. Students were often more engaged when quizzes were incorporated into their learning experience. By providing a structured assessment, quizzes could help students stay focused and improve their understanding of the material. Moreover, quizzes could help students better understand how to analyze a particular topic, which was more effective than simply memorizing information. Indicative quotes are demonstrated as follows.

Adding small quizzes such as multiple-choice questions after class can help consolidate and recall knowledge quickly. (S2)

I hope to add some quizzes to the online classes, whether in the middle of the class or after the end. (S6)

There should be a prereading task before the class, like doing some test questions or something …Rolling call of answering questions in class is supervision for students. In this way, everyone did not dare to sleep in class and do something else because he might be asked questions at any time. It is helpful to his own learning effect. (S4)

The scores of each quiz should be included in the final grade … (S8)

Subtheme 2: Optimizing the Design of Online Courses

Several nursing students stated their negativity about the learning effect of online courses. First, it is difficult to have effective and timely interactions. Second, it is a great challenge for students’ self-discipline. To urge nursing students to complete the teaching assignments, this course counts students’ online class completion as 10% of the final grade; however, it is still a great challenge to students’ self-directed learning ability. The following statements contribute to these findings.

The online course, um, is indeed not as efficient as offline learning. (S1)

Most students may not watch online lecture videos, and some people may just click on it and let it play automatically, and then do something else. Online content is not very impressive, and it is forgotten after reading it. (S6)

You cannot have timely interaction with teachers. (S3)

There is no direct communication in online classes. If you have questions, you can't get answers in time, and you can't have a good discussion with people around you…Online classes do not need to be in that classroom. You may get distracted, and this efficiency will drop very low. The traditional classroom at least formally guarantees that students must go to the classroom to learn. (S9)

In view of the problem with online learning, students suggested reducing the proportion of online courses or appropriately increasing the number of quizzes.

Try to make a little less proportion of online lectures. (S4)

If it involves online classes, I’d like to have quizzes in the course. (S2)

Subtheme 3: Improving the Quality of Group Learning

Many students reported dissatisfaction with the effectiveness of group learning. One is that there is no real cooperation among team members. Second, the workload of the team members is uneven.

Everyone just completed the task they are responsible for individually, without communication and discussion, and no substantial cooperation is achieved. (S3)

The so-called group work is a patchwork of last resort … When the group work is reported, maybe the one who reports understands the whole process better, and the others just do their own work. (S6)

The students proposed potential solutions based on their personal learning experiences, including suggestions for group size, leadership strategies, and methods for evaluating group work. It was suggested that group size should be limited to 2–3 people. Criteria for selecting group leaders should be established, and supervision should be provided during the completion of group work. When checking the completion of group work, it should be ensured that each group member is evaluated to maintain their participation in group activities. Indicative quotes are shown as follows.

Group work is prone to some students not working hard. It is the active person who then must take on a lot of the work, but the final grade is counted for everyone… I think there should be fewer members in the group, for example, two or three, so that everyone will be more serious. (S8)

The team leader is actually very important to bring everyone together. (S5)

At the beginning, we should have an overall discussion, determine the framework, and what to focus on, and then search for information separately, and then discuss how to integrate these materials together after finishing. When the group reports, all members of the group should be required to report and answer questions so that everyone feels stressful. Then, everyone must be fully involved in this process; otherwise, they won't be able to answer the questions. (S4)

Discussion

We found that most nursing students were satisfied and had positive learning experiences with blended learning in pediatric nursing. This is consistent with the results of previous studies (Alshawish et al., 2021; Chen et al., 2020). The Community of Inquiry framework claims that teaching presence has a decisive impact on learner satisfaction, sense of community, and learning outcomes (Garrison et al., 2004). Previous study showed that students’ learning satisfaction was higher with blended learning than with traditional lectures (Hee & Hae, 2021). In our study, students’ positive learning experience also comes from their perception of blended learning to improve learning outcomes. Students concur that blended learning facilitates the retention, comprehension, and application of knowledge, improves their problem-solving abilities, and fosters clinical reasoning. Previous studies have shown that blended learning can improve students’ independent learning, comprehension, and problem-solving skills (Chen et al., 2020; Hee & Hae, 2021). Blended learning has a more purposeful instructional design; students have access to more explicit instruction through online resources, activities, and assessments; digital learning materials facilitate learning according to students’ self-needs; and social interaction enhances opportunities for interstudent participation in instructional activities. In addition, diverse assessment methods can provide a more comprehensive picture of student learning.

Many students stated that the application of CBL in pediatric nursing developed clinical thinking and was well received. This has also been demonstrated in our previous study (Yang et al., 2021). Through the analysis and discussion of cases, the CBL method arouses students’ curiosity, encourages their active participation in learning activities, and cultivates students’ rapid analysis, decision-making, and verbal skills as well as critical thinking. It is an effective way to cultivate their comprehensive professional ability, which also embodies the teaching philosophy of “student-centered, teacher-led” (Burucu & Arslan, 2021; Zhu et al., 2020). In addition, students’ satisfaction with the FC in this study reached 89.9%. The FC is an active learning method that can effectively promote students’ critical thinking and turn traditional classrooms into dynamic and interactive learning classrooms (McLaughlin et al., 2014). It may enhance students’ active learning and engagement, as well as their ability to apply knowledge gained in the classroom to nursing practice (Sullivan, 2022).

Previous studies have found that blended learning has greater course tasks and pressures than traditional teaching (Alshawish et al., 2021; Chen et al., 2020). However, in our study, students reported that the stress in the pediatric nursing course needs to be appropriately increased. This may be due to the high proportion of group learning tasks in this course, as well as the shifting of responsibilities among team members. Individual responsible students take on all tasks, while other members feel less pressure. Additionally, in this course, not all the scores of the usual tests are factored into the total course score, so students feel less pressure. Since childhood, Chinese students are accustomed to learning in a stressful environment (Xinhua News Agency, 2016). Stress is an external force and things need to change with it. Stress is the force that compels individuals to adhere to a predetermined law and develop in a predetermined manner. Studies have shown that there is a significant positive correlation between students’ learning stress and the amount of homework (Meng et al., 2021). Therefore, it is recommended that the amount and difficulty of homework should be appropriately increased in future teaching, while the assignment and completion of group work should be strictly monitored and the proportion of the usual scores in the final grade should be increased to motivate students to improve their learning efficiency under certain pressure.

The questionnaire survey revealed that students were least satisfied with online classes among the multiple teaching methods; most students interviewed felt that online classes were very testing for student autonomy and that the learning experience was not good. This is consistent with the perceptions of undergraduate nursing students on the blended learning of community nursing (Jin et al., 2019). Most students do not prefer online instruction alone, likely due to the absence of interpersonal interaction (Hameed et al., 2020). Although online classes have their own advantages (Scott et al., 2017), such as flexibility of learning time and place, low cost, and convenience, their disadvantages are also apparent, such as students’ tendency to be inattentive and not interactive enough during the learning process (Daroedono et al., 2020). Similarly, this was reported by the students in this study. The proportion of online course hours to the total hours in pediatric nursing courses was 22.2% (12/54). In light of the students’ negative perceptions of the efficacy of online classes, the proportion of online classes can be reduced in the future in accordance with the findings of this study. The interactive process, such as adding quizzes in the middle and at the end of the course videos, can be increased to supervise students and prevent the learning effect from being affected by inattentiveness.

In this survey, many students pointed out the problems in group learning, such as the uneven distribution of tasks among group members and the lack of interaction. The Community of Inquiry framework advocates support for collaborative learning and critical reflective dialogue, leading to deep and meaningful online and blended learning. Social presence requires participants to have the ability to connect themselves to a community, to communicate in an environment they trust, and to develop relationships by expressing their individuality (Yang et al., 2016). Effective group learning depends on active participation, “face-to-face” contact between participants, and purposeful activities (Burgess et al., 2020). Group composition also affects student interaction and achievement (Lei, 2010). The grouping in our study was formed spontaneously by students and did not fully consider the basic principle of “heterogeneity within groups” (Lei, 2010). It is suggested that in the future, teachers should play a managerial role in grouping students with diverse knowledge, abilities, and personalities into one group so that group members can complement each other's strengths and make progress together in the process of completing group tasks (Burgess et al., 2020). At the same time, students with organizational and managerial skills and a strong sense of responsibility should be selected as group leaders to manage the group's learning activities. Teachers should guide the group in the process of learning, such as guiding how to assign tasks and how to coordinate and cooperate among members (Burgess et al., 2020). Moreover, they should ensure that each group member is assessed when checking the group's homework to ensure the effectiveness of group learning because student engagement enhances student learning (Hommes et al., 2014).

Strengths and Limitations

The study was limited to a small number of students enrolled in a pediatric nursing course at a Chinese university. The recall rate of questionnaires is low. Accordingly, the results should be cautiously generalized to other populations and courses. Additionally, no appropriate instruments or scales were found in the literature to evaluate the learning experience of blended learning. Although the questionnaire used in the study was developed based on the literature, and evaluated for reliability and content validity, it should be reassessed when applied to other studies.

Implications for Practice

This study confirms that blended learning is recommended from the perspective of students’ learning experience. To achieve a better learning effect of blended learning, it is suggested that attention should be paid to providing appropriately stressful learning tasks, playing a role in supervising learning, adjusting the proportion of online courses, and increasing interaction and assessment. In group learning activities, teachers should play the role of supervisor and improve the evaluation mechanism to improve the effect of group learning (Burgess et al., 2020; Hommes et al., 2014). Additionally, future research should combine students’ perceptions of the learning effects of blended learning with quantitative indicators of learning outcomes to more fully reveal the actual effects of blended learning.

Conclusions

Nursing students have a positive learning experience with the blended learning model of pediatric nursing, the course is structured based on the Community of Inquiry framework to be reasonable and helpful in improving students’ problem-solving skills and developing clinical thinking. CBL was the most preferred among the teaching methods. Ongoing assessment and improvement of the blended learning design are needed to optimize students’ learning experience of this teaching model.

Supplemental Material

sj-docx-1-son-10.1177_23779608241274214 - Supplemental material for Nursing Undergraduate Students’ Experiences and Perceptions of Blended Learning in Pediatric Nursing: A Mixed Methods Study

Supplemental material, sj-docx-1-son-10.1177_23779608241274214 for Nursing Undergraduate Students’ Experiences and Perceptions of Blended Learning in Pediatric Nursing: A Mixed Methods Study by Yuanyuan Yang, Hua Chen and Hongyu Sun in SAGE Open Nursing

Supplemental Material

sj-docx-2-son-10.1177_23779608241274214 - Supplemental material for Nursing Undergraduate Students’ Experiences and Perceptions of Blended Learning in Pediatric Nursing: A Mixed Methods Study

Supplemental material, sj-docx-2-son-10.1177_23779608241274214 for Nursing Undergraduate Students’ Experiences and Perceptions of Blended Learning in Pediatric Nursing: A Mixed Methods Study by Yuanyuan Yang, Hua Chen and Hongyu Sun in SAGE Open Nursing

Footnotes

Acknowledgments

The authors were very grateful to all participants in this research.

Availability of Data and Materials

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

CRediT Authorship Contribution Statement

Yuanyuan Yang: conceptualization, methodology, data analysis, writing–original draft, writing–review and editing. Hua Chen: conceptualization, methodology, data analysis, writing–original draft, editing. Hongyu Sun: conceptualization, methodology, writing–review and editing.

Consent for Publication

Written informed consent for publication was obtained from all participants.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics Approval and Consent to Participate

This study was approved by the Peking University Institutional Review Board [IRB00001052-22143].

Funding

This work was supported by the Peking University Health Science Center Education and Teaching Research Project [grant number 2021YB24].

ORCID iD

Yuanyuan Yang

Supplemental Material

Supplemental material for this article is available online.

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