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J Dent Educ. 72(9): 1048-1057 2008
© 2008 American Dental Education Association
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Educational Methodologies

A Blended Learning Course Taught to Different Groups of Learners in a Dental School: Follow-Up Evaluation

Kimon Pahinis, D.D.S., M.Sc., Ph.D.; Christopher W. Stokes, M.Ed., Ph.D.; Trevor F. Walsh, B.D.S., F.D.S.R.C.S., M.Sc., D.D.S.; Effrosyni Tsitrou, D.D.S., M.Med.Sci., Ph.D.; Giuseppe Cannavina, Ph.D.

Key words: dental education, computers, web-based, blended learning, online, evidence-based

Submitted for publication 05/29/07; accepted 04/17/08


   Abstract
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 Author information
 Abstract
Evolution of the blended...
 Methods
 Results
 Discussion
 Conclusions
 References
 
This article reports the results of a follow-up study conducted to investigate students’ perceptions about a blended learning health informatics course that combined online and traditional classroom instruction. The course is taught to five different groups of students at the School of Clinical Dentistry of the University of Sheffield each academic year: first-, third-, and fourth-year dental students, dental hygiene and therapy students, and postgraduate dental students. The goal of the study was to determine the impact of the modifications made to the course after the first year of implementation. To accomplish this goal, students’ perceptions of this blended learning course were compared after the first and second implementations. The methodology used for this study was action research. The data were collected using three processes: questionnaires were used to collect contextual data from the students taking the course; a student-led, nominal group technique was used to collect group data from the participants; and a non-participant observer technique was used to record the context in which certain group and individual behaviors occurred. Depending on group assignment, between 41.5 and 91.5 percent of students believed that the blended-learning course had added to their skills. The online learning environment was perceived as a useful resource by 75 percent of students in four of the five student groups, but only 45 percent of the fourth-year dental students indicated it was a useful resource. The perceived lack of sufficient online support material was one of the main concerns of the students at the nominal group evaluation sessions. The non-participant observer technique identified different engagement levels among the student groups. Discernible differences were identified, with improvement in some areas and a decline in others compared to a previous evaluation. The change in the delivery method influenced the students’ comprehension of the material negatively and the learning environment positively, but did not influence online collaboration among students.

Electronic education (e-education or online learning) has the potential to shift the paradigm from passive teacher-centered learning to active learner-centered learning.1 Constructivism, one of the learning theories often associated with e-learning, views learning as an active process in which learners construct new ideas or concepts based upon their current and/or past knowledge.2 E-education can greatly promote activity and engagement by the use of interaction.3 Active learning can motivate learners to become more engaged with the content.3 A well-designed e-course can enhance learner-content interaction by the use of hyperlinks, as well as learner-learner and learner-tutor interactions with the use of synchronous and asynchronous communication tools such as forums.

Blended learning is the latest approach in e-education that combines (blends) the use of the online learning with traditional classroom-based learning.4 The main advantage of blended learning is that it integrates the strengths of synchronous (face-to-face) and asynchronous (web-based) learning activities. Various types of blended learning can exist, depending on how the two approaches are balanced. Some variations are that learners may be given access to the online material before, during, or after the traditional sessions. Also, attendance at the traditional sessions may or may not be compulsory.

The Internet’s influence on dental education has been evident in the literature since the beginning of this decade.5–8 Using the advantages of e-education, dental schools are beginning to support face-to-face teaching using online educational tools,9–11 but only a few studies have been published evaluating this change in teaching and learning.6,12,13 Therefore, more research is required to evaluate the application of these new educational methods. Using the learners to evaluate e-education is critical because the educational environment is intended for them and should accommodate their needs if they are to become motivated and active learners. Students’ appraisal of the utility and value of e-education and assessment of their attitudes are essential before any learning outcomes achieved by e-education can be evaluated. Pilot-testing by students can also ensure that the system is not an ineffective application of the technology, but one that meets the users’ needs.

This article reports the results of a follow-up study to further investigate students’ perceptions about a blended-learning course initially described in a previous article published in this journal.13 The purpose of this follow-up study was to evaluate the second implementation cycle of this blended-learning course titled "Health Informatics," developed for undergraduate dental students (B.D.S.), postgraduate dental students, and Diploma in Dental Hygiene and Therapy students (D.H.T.) at the School of Clinical Dentistry of the University of Sheffield. To assess the impact of the modifications made to the course after year one, students’ perceptions after the first and second implementations were compared.


   Evolution of the Blended Learning Health Informatics Course
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 Abstract
 Evolution of the blended...
Methods
 Results
 Discussion
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In 2003–04, the health informatics (HI) course formerly known as "Information and Communication Technology" (ICT) was redesigned to be the first electronically supported course at the dental school in Sheffield. The course, which has been a part of the curriculum since 1999, was developed using a blended-learning approach that accommodates both face-to-face sessions and an asynchronous online environment.

The virtual learning environment (VLE) used to support this course was changed from the iCT portal (a bulletin board-based system) reported in the first article (which described the fundamental design of the course)13 to the Moodle-based LEGA (learning environment for group activity). Moodle is a popular VLE that is designed especially for educational purposes.14 Moodle offers several advantages over the previous bulletin board-based system. It is designed based on a social constructivist model of learning; it is open source; it is being used by a wide community, who offer modifications that can be integrated; and finally, it is very easy to edit and administer. A screenshot of the welcome page is shown in Figure 1Go.


Figure 1
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  		Figure 1. LEGA front-end original version

 
The course was taught to five groups of students each academic year. The groups and the teaching hours were as follows: first-year B.D.S. (twelve contact hours), third-year B.D.S. (twelve contact hours), fourth-year B.D.S. (eight contact hours), Diploma in Dental Hygiene and Therapy (D.H.T.; twenty contact hours), and postgraduate dental students (twenty contact hours).

The core objectives of the HI course were for the students to learn information-sourcing techniques, data manipulation, and evidence appraisal, while building on their practical information technology skills (such as finding literature online, enhancing word-processing skills, preparing spreadsheets, etc.).

As shown in Table 1Go, the formats of the educational activities of the five groups of students were essentially the same. The first and the last sessions of the course were in a traditional lecture setting, while the middle sessions were online, supported (blended) practical sessions. For the practical sessions, all the information required to complete the sessions was given through the Moodle (LEGA) system; the presence of the tutor was mainly to provide synchronous support to the students. Similar to the previous version of the course,13 attendance at the course sessions was compulsory for all groups. Course assessment was based on the session assignments.


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  		Table 1. Course outline and structure
 
The sessions in the HI course were based on the student-centered, direct instruction, and minimalist approaches described previously13 (Table 1Go). For the sessions based on the direct instruction approach, a step-by-step instruction guide was given to the students. For the sessions based on the minimalist approach, only minimum instructions were given to the students to assist them in completing the tasks. For the sessions designed with the student-centered approach, students were required to work in groups based on experience gained from the previous sessions.

The most important change from the previous course implementation strategy was that the course materials were available online a week before the session so that students could access these items and gain familiarity with them before attending the practical session. Furthermore, apart from the substitution of the VLE used in the initial version of this course (and its inherently more visual format), the new VLE was integrated with the university’s account database to allow students to use their university account to access the system and to reduce password-related problems. Another change from the original version of the course was that computer-based animations were introduced into the course material in an attempt to explain and simplify session tasks.


   Methods
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 Evolution of the blended...
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Results
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The sample of this study consisted of students from the first, third, and fourth B.D.S. years, D.H.T. students, and postgraduate dental students who participated in the health informatics course during the year 2005 at the dental school of the University of Sheffield.

The overall methodology used to conduct the study was action research.15,16 The action research model is a spiral process: the actual cycle comprises diagnosis (data-gathering, analysis, and representation), action planning, action taking, and action evaluation.17 The data were collected using three processes: questionnaires were used to collect contextual data from the students taking the course; a student-led, nominal group technique was used to collect group data from the participants of the course; and non-participant observer technique was used to record the context in which certain group and individual behaviors occurred.

Questionnaires18 consisted of both closed and open-ended questions. The questions focused on eliciting learners’ attitudes towards the course content, the educational setting, and the e-learning applications in the course, as well as past, current, and possible future behaviors. Anonymous questionnaires were distributed at the start of the last session of each class for each group of students and were collected at the conclusion. The students were informed that completion of the questionnaire was voluntary.

The nominal group (NG) technique19 was used to identify strengths and weaknesses, using a group setting, and to allow solutions to be thought out and analyzed and plans for their implementation to be considered. The NG technique is split into four stages: idea, round-robin, clarification, and voting.20 One NG session was organized for each group of students, and five to ten students were invited with an email for each session. All of the nominal groups took place within two weeks of the completion of the course. The researcher introduced the NG technique to the students and answered any queries. The same instruction sheets were given to all student groups, and the venue for all sessions was the same. Only the students were present during the nominal group sessions, and the group participants were self-selected.

Non-participant observation21 is an ethnographic technique that provides information about the group dynamics. A structured approach was used, and the researcher was present at all sessions. Students were not informed of the intention of the observation in order to avoid any change in behavior.

The quantitative analysis of the closed questions data was done with SPSS v13.22 The chi-square ({chi}2) test was used to compare categorical data, and ANOVA was used to compare means.23 The level of statistical significance was set at p<0.05. Thematic analysis was performed for the nominal group, non-participant observation, and the open questions data from the questionnaires.


   Results
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 Evolution of the blended...
 Methods
 Results
Discussion
 Conclusions
 References
 
An overall response rate of 90 percent of the distributed questionnaires was obtained (186 out of 208). For each individual class, the response rate was as follows: first-year B.D.S., 92 percent (n=69); third-year B.D.S., 83 percent (n=34); fourth-year B.D.S., 90 percent (n=47); postgraduate dentists, 100 percent (n=7); and D.H.T., 100 percent (n=29). Thirty-three percent of the respondents were male (n=62), and 66 percent were female (n=124). There was a statistically significant difference in gender distribution among participants from each year (p<0.01), which was mainly due to the D.H.T. course, which consists of female students only. There was no statistically significant difference in gender distribution among participants if the D.H.T. course was excluded from the above analysis (p>0.15).

For the nominal group session, participation varied from five to seven students. For each individual class, the participation was first-year B.D.S., six students (three female, three male); third-year B.D.S., five students (three female, two male); fourth-year B.D.S., no students volunteered; postgraduate, five students (four female, one male); and D.H.T., seven students (all female).

For the non-participant observations, all sessions in the course were observed. Six sessions were observed for the first-year B.D.S. course; six for the third-year B.D.S. course; four for the fourth-year B.D.S. course; nine for the postgraduate course; and nine for the D.H.T. course.

The following sections summarize the findings from the questionnaires, nominal group, and non-participant observations.

Summary of Data from Questionnaires
Approximately 63 percent of the respondents agreed that the teaching sessions were well constructed and understandable. When asked if the practical sessions were understandable, 51 percent of the respondents gave a positive response (strongly agree and agree). A statistically significant difference was found between the years and the genders for these questions (p<0.01).

On the question about the skills gained from the course, 61 percent (strongly agree and agree) of the respondents believed that their skills had improved (Table 2Go). There was a statistical difference among the five student groups (p<0.01).


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  		Table 2. Response to question: This course has added to my skills
 
The Moodle-based (LEGA) environment was a useful resource according to 70 percent of the respondents (strongly agree and agree) (Table 3Go). A statistical difference between the student groups was found (p<0.01), but not between the genders. Sixty-two percent of the respondents believed that Moodle (LEGA) was easy to navigate.


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  		Table 3. Response to question: The LEGA environment was a useful resource during the course
 
Approximately 85 percent of the respondents replied that the demonstrating animations in Moodle (LEGA) were useful. There was no statistical difference between the five student groups and the genders. When asked if making didactic tutorials available online with recorded speech would be useful, more than half of respondents expressed a neutral opinion (51 percent), while the useful and the not useful answers were split (24 percent each).

The course in general promoted the use of the Moodle (LEGA) forums according to 63 percent of the respondents. There was a statistical difference among the student groups (p<0.05).

For a question asking if they would use Moodle (LEGA) in the future after the course had finished, 40 percent of students were neutral, while the positive and negative opinions were split (Table 4Go). When comparing responses about future Moodle use between the different student groups, a statistical difference was found (p<0.05).


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  		Table 4. Response to question: I will continue to use LEGA regularly now that the course has finished
 
Sixty-six percent of the respondents used Moodle (LEGA) to gain access to the course content outside sessions. There was a statistically significant difference among the years. Table 5Go summarizes the various student-LEGA interactions and where statistically significant differences occurred.


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  		Table 5. ICT portal interactions throughout the years (the positive answers are calculated from the total number of responses)
 
Finally, the sessions on "finding literature online" with a mean 2.94 (with 5 being the most difficult) and "spreadsheets/statistics" with a mean 2.93 were identified as the most difficult and most useful by all student groups.

Summary of Data from Nominal Group Sessions
Table 6Go provides an overall summary of the similarities and differences among students in different academic years and programs as revealed by the analysis of the nominal group (NG) sessions. This section highlights some of the key NG findings.


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  		Table 6. Key points from nominal groups
 
The online Moodle (LEGA) environment was viewed by all student groups as a useful part of the course. According to the B.D.S. students, Moodle (LEGA) encouraged intrastudent communication with the use of the forums. Conversely, postgraduate students believed that forums worked only on a forced basis (e.g., when they were mandatory). Postgraduate students also reported that remote access to the material through Moodle (LEGA) was very useful. A lack of integration with MUSE (My University of Sheffield Environment, which gives secure access to online university resources from anywhere in the world), lack of privacy, and the inability to attach large files to forum postings were the reported problems of Moodle (LEGA).

Regarding the course content, word-processing, spreadsheets/statistics, and referencing were considered the most interesting topics covered by the course; however, D.H.T. students felt that the referencing session was unclear. There was a suggestion to include other more dentally oriented subjects such as computer-assisted learning (CAL) packages for denture design. Presentation software training should be included among the topics, according to first-year B.D.S. students.

Students reported that the instructions available online were not sufficient to carry out the tasks and stated that more resources to complete the tasks were needed. Online animation, group work, and tutors were commented on positively by all groups although D.H.T. students did not like the lack of online tuition. No time problems were reported, but postgraduate students indicated they experienced a lot of interruptions by other students during the practical sessions.

Finally, another aspect reported was the diversity of computer skills among the students. A more detailed view of the similarities and differences as revealed from the NG session analysis can be seen in Table 6Go.

Summary of Data from Non-Participant Observations
Overall, similar student behaviors were observed as previously reported.13 Differences regarding the overall engagement with the course between the student groups (years) were observed. A noted difference was that queries towards the tutors were more frequent at the early stages of the sessions, possibly due to the fact that the students were already familiar with the material because they could access it before attending. Postgraduate and D.H.T. students showed increased course-related activity during the course sessions; interactions between students and tutors were quite frequent; and most students attended the sessions. Based on observations and audit of the server-log, the first- and third-year B.D.S. students showed less engagement than the D.H.T. and postgraduate students. The level of engagement among the fourth-year B.D.S. students was observed to be limited, and the impression given during the sessions was that most of these students were not interested in the subjects taught.

With regard to the group behaviors and group dynamics, similarities were recorded among the five groups of students. When the direct instruction approach was used for the development of the session, students worked alone, with interactions occurring only between adjacent sitting students, and those were reported to be minimal. At the minimalist sessions, some limited group formations were recorded. During the student-centered sessions, students worked collaboratively, and a process of group formation was evident. However, this collaboration was mainly face-to-face. The Moodle (LEGA) forums were only used for information-sharing for the group presentations in the final session of the course and when it was required to complete tasks.


   Discussion
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 Abstract
 Evolution of the blended...
 Methods
 Results
 Discussion
Conclusions
 References
 
Our previous article on this topic13 reported the first evaluation of a blended-learning course based on data from multiple groups of learners. The present study provides a comparison between the results of the two evaluation cycles and also investigates the course modifications that occurred and measures their impact.

The results from the current study indicated that discernible differences were identified compared to the previous study, with improvement in students’ perceptions of the course and use of blended-learning components in some areas and a decline in others. Students’ perception of the clarity of the practical sessions declined from the first to second cycles, while the most substantial improvement was the students’ assessment of the usefulness of the new VLE.

Two studies on the use of computers in dental education reported that males perceived that they were more competent with the use of ICT than were females.24,25 However, in this study, no statistically significant differences between genders were identified.

Overall, the majority of the students were satisfied with the course; however, significant differences were recorded among the student groups as demonstrated by the data displayed in Tables 2Go and 3Go. More than 90 percent of D.H.T. students claimed that they gained some skills from this course, while only 41.5 percent from the fourth-year B.D.S. students agreed with this statement (Table 2Go). Differences in the level of computer skills among the various student groups were evident from the initial skills questionnaire.26 This provides a context and potential explanation for the variations regarding the students’ appraisal of the skills gained from this course.

The VLE of the course was implemented to resolve the problems noted during the first implementation of the revised health informatics course and also to increase usability, accessibility, and usefulness. The Moodle (LEGA) environment was accepted as a valuable resource by all student groups. Comparing the previous iCT Portal with the current Moodle (LEGA), the usefulness rating increased from 65 percent to 70 percent. The Moodle-based online learning environment was perceived as a useful resource by 75 percent of students in four of the five student groups, but only 45 percent of the fourth-year dental students indicated it was a useful resource. Navigation issues reported during the previous cycle13 were resolved with the implementation on the new VLE. Moodle (LEGA) was easy to navigate, according to 66 percent of the respondents. Also, fewer logistical problems were reported during the nominal group sessions, and these problems were not rated by the respondents as very critical.

Having the material available online a week before the session increased the usage of the system from the previous cycle from 57 percent to 66 percent; additionally, the novel features available in the new VLE were used satisfactorily. However, despite the fact that Moodle (LEGA) was also based on the social constructivism learning theory,27 similar to the iCT portal, and promoted learner-tutor and learner-learner types of interaction through the use of forums, collaboration among the students remained similar with the previous cycle—at a low level. It was expected that modification of the blended-learning method would increase the necessities for online collaboration, but practically no discussion and collaboration within the student groups were observed. Only some information-sharing through posting outside sessions was recorded. To investigate students’ perceptions about the lack of collaboration, which was also identified in the first implementation of the course, students were asked if the materials did not promote online collaboration, but 63 percent replied that it did. Potential reasons for the low levels of collaboration are the students’ limited previous experience with online communities and/or their overall motivation during the course.

During the first implementation of this course, students indicated no preferences for face-to-face versus online/blended learning, and students indicated that they felt comfortable with both methods. In the second year of the course, 63 percent of students indicated that the teaching sessions were understandable, which was the same as in the previous cycle. However, only 51 percent of the students in this cycle of the course indicated that the practical sessions were understandable, which represents a decrease of 12 percent in comparison with the previous cycle. This difference is probably related to the change of the delivery method. In the previous cycle, the blended-learning environment was balanced towards traditional classroom-based learning. The learners could only access the material online during and after the sessions, when synchronous support from the tutors was available. But as the type of the blended-learning method changed to a more balanced approach, the learners could access the online material before the sessions, when synchronous support was not available. This may have resulted in difficulties for some learners, especially the less confident ones, as they could not find an immediate answer to their queries. This lack of tangible support was also raised during the nominal group sessions. Furthermore, these findings are in accordance with the increased number of queries at the early stages of the sessions recorded during the non-participant observations. If the material is redesigned to provide a learner-customized content by being more interactive, this problem could be reduced.

Animations can demonstrate real world situations, and depending on the design, they can further promote active learning through learner-content interaction.28 However, for this to occur, the animation should not be just a linear sequence of events. The animations created for this course were linear, as the only interaction that the students could do was "back" and "next." Despite this limitation, 85 percent of the learners found them useful. However, comparing the difficulty of the sessions (when animations were used) with the results from the previous cycle, there was no improvement. The learners may have been impressed with the new technology and responded that it was useful at the direct question, although its actual value as a support tool was confirmed by indirect questioning.

Furthermore, it is interesting to note that fourth-year B.D.S. students gave a lower positive feedback than the other student groups. The same cohort of students (third-year B.D.S. in the previous study) also gave a much lower positive feedback than the other student groups. It was not feasible to arrange a nominal group session with this group of students to explore their perceptions in more depth, even though several attempts were made. The substantial differences in perceptions between this particular group of learners and all the other groups, during both reported cycles, indicate that this group, for a reason unexplained by this study, had a significantly lower interest level during the course. Unfortunately, there will be no opportunity in the future to investigate the reason for this group’s behavior because these students have now graduated. Moreover, if this study had been implemented with just one cohort of students like many educational research studies in the literature and the only group selected for this investigation had happened to be the fourth-year B.D.S. students, the findings reported here would have been very different. Given that, it is important for this type of research to use more than one group of students to avoid potentially misleading or non-representative findings.


   Conclusions
Top
 Author information
 Abstract
 Evolution of the blended...
 Methods
 Results
 Discussion
 Conclusions
References
 
Within the limitations of this study, it was found that there were discernible differences among students’ perceptions of the value and utility of a blended-learning health informatics course, with improvement in some course components/features and a decline in others in comparison to a previous evaluation of the course. The change in the delivery method influenced negatively the students’ understanding of the material and influenced positively the students’ usage of the online learning environment, although it did not influence online collaboration among students.

The implementation of the Moodle (LEGA) online learning environment increased the students’ acceptance of the online environment of the course. Differences among different groups of learners were recorded, but there were no significant differences between males and females. Finally, the findings from this study indicated the importance of obtaining data from more than one group of students when assessing innovations in educational methods to minimize the potential of respondent group bias.


   Author Information
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 Author information
Abstract
 Evolution of the blended...
 Methods
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Dr. Pahinis is a dentist and was a Ph.D. student, Department of Adult Dental Care at the time of this study; Dr. Stokes is a University Teacher, Department of Adult Dental Care; Dr. Walsh is a Professor of Restorative Dentistry and Dean; Dr. Tsitrou is a University Clinical Teacher, Department of Adult Dental Care; and Dr. Cannavina is Director of the WILeN Project, Department of Adult Dental Care—all in the School of Clinical Dentistry, University of Sheffield. Direct correspondence and requests for reprints to Dr. Kimon Pahinis, Department of Adult Dental Care, School of Clinical Dentistry, University of Sheffield, Claremont Crescent, Sheffield S10 2TA, UK; 44-789-641-5368 phone; 44-114-279-7050 7050 fax; k.pahinis{at}sheffield.ac.uk.


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 Evolution of the blended...
 Methods
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 Discussion
 Conclusions
 References
 

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