The blended educational program as a modified educational program in medical education and the effect on students' critical thinking

(

Mosalanejad L (1) Alipor A (2) Zandi B (3) Zare H (2) Shobeiri SM (4) (1) Dept. of Mental Health , Faculty of Nursing and Paramedicine, Jahrom University of Medical Sciences, Jahrom, Iran. (2) Dept. of Psychology. Payamnoor University, Tehran, Iran. (3) Dept. of Educational Curriculum Development. Payamnoor University, Tehran, Iran. (4) Dept. of Educational Planning and Environmental Health, Payamnoor University, Tehran, Iran. Correspondence: Leili Mosalanejad, Jahrom University of Medical Sciences, Motahari Street, Jahrom, Iran. Postal code: 74148 Phone: 09177920813 Email: mossla_1@yahoo.com

Abstract Introduction: Blended learning is a mixture of various learning strategies and delivery methods to optimize the learning experience of the users. Objectives: The objective of this study was to compare a designed blended educational method with classical face to face method in the cognitive effect of the program on the students' critical thinking. Methods: A comparative study was conducted on 41 first year nursing students of Jahrom University of Medical Sciences who participated in the psychiatry course in 2008-2009. The students were randomly divided into two groups of conventional and blended educational methods. The Watson Glazer test was used for assessment of critical thinking. Results: There was a significant increase in student's critical thinking skills in both groups after conducting of the course. Analysis of variance results showed that there was a significant relationship between students' final score, teaching method and critical thinking in conclusion skills. The mean of final scores of the students who participated in the blended educational group was significantly more than that of those who participated in the face to face teaching approach. Conclusion: The use of blended educational method is recommended for teaching in Medical and Para-medical sciences. Key words: Face to face education , Critical thinking, Educational Psychology, Active Learning, Computer Uses in Education, Academic achievement

Introduction
One of the most important challenges of education in the twenty-first century is how to train students in having necessary readiness for confronting the changing society and complexities of the information explosion age. "In addition, the professional world asks the universities to provide formative opportunities that train students to fulfill their roles as working professionals,"(Ugarte & Naval, 2008).

Today, teaching and learning are mostly supported by digital material and electronic communication. At present, Web-based learning (WBL), problem-based learning (PBL), and collaborative learning are the most powerful educational options in higher education. New teaching methods and especially electronic learning is on the top of the educational curriculums of all countries and mainly the advanced countries. (Henrich & Sieber, 2009; Taradi, Taradi, Radic, & Pokrajac, 2005).

New pedagogical paradigm is replacing the classical system with its unique characters (Gerreson & Anderson, 2003; Brower, Dejone, & Stout, 2004). Therefore, it gives priority to using some techniques which can develop maximum learning for the students and provide a deeper learning by using the benefits of both conventional and new methods.

In order to respond to these requirements, blended learning has become increasingly popular and is particularly suitable to the process of transitioning towards E-learning from classical forms of teaching.(Hoic, Mornar, & Boticki, 2009).

Blended educational method hjas been widely studied and its mechanisms explained by different research (Valiathan, 2002; Harvey, 2003; Allison, Felicia, & Rebecca, 2008; Michael & Renate, 2003; Rossett, 2003). The available evidence demonstrated that blended learning is better than conventional methods and the E-learning technology and is not only able to transfer information more efficiently but it is also a more effective pedagogical method(Alvarez, 2008).

Much research has been accomplished on the effects of blended education learning on the various aspects of Students' learning, so that some research reflects a combination of both traditional learning (face to face) and electronic learning has influence on student's learning. For example, Reynold maintains that the advantage of using blended education learning especially electronic learning for training dentists is their deep understanding of subjects, so that most students preferred the blended education learning to the conventional learning and they consider the blended education learning as a successful experiment for themselves (Chamberlain & Reynolds, 2007).

Valiathan considers the blended education teaching as a very successful method for teaching anatomy and they think that it is more effective than the traditional teaching (Valiathan, 2002).
Some researchers remarked that the blended education learning derives its success from the acquaintance of students with electronic learning and participatory and collaborative learning in which both hardware and software topics are of great importance and pedagogical bases are ready for using it (Oh & Park, 2009). This method could decrease the gap between theoretical and practical subjects (Sung, Kwon, & Ryu, 2008). Others showed that electronic learning as a supporter of traditional learning could play a role in bolstering the learning of students (Kay, 2006).

Others demonstrated the achievements of the electronic learning of the students in instructing medical sciences. They found that some considered this kind of learning as effective, and others thought that it was not effective because of its maladjustment with their learning methods (Watson & Glaser, 1998).

One research on instructing on medicines for knowledge advancement, one's self-efficiency and its practical use in the clinical skills showed that information and knowledge of nurses increased remarkably, but this issue didn't have any significant effects on self-efficiency and practical use in the clinical skills (Magnusen, 2000).

Key, 2006 applied it to the students taking the unit of physiology. Their research showed that there were not any significant differences between the final scores of students in both traditional and blended education groups; the blended education learning could help students deepen their perceptions of subjects and increase their understanding of practical units in the laboratory. This issue was found by evaluating the relationship between students' practical scores and degree of their learning through blended education learning (Kay, 2006).

Owing to the rapid evolution of science and knowledge in different fields, it is possible to present effective teaching through new methods providing deep and fast learning.

Considering medical courses are an integration of theoretical and practical parts and psychomotor domain it is of great importance because working in the clinical environment, it is necessary to have regard for electronic learning through novel and different methods. Also concerning the positive aspects underlined in different research and lack of studies about its cognitive effects between research accomplished inside and outside of the country, we evaluate these effects and use the aforementioned pedagogical methods to make a teaching culture and deepen learning of students and introduce unknown effects and aspects of this kind of teaching and plan the path of future research in other fields.

We hope this research can provide a dynamic ground for studying the pedagogical research in the field of medical sciences and also the results of this research can be used by our researchers for attaining a better education.

Methods
A comparative study was conducted among 41 nursing students of Jahrom Medical Sciences medical school who participated in the course of psychiatry in the academic year 2008 -2009.
Blended learning is a novel method, based on the conventional and electronic methods of teaching. We considered the organization of the class to encourage critical thinking to attain a balance between the content and the process of education, between lecture and interaction, create discussion in the class and use a student center in learning via assignments and educational projects.

In the conventional method, we used the common methods of lecture and face to face education during the term. In the blended group we used the standard educational designed models and the educational process was started using lectures and face to face education; this procedure was maintained by the aid of active teaching and learning while venturing to e-learning, electronic self - learning and Asynchronous virtual learning as personal or collaborative projects.

To design this research, the students were randomly divided into two 20 and 21 member groups according to their students' numbers and orienting the empirical groups to reduce resistance to involvement in active education, we used face to face education to present the basic principles and it was maintained by active educational techniques such as PBL, scenario, writing simulation, group discussion and role playing (12 two hour weeks). Then it was maintained by asynchronized electronic education such as self- =electronic learning via digital libraries and scientific sources, presenting abstracts of scientific essays from the latest relevant sources by the student (12 two hour weeks, the last 15 each of session). Students contacted with the teacher by email (during the term and before each session), and using educational films and CDs.


Table 1: Activities in the blended model

In the other group we used other usual teacher-centered methods and for preventing the impression of selection and abiding to the ethics of education, we gave an extract of the material presented by the empirical group to the students who received traditional education after the final exam.

We also explained to respective groups at this time how to use the electronic sources. Students in both groups were randomly distributed and the midterm and final exams were taught identically. In educational designing of the research we considered the standard educational design and the following steps for designing and practicing blended education. These steps consisted of assuring the learner preparation (justification of education type), presenting the material (using active educational strategies mixed with online education), displaying the working mechanism (searching sources and digital libraries' systems supporting the student's learning), practice (giving feedback), evaluation, (comparative, summative, individual and group conferences and presenting scientific essays), providing support (access to online system and professional service for digital sources), and supervising the student learning and sustaining communication with emails and cooperation in learning (Kay, 2006).

The test used in this research was a normalized version of Watson Glazer Critical Thinking Test, which contains eighty general questions in five parts: comprehension skill, recognition of pre-assumptions, conclusion skill, interpretation, and evaluation skill (Magnusen, 2000; Watson & Glaser, 1998). This test was normalized in Iranian society (Islami, Shekarabi, Behbahani, & Jamshidi, 2004). The students were examined pre and post test, and their academic achievements were measured by comparing the scores of the two groups.

The difference between the score of critical thinking in pretest and posttest was studied by a quantitative evaluation so that the scores below 54, the scores between 55- 60 , and the scores between 61 - 80 were considered as weak, average, and strong respectively (Magnusen, 2000).

A qualitative analysis was performed to investigate the degree of students' satisfaction by open questionnaire. As a normal distribution of variable , we used Paired t-test to compare mean scores in the pretest and posttest result; student t-test was used to compare the differences of mean scores in the two groups of traditional and blended teaching and chi-squaire and analysis of variance to assess interaction between variables.

Results
Through the qualitative study by open questionnaire, we evaluated students' satisfaction in the two groups. Students who were in the blended educational group 20 (93.8%) were satisfied with this kind of teaching. They believed that this kind of teaching approach could provide in-depth learning, improve their knowledge (n=19), facilitate access to the essential sources (n=13), and provide more self-learning (n=16). They also mentioned that it was a user-friendly method (n= 8). Also (83.7%) of the conventional group were satisfied with teaching, but there were no significant differences between them.

Table 1 illustrates that the mean scores of critical thinking skills changed in both groups. However the mean of scores of the evaluation factor decreased in both groups, with more decrease in the conventional group.

The result of Paired t-test in blended groups shows that there is a significant difference between perception skills (P = 0.005).

Conventional group pre test and post test showed a significant relationship between means of data in recognition of pre-assumptions, conclusion and interpretation. Mean of evaluation score decreased significantly in the posttest. (10.68 ± 1.70 in pretest vs. 80.06 ± 1.43 in post-test)
( p = 0.001). (Table 2)

Click here for Table 2: The Mean Score Of Critical Thinking Skills before and after Education in the Two Groups

Moreover, the student t-test didn't show any significant differences between the mean of critical thinking skills in both educational groups. It clarified that both kinds of teaching played the same role in the improvement of students' critical thinking. Mean of perception, recognition of assumption and evaluation in the blended group was higher than the other group. Table 3.


Table 3 : Differences Between Mean Of Critical Thinking skills In the Two Groups

As a scoring of test we consider the scores below 54, the scores between 55- 60, and the scores between 61 - 80 were considered as weak, average and strong respectively. (22)

The difference between score of critical thinking in the pretest and posttest showed that the difference of means was significant in the blended education group (4).


Table 4 : Differences Total Critical Thinking in the two Groups Before And After Teaching

Analysis of variance results showed that there was a significant relationship between students' final score , teaching method and critical thinking in conclusion skill.
(Table 5).

Table 5 : The Effect Of Education On Student Critical Thinking By Analysis of variance

We used chi square test to compare the strength of critical thinking in educational groups after teaching. These results revealed that there was significant differences between the evaluation skills in the two educational groups. (x2=0.04, p=0.03). As a result students who received blended learning `were significantly stronger' than those in the conventional group in evaluation skills.

There was a significant difference in the final score of students' in the conventional and blended groups; blended teaching had more effects on the improvement of students' final scores.(Table 6)

Table 6 : Difference of Final Score in Educational Groups

Discussion
The result finding of this study showed that 93.8% of blended group and 83.7% of conventional group were satisfied with the teaching method. Some research states that most teachers have a positive attitude towards blended instruction as they believed it played a role in improving the quality of their instruction (Kay, 2006 ; So & Brush, 2008). Others stated that most of students have a positive perception and satisfaction toward blended learning so that this method effects student self regulation, student perceptions of collaborative learning, social presence and critical factors (So & Brush, 2008; Kim, Bonk, & Teng, 2009). However some research revealed that the perceived communication, collaboration, and satisfaction levels of students in blended learning varies according to their levels of computer and Internet literacy(Rossignol, 1997).

The results of investigations confirm the present research and affirms the impact of blended learning on the students' attitudes and satisfaction.

Conventional teaching also had a positive effect on students' satisfaction and improved critical thinking skills of students in the present research. Much evidence revealed that lecturing and teacher centered method is more effective in presenting the background and introduction to a topic or issue.(Owens & Walden, 2001) The impact of conventional method on students' critical thinking may be related to students' tendency toward teacher-centered learning and provision of reliable information by teachers that leads to the promotion of critical thinking skills.

This study revealed that blended educational method has an effect on improving critical thinking skills; a similar finding was reported from other studies (Marinick, 2006; Tiwari & Lai, 2006; Gokhale, 2006; Staib, 2003; Badawi, 2009; Campbell, Gibson, & Hall, 2008). Others reported the positive effect of blended learning in developing prospective pedagogical knowledge and performance (Mongust, Fabregas, & Delgado, 2000).

This study did not find any significant difference in students' critical thinking in blended method and conventional method. This finding was in agreement with a similar finding (Rossignol, 1997).
Furthermore, the results showed that the blended teaching had more effects on student learning. This may be due to the identified relation between web-centered teaching based on problem solving skills, self directed learning and improvement in students' attitudes about learning (Taradi et al., 2005; Campbell et al., 2008; (Delialioglu & Yidirim, 2009). This result agrees with the present result, and confirms educational effects of blended learning on cognitive aspects of students.

This research also showed that we can profit by the integration of conventional and electronic methods as a synergic effect to increase students' satisfaction and provide deepened learning, self directed learning and self monitoring. This integration in turn effects students' learning, critical thinking and academic achievement in a positive way.

As a limitation to the present research we can point to the lack of electronic infrastructures and unfamiliarity of teachers with new strategies especially for electronic learning; we need more information about effectiveness of this method by further research. We need also greater responsibility and commitment on the part of higher education managers in order to provide electronic infrastructures to assess the application of this novel method in our country.

Conclusion
The study showed the positive effect of blended learning method on learning, critical thinking and satisfaction from teaching- learning strategies. Therefore the use of blended educational method is recommended for teaching in Medical and Para-medical sciences.

Acknowledgement : We thank Saed Sobhanian, M.Sc., greatly for his assistance with statistical analysis.

References
Allison, R., Felicia, D., & Rebecca, V. F. (2008). Strategies for building blended learning. [cited 2008 Jun 30]. Available from http://www.astd.org/LC/2003/0703_rossett.htm,.Accessed
Alvarez, S. (2008). Blended learning solutions. In B, Hoffman (Ed), Encyclopedia of Educational Technology. [cited 2008 sep 12]. Available from :file:///C:/Documents%20and%20Settings/Saeed/Desktop/new%20res%203/blend4_files/start.htm,.
Campbell, M., Gibson, W., & Hall, A. (2008). Online vs. Face-to-face discussion in a web-based research methods course for postgraduate nursing students: A quasi-experimental study. International Journal of Nursing Studies, 45(5), 750-759.
Badawi, M.F. (2009). Using blended learning for enhancing EFL prospective teachers pedagogical knowledge and performance, paper presented at learning & language . The spirit of the age conference . Cairo, Egypt.
Brower, E. W., Dejone, J. O., & Stout, V.J. (2004). Moving to online : Making the transition from traditional instruction and communication strategies. Translated by Farideh Mashayekh and Abbas Bazargan.T. Tehran: Agah publishing House.
Chamberlain, M., & Reynolds, C. (2007). Blended Learning Initiatives in Higher Education: Opportunities and Challenges. In Montgomerie C.& Seale J. (Eds.), Proceedings of World Conference on Educational Multimedia. . Hypermedia and Telecommunications 2007,( pp. 2397-2402). Chesapeake, VA: AACE. Retrieved from http://www.editlib.org/p/25706. .
Delialioglu, O., & Yidirim, Z. . (2009). Design and development of a technology enhanced hybrid instruction based on MOLTA model: Its effectiveness in comparison to traditional instruction. Computers & Education . 51(1), 474-483.
Gerreson, D.R., & Anderson, T.E . (2003). Learning in the 21st century: A framework for research and practice. Translated by Mohammad Ataran. Tehran: Madares Hoshmand publishing.
Gokhale, A.A . Collaborative learning enhances critical thinking. Journal of Technology Education [cited 2006 Aug], Available from :http://scholar .lib.vt.edu/ejournals/jTE/Jte-v7n1/gokhale.jte-v7n1.html.
Harvey, S. (2003). Building effective blended learning programs. Issue of Educational Technology 43 (6), 51-54.
Henrich, A., & Sieber, S . (2009). Blended learning and pure e-learning concepts for information retrieval: experiences and future directions. Information Retrieva 12(2), 117 - 147.
Hoic, B. N., Mornar, V., & Boticki, I. (2009). Blended learning approach to course design and implementation education. IEEE Transactions . 52(1), 19-30.
Kay, B.E. (2006). Key Steps to Implementing a successful blended Learning Strategy. . Journal of Industrial and Commercial Training . 38(3), 156 -163.
Kim, K.J., Bonk, C., & Teng, Y.T. (2009). The present state and future trends of blended learning in workplace learning across five countries. Asia Pacific Education Review 10(3), 299-308.
Magnusen, L . (2000). The impact of the use of inquiry based learning as a teaching methodology on development of critical thinking. Journal of Nursing Education 39(8), 360-364.
Marinick, H.M. (2006). Thinking critically about critical thinking. [cited 2006 January 1 ]. Available from http://www.mcli.dist.maricopa.edu/forum/fall01/tl.html.
Michael, D., & Renate, M. P. (2003). Pattern for blended, person central learning: strategy, concepts, experience, and evaluation. Technical Department of Computer and Business Informatics,. University of Vienna.
Mongust, J .M., Fabregas, J .J., & Delgado, D. (2000). Effect of blended learning on student', motivation and learning performance. Interciencia
31(3), 190-196.
Oh, E., & Park, S. (2009). How are universities involved in blended instruction? Educational Technology & Society. , 12(3), 327-342.
Owens, D. L., & Walden, S.D. (2001). Peer instruction in learning labratory, a strategy to decrease student anxiety. Journal of Nursing Education 40(8), 375-377.
Rossett, A. (2003). The ASTD E-Learning Handbook. . New York: McGraw-Hill [cited 2008 Sept 12]. Available from :http://www.books.mcgraw-hill.com/authors/ University of Vienna, October 2003.rossett/.
Rossignol, M. (1997). Relationship between selected discourse strategies and student critical thinking. Journal of Nursing Education 36(10), 467.
Islami, A. R., Shekarabi, R., Behbahani, N.R., & Jamshidi, R. (2004). Critical thinking ability in nursing students.
Iran Journal of Nursing 39(17), 15-20.
So, H.J., & Brush, T. (2008). Student perceptions of collaborative learning, social presence and satisfaction in a blended learning environment: Relationships and critical factors. Computers & Education 51(1).
Staib, S. (2003). Teaching and measuring critical thinking. Journal of Nursing Education, 42(11), 498-508.
Sung, Y.H., Kwon, I, G., & Ryu, E. (2008). Blended learning on medication administration for new nurses: Integration of e-learning and face-to-face instruction in the classroom. . Nurse Education Today, 28 (8), 943-952.
Taradi, S. K., Taradi, M., Radic, K., & Pokrajac, N. (2005). Blending problem-based learning with web technology positively impacts student learning outcomes in acid-base physiology. Advances in Physiology Education, 29(1), 35-39.
Tiwari, A., & Lai, P. (2006). Promoting Nursing Students' Critical thinking through problem-based Learning [cited 2006 sept 12] . Available from : http://www.edu.au/conferences/herdsa/main/papers/nonref/pdf/AgnesTiwari.pdf.Accessed .
Ugarte, C., & Naval, C. (2008). Training in professional skills: a blended learning experience. Ese-Estudios Sobre Educacion 15, 53-86.
Valiathan, P. (2002). Blended learning models. [cited 2002 Aug]. Available from: www.learningcircuits.org/2002/aug2002/valiathan.html .
Watson, G., & Glaser, E. M. (1998). Critical thinking appraisal manual. The Psychological corporation:Haraout Brace Jovanovich , Inc.