az senge 1990 declares ,  learning is a much more complicated phenomenon that can ever be limited to a classroom  ( p. 63 ) . many of the students today are attempting to adjust their family life , job , and university life toward having more flexibility in their learning programs .
current studies have suggested that a combination of face - to - face and e - learning methods would be an adjustable way of teaching that helps the students meet these challenges .
continuous learning , saving time , and reducing transportation expenses are the most commonly quoted benefits of blended learning ( bl ) .
in addition , learners are being educated in a holistic manner , in which their individual characteristics including attitudes , beliefs , view points , knowledge , skills , and mental power are regarded . some authors with a constructivist , student - centered , and person - centered standpoint have noted that holistic educational pedagogies have more likelihood of success than traditional ones .
application of bl has been increased in both academic and business fields and many studies have been conducted in this area .
some of these investigations have shown that students outcomes in bl method are better than or similar to those of face - to - face method .
however , recent investigations have revealed the defeat of most web - based projects because of disregarding stakeholders opinion , and lacking appropriate technological and executive infrastructures .
thus , conducting investigations which address these pre - requirements seems essential . on the other hand ,
there has been less attention to application of current electronic learning methods by universities and bl is relatively new to the educational systems of iran ; therefore , there would be a concern about the outcomes of applying such programs .
to the best of our knowledge , outcomes of the implication of bl program within the educational , technological , and cultural context of iran have not been investigated .
therefore , the aim of present study was to assess the outcomes of the bl program in the faculty of nursing and midwifery , tehran university of medical sciences ( tums ) , iran ; these outcomes included students grade point average ( gpa ) , participation in , and attitude and opinion about the program , and faculty instructors attitude and opinion about the program .
this study was conducted in the form of participatory action research ( par ) which encompasses five steps including analysis , design , development , implementation , and evaluation ( addie ) ( chang et al . , 2008 ) to develop the bl program in the faculty of nursing and midwifery , evaluate its preliminary outcomes , and re - run it after potential modifications . in this paper ,
nursing and midwifery students who were studying bachelor 's , master 's , and doctoral degrees ( n = 467 ) and instructors who were fulltime faculty members in faculty of nursing and midwifery ( including 50 faculty members and 10 mentors ) participated in this study .
students who had no theoretical courses ( those in 1 and 2 semesters of bachelor 's degree program ) were excluded from the study .
this step included defining the need for such program , and evaluating the existence of the capacity for development and implementation of a bl program .
as the need for such a program and the required capacity was recognized to exist ( after group discussions and collecting experts opinion inside and outside the university ) , decision was made to design a bl program for educating nursing and midwifery students in the faculty of nursing and midwifery ( tums ) .
technological infrastructures a computer lab with sufficient number of computers connected to high - speed internet was established to facilitate students access to computer and the internet ( n = 104 ) . moreover , fulltime access to high - speed internet was provided for faculty members in their office . as instructors were not familiar enough with it and bl programs , a number of workshops were held a semester before execution of the program to improve instructors it knowledge and skills .
the importance and necessity of using bl method and how to design course matters , course scenarios , specify individuals responsibilities were debated in these workshops .
moreover , in a single session , students were informed about the way they should work with bl system .
executive infrastructure in order to promote the feasibility of the program , some executive infrastructures were developed .
most importantly , a distance learning committee was organized consisting of five specialists in the field of distance learning who were responsible for making decisions , rules , macro policies , and developing new strategies .
moreover , members of either educational committee or distance learning committee of tums passed a number of educational regulations ( e.g. , each faculty instructor was permitted to hold 4/17 of his / her course credit in the form of e - learning ; some incentives were designed to be offered to instructors who had used bl method in teaching students , etc . ) . designing bl platform and bl courses bl platform
was designed based on three major principles : user friendliness , stability of the system , and accessibility .
twenty - two theoretical courses ( including basic , core , and specialized courses which were valued as 48 course credits ) were approved by distance learning committee for designing in the form of bl courses .
preparing courses for bl program , each instructor should write and design course scenarios , designate particular activities for face - to - face and e - learning parts , specify individual activities and responsibilities , schedule for the course , develop online quizzes , and consider how he / she will give feedback to students and how teacher 
after they signed the agreement form , students were given a personal user account ( including a user name and a password ) in order to sign in to bl website at//http://dln.x.ac.ir/. then , the students were supposed to select their courses at bl website .
initial instructions were provided for students by researcher about how to work with the bl system , get access to scientific resources , take online tests , upload tasks , download educational e - contents , and interact with teacher and other students before starting the course .
bl program was implemented at the faculty of nursing and midwifery in tums for one semester .
instructors delivered their courses which had been designed and approved a couple of months before running the program .
checklists of students participation were filled for each student in face - to - face method and for bl method by the in - charge instructors .
students individual characteristics , gpa , participation in courses , and opinion , and instructors demographics , attitude , and opinion toward teaching methods were assessed by the following researcher - made data collection tools : students individual characteristics : were recorded via a 9-item questionnaire .
students participation in courses : we developed two checklists ( one for bl and one for face - to - face method ) to quantify each student 's participation throughout the course sessions .
we considered the time and duration each student logged in to the bl website and the time he / she used the bl website 's chat room as indicators of participation with the bl courses . on the other hand , the time and duration the student was present in class and the time he / she involved in scientific discussions were considered as indicators of participation in face - to - face classes . both checklists
were scored based on their values and the sums of scores were classified into three distinct levels : high participation , > 75% ; moderate participation , 50 - 75% ; and low participation , < 50% .
students gpa : students gpa in bl method was compared to that of previous semester ( face - to - face method ) .
instructors attitude : was measured via a 3-point , likert - scale questionnaire ( 1 = agree , 2 = agree to some extent , and 3 = disagree ) , including an open - ended question at the end to seek the instructors suggestions .
participants opinion : focus group discussions were conducted separately for students and instructors to explore their  opinion  about bl and face - to - face methods .
these qualitative data were analyzed with textual analysis . to develop the data collection tools , relevant literature reports were reviewed .
those items were then evaluated for clarity and face and content validity by 10 experts in the field of education .
cronbach 's alpha was applied to examine the internal consistency of the opinion and attitude questionnaires ( alpha = 0.83 and 0.81 , respectively ) .
were used to compare students gpa between the two methods ( bl and face - to - face ) paired t - test and wilcoxon test were respectively used to compare students gpa and participation between bl and face - to - face methods .
chi - square and fisher exact test were used to examine the association between categorical variables .
this step included defining the need for such program , and evaluating the existence of the capacity for development and implementation of a bl program .
as the need for such a program and the required capacity was recognized to exist ( after group discussions and collecting experts opinion inside and outside the university ) , decision was made to design a bl program for educating nursing and midwifery students in the faculty of nursing and midwifery ( tums ) .
technological infrastructures a computer lab with sufficient number of computers connected to high - speed internet was established to facilitate students access to computer and the internet ( n = 104 ) . moreover , fulltime access to high - speed internet was provided for faculty members in their office . as instructors were not familiar enough with it and bl programs , a number of workshops were held a semester before execution of the program to improve instructors it knowledge and skills . the importance and necessity of using bl method and how to design course matters , course scenarios ,
moreover , in a single session , students were informed about the way they should work with bl system .
executive infrastructure in order to promote the feasibility of the program , some executive infrastructures were developed .
most importantly , a distance learning committee was organized consisting of five specialists in the field of distance learning who were responsible for making decisions , rules , macro policies , and developing new strategies . moreover
, members of either educational committee or distance learning committee of tums passed a number of educational regulations ( e.g. , each faculty instructor was permitted to hold 4/17 of his / her course credit in the form of e - learning ; some incentives were designed to be offered to instructors who had used bl method in teaching students , etc . ) . designing bl platform and bl courses bl platform
was designed based on three major principles : user friendliness , stability of the system , and accessibility .
twenty - two theoretical courses ( including basic , core , and specialized courses which were valued as 48 course credits ) were approved by distance learning committee for designing in the form of bl courses .
preparing courses for bl program , each instructor should write and design course scenarios , designate particular activities for face - to - face and e - learning parts , specify individual activities and responsibilities , schedule for the course , develop online quizzes , and consider how he / she will give feedback to students and how teacher 
after they signed the agreement form , students were given a personal user account ( including a user name and a password ) in order to sign in to bl website at//http://dln.x.ac.ir/. then , the students were supposed to select their courses at bl website .
initial instructions were provided for students by researcher about how to work with the bl system , get access to scientific resources , take online tests , upload tasks , download educational e - contents , and interact with teacher and other students before starting the course .
bl program was implemented at the faculty of nursing and midwifery in tums for one semester .
instructors delivered their courses which had been designed and approved a couple of months before running the program .
checklists of students participation were filled for each student in face - to - face method and for bl method by the in - charge instructors .
this step included defining the need for such program , and evaluating the existence of the capacity for development and implementation of a bl program .
as the need for such a program and the required capacity was recognized to exist ( after group discussions and collecting experts opinion inside and outside the university ) , decision was made to design a bl program for educating nursing and midwifery students in the faculty of nursing and midwifery ( tums ) .
technological infrastructures a computer lab with sufficient number of computers connected to high - speed internet was established to facilitate students access to computer and the internet ( n = 104 ) . moreover , fulltime access to high - speed internet was provided for faculty members in their office .
as instructors were not familiar enough with it and bl programs , a number of workshops were held a semester before execution of the program to improve instructors it knowledge and skills .
the importance and necessity of using bl method and how to design course matters , course scenarios , specify individuals responsibilities were debated in these workshops .
moreover , in a single session , students were informed about the way they should work with bl system .
executive infrastructure in order to promote the feasibility of the program , some executive infrastructures were developed .
most importantly , a distance learning committee was organized consisting of five specialists in the field of distance learning who were responsible for making decisions , rules , macro policies , and developing new strategies .
moreover , members of either educational committee or distance learning committee of tums passed a number of educational regulations ( e.g. , each faculty instructor was permitted to hold 4/17 of his / her course credit in the form of e - learning ; some incentives were designed to be offered to instructors who had used bl method in teaching students , etc . ) . designing bl platform and bl courses bl platform
was designed based on three major principles : user friendliness , stability of the system , and accessibility .
twenty - two theoretical courses ( including basic , core , and specialized courses which were valued as 48 course credits ) were approved by distance learning committee for designing in the form of bl courses .
preparing courses for bl program , each instructor should write and design course scenarios , designate particular activities for face - to - face and e - learning parts , specify individual activities and responsibilities , schedule for the course , develop online quizzes , and consider how he / she will give feedback to students and how teacher 
after they signed the agreement form , students were given a personal user account ( including a user name and a password ) in order to sign in to bl website at//http://dln.x.ac.ir/. then , the students were supposed to select their courses at bl website .
initial instructions were provided for students by researcher about how to work with the bl system , get access to scientific resources , take online tests , upload tasks , download educational e - contents , and interact with teacher and other students before starting the course .
bl program was implemented at the faculty of nursing and midwifery in tums for one semester .
instructors delivered their courses which had been designed and approved a couple of months before running the program .
checklists of students participation were filled for each student in face - to - face method and for bl method by the in - charge instructors .
students individual characteristics , gpa , participation in courses , and opinion , and instructors demographics , attitude , and opinion toward teaching methods were assessed by the following researcher - made data collection tools : students individual characteristics : were recorded via a 9-item questionnaire .
students participation in courses : we developed two checklists ( one for bl and one for face - to - face method ) to quantify each student 's participation throughout the course sessions .
we considered the time and duration each student logged in to the bl website and the time he / she used the bl website 's chat room as indicators of participation with the bl courses . on the other hand ,
the time and duration the student was present in class and the time he / she involved in scientific discussions were considered as indicators of participation in face - to - face classes .
both checklists were scored based on their values and the sums of scores were classified into three distinct levels : high participation , > 75% ; moderate participation , 50 - 75% ; and low participation , < 50% .
students gpa : students gpa in bl method was compared to that of previous semester ( face - to - face method ) .
instructors attitude : was measured via a 3-point , likert - scale questionnaire ( 1 = agree , 2 = agree to some extent , and 3 = disagree ) , including an open - ended question at the end to seek the instructors suggestions .
participants opinion : focus group discussions were conducted separately for students and instructors to explore their  opinion  about bl and face - to - face methods .
students individual characteristics , gpa , participation in courses , and opinion , and instructors demographics , attitude , and opinion toward teaching methods were assessed by the following researcher - made data collection tools : students individual characteristics : were recorded via a 9-item questionnaire .
students participation in courses : we developed two checklists ( one for bl and one for face - to - face method ) to quantify each student 's participation throughout the course sessions .
we considered the time and duration each student logged in to the bl website and the time he / she used the bl website 's chat room as indicators of participation with the bl courses . on the other hand ,
the time and duration the student was present in class and the time he / she involved in scientific discussions were considered as indicators of participation in face - to - face classes .
both checklists were scored based on their values and the sums of scores were classified into three distinct levels : high participation , > 75% ; moderate participation , 50 - 75% ; and low participation , < 50% .
students gpa : students gpa in bl method was compared to that of previous semester ( face - to - face method ) .
instructors attitude : was measured via a 3-point , likert - scale questionnaire ( 1 = agree , 2 = agree to some extent , and 3 = disagree ) , including an open - ended question at the end to seek the instructors suggestions .
participants opinion : focus group discussions were conducted separately for students and instructors to explore their  opinion  about bl and face - to - face methods .
those items were then evaluated for clarity and face and content validity by 10 experts in the field of education .
cronbach 's alpha was applied to examine the internal consistency of the opinion and attitude questionnaires ( alpha = 0.83 and 0.81 , respectively ) .
were used to compare students gpa between the two methods ( bl and face - to - face ) paired t - test and wilcoxon test were respectively used to compare students gpa and participation between bl and face - to - face methods .
chi - square and fisher exact test were used to examine the association between categorical variables .
one hundred and eighty - one nursing and midwifery students and seventeen instructors consented to take part in the study .
students individual characteristics : most students were 18 - 25 years old ( n = 148 , 81.8% ) , single ( n = 162 , 89.5% ) , and females ( n = 163 , 90.1% ) . details of students demographics and computer skills are presented in tables 1 and 2 , respectively .
participants individual characteristics participants level of familiarity with computer skills students participation in courses : students participation during course sessions was significantly higher in bl compared to face - to - face method ( wilcoxon , p < 0.0001 ) [ table 3 ] .
students participation and grade point average in blended learning and face - to - face methods students gpa : averages of students grade points were significantly higher in bl than in face - to - face method [ mean ( sd ) of gpas in bl method = 15.96 ( 1.43 ) , in face - to - face method = 15.44 ( 1.49 ) ; paired t - test , p < 0.0001 ] [ table 3 ] .
instructors demographics : most instructors were married ( n = 14 , 82.4% ) and were interested in participating in bl training workshops ( n = 15 , 88.2% ) .
instructors attitude : about 34% of respondents indicated  completely positive  attitude , 66% of them indicated  positive  attitude , and none of them indicated  negative  attitude toward bl method ; all participants appreciated the bl method as one of inevitable educational requirements in today 's world .
a significant positive association was revealed between instructors attitude and their willingness to participate in workshops ( fisher 's exact , p < 0.0001 ) , and also their interest to bl course design ( fisher 's exact , p < 0.0001 ) . there was no significant difference between instructors attitude and their individual characteristics .
participants opinion : textual analysis of the focus group discussions showed that most students admired the bl program as a teaching method in nursing and midwifery education and preferred it to traditional method .
one student said :  previously , getting the right course materials and contents was a big concern for me .
now i can easily find the right content ; contents are also clearly classified into subtitles and make it easy to know which topics are included in each course .  about content development issue
there was a plenty of references for each course , it is good that we are offered a variety of resource addresses , in different types .
i prefer to have written opinions rather than just hear them , because in the former , i can save them and refer to , whenever i need .  another student indicated thus : 
i feel i can learn better because it is possible to get my instructor 's instant feedback about my task performance , which was not occurring in previous semesters .
i could test myself whenever i wanted and surprisingly i could get the result of the online test in the moment ! 
i like the electronic parts of the course because i study them whenever i wish to .
in terms of easy access to internet , one student said thus :  although we have access to high speed internet in the faculty , i have problems about uploading my tasks when i am at home . 
another student pointed to her weakness of computer skills as a limitation and said :  it is hard for me to work with the bl system , tasks are also too much , sometimes i get confused .
 some of them also complained about supportive aspects of the program . including one student :  there are lots to do within a course .
one instructor noted thus :  i can schedule in a more flexible manner because i do parts of my course duties in my spare time . 
i think we can gradually gain a reach collection of course materials and questions for quizzes by working with bl system .
 instructors were also appreciated with incentives which had been provided to persuade them for using bl method .
one of them said :  if there were not an incentive for instructors who use this method in the faculty , the participation of instructors could n't be guaranteed .
 a couple of instructors complained about the time - consuming nature of bl course design .
one of them said :  answering to students questions , applying online tests and development of e - contents takes a lot of time .
 most of the faculty members believed that existence of a reward ( 67.90% ) and a supervisory system ( 80.40% ) for instructors who use this method is necessary .
our results showed that students gpa and participation in courses were higher in the bl method .
students had also a high regard for some aspects of the bl program , including 
 lesson plan ,  and  feedback ;  however , they claimed about some  technological aspects  ( including lack of  access to  and  skill of  using the computer and the internet ) .
our result about the improvement of students gpa in the bl method is congruent with that of some other investigations .
however , some authors have reported similar learning outcomes for e - learning and face - to - face methods . in this regard ,
a longitudinal investigation that had included teacher 's routine feedback in e - learning method has shown a 19% boost in e - learning efficacy rather than in face - to - face method . thus , it seems logical to gain better learning outcomes in bl rather than e - learning and traditional method since in this way , students can benefit from both methods .
thurmond ( 2003 ) concluded that the more frequent interactions are prepared ( whether in the form of email or online chat ) , the more participation rates are gained , which can itself lead to better learning outcomes .
however , beard and harper ( 2002 ) suggested that interactions more frequently happen in face - to - face method rather than e - learning and considered that as a weak point of the latter method .
high proportion of faculty members had positive attitude toward applying bl method and were eager to participate in bl workshops .
development of distance learning has been a macro policy of tums since the year 2002 ; in addition , the university and faculty developed some obligation in which they offered some job promotion and financial incentives for faculty members who became volunteers to use bl method .
it seems that all these situations made instructors aware of the new system and led to positive atmosphere in the university about bl ; these changes themselves seem to influence on instructors attitude in a positive manner .
maneie ( 2003 ) and bagherian ( 2002 ) noted that efficacy and success of new educational technologies is highly related to users psychosocial background and attitude as well as options of the technology ; the positive correlation between faculty members attitude and their willingness to enroll in workshops also proves this matter . in our study , students were more satisfied with bl educational contents rather than those of face - to - face method students also admired supportive aspects of the program .
thurmond ( 2003 ) concluded that since students devote a considerable amount of time on task fulfillment , preparing inadequate support makes them disappointed with their attempts .
sherry et al . ( 1998 ) noted that teacher 's instant feedback to students in e - learning method positively influences learner 's motivation and provides a feeling of support .
learner and teacher  learner interaction , designing more supportive and interactive programs is suggested ; in this regard , further investigations should determine the effect of interaction option in bl program on participants satisfaction .
learner - related matters could not have made students completely satisfied . since learners success in bl program depends on their computer skills , an average technological skill and lack of constant access to computer for half of the students may affect their satisfaction of the program . therefore , to ensure easy access and application of technologies required for working with bl system , better educational and technological infrastructures could help participants satisfaction and appropriate involvement with the program .
( 2008 ) found that there is a positive correlation between easy application of educational methods and learners satisfaction .
development of appropriate technological and institutional infrastructures before running the program ( such as providing access to it center and high - speed internet , holding bl training workshops for educators , and removing some structural and organizational barriers ) and motivating participants to use bl program seem to be influential elements .
philips ( 2002 ) conducted a comprehensive analysis on the causes of defeat in web - based educational approaches ; he explored three major causes : causes related to project output ( e.g. , weak site design , inappropriate or inadequate technical infrastructures ) , causes related to learners ( e.g. , learner 's unwillingness , unpreparedness , or lack of time ) , and causes related to organization ( e.g. , lack of organizational support or reward system ) .
the nature of the way we assessed students participation in bl method was different from that of face to face method , however , we tried to make them more similar by considering all aspects which can be considered as  participating in a course  and asking experts opinion in this regard .
we presented preliminary outcomes of bl program in educating nursing and midwifery students in this paper .
the strengths and weaknesses of the program will be considered for design and implementation of subsequent steps of our par project .
considering lack of evidence regarding effectiveness of bl programs in the field of medical education in iran , preliminary results gained by the present study might be helpful for decision makers who tend to develop similar programs in the country . in this regard , considering motivational and supportive aspects and providing appropriate technology basis besides proper development of knowledge and skills for users is recommended for developing successful programs .
 background : we aimed to develop and evaluate outcomes of a blended learning ( bl ) program for educating nursing and midwifery students of tehran university of medical sciences ( tehran , iran).materials and methods : this was a participatory action research project . after designing bl website , providing technological infrastructures , and holding preparatory workshops , 
 22 blended courses were designed . 
 bl method was implemented for one semester . 
 students grade point average , participation with courses , and opinion about educational methods , and instructors attitude and opinion about educational methods were assessed.results:most students ( n = 181 ; 72.1% ) and 17 instructors ( 28.3% ) consented to participate in the study . 
 students grade point average and participation was significantly higher in bl rather than in face - to - face method ( p < 0.0001 ) . 
 most instructors ( n = 11 , 65% ) had positive attitude toward bl method . textual analysis of participants opinion showed that most students preferred bl method and felt more independent in this method . 
 however , they complained about lack of easy access to internet and weakness in computer skills . 
 instructors admired the flexibility and incentives that had been provided in the program . 
 however , some of them complained about the time - consuming nature of bl course design.conclusion:the program showed positive effect on students learning outcomes and participation . 
 the strengths and weaknesses of the program should be considered for development of next phase of the project . 
 lessons learned in this phase might be helpful for decision makers who tend to develop similar programs in iran . 
 motivational and communicational issues and users it skills should be addressed in every bl program . 
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The program
Analysis (January-August 2008)
Design (August-December 2008)
Implementation (February-June 2009)
Evaluation
Data collection tools
Validity and reliability
Data analysis
Ethical consideration
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