Blended learning Component in nursing education: A systematic review

Abstract

Nursing education stands to benefit from the potential effectiveness and elevated quality offered by blended learning programs. Through the evaluation of analogous works, this study endeavors to pinpoint the essential components of blended learning in nursing education. This study employed a systematic review methodology encompassing literature search, data evaluation, and data analysis. Comprehensive searches were conducted across PubMed, Scopus, Web of Science, ProQuest, and ERIC databases using predefined keywords related to the Blended Learning Component in Nursing Education. Articles published between 2000 and 2024 were selected based on specific criteria. Independent reviewers screened and assessed these articles, resolving discrepancies through discussion. Quality evaluation and data extraction focused on key information about blended learning in nursing education. The synthesized findings identified themes and patterns, with researchers categorizing and describing various aspects of blended learning in this field. Through rigorous analysis, four key components emerged: educational design, technology infrastructures, instructional strategies, and assessment techniques. By recognizing and integrating key components, this study emphasizes the potential for developing highly effective blended learning programs in nursing education, signaling a promising avenue for future educational innovation and improvement.

Introduction

The growth of health care services and the development of information and communication technologies have rendered traditional education inadequate for meeting the learning needs of nursing education.[1] Moreover, traditional education becomes impractical during crises, as demonstrated by the coronavirus pandemic.[2] Consequently, many advanced countries are now establishing and offering online universities and courses. Virtual universities and courses provide numerous benefits, including increased enrolment, removal of geographical and physical barriers, easy access to information resources, improved communication between students and professors, recruitment of expert faculty from around the globe, and reduced administrative obstacles.[3] Virtual education comes with many benefits; however, it also comes with some disadvantages and challenges. Nevertheless, virtual training will promote the growth of skills, imagination, and new ideas while also improving the efficiency of educational processes.[4,5] Virtual education cannot solely provide the practical, hands-on experience necessary for nursing education.[6] It is challenging to recreate clinical skills, patient interactions, and real-world problem-solving in a virtual setting.[7] Lack of in-person interaction with teachers and classmates can impede the growth of important communication abilities and limit chances for mentorship and cooperative learning, crucial in nursing.[6,7] Evaluating hands-on abilities and competencies in a virtual setting can present challenges. Maintaining the trustworthiness and precision of Internet evaluations, especially for clinical abilities, is difficult and frequently necessitates additional face-to-face assessments.[8]

In addition to these educational shifts, the role of nursing managers and their leadership style within hospitals significantly impacts nursing education. Effective leadership by nursing managers can foster a supportive learning environment, enhance professional development, and ensure that nurses are well prepared to meet the challenges of modern healthcare. Leadership styles that emphasize mentorship, collaboration, and continuous improvement contribute to a culture of excellence in nursing practice, thereby directly influencing the quality and efficacy of nursing education.[9]

Research suggests that incorporating blended learning initiatives can improve the quality and effectiveness of nursing education.[10] Blended teaching, which is becoming more common in educational settings, integrates in-person and online learning using Learning Management Systems (LMS). This approach, known as blended learning, lacks a universally accepted taxonomy.[11] Blended learning positively affects nursing students’ knowledge and skills due to its adaptability to their needs and expectations.[10] Nursing students’ academic achievement can improve through the effective application of a logical and flexible blended learning strategy.[12] Nursing is a field that integrates theoretical and clinical knowledge and is constantly evolving, making blended learning crucial.[13]

A comprehensive review of blended learning in nursing education, especially in the context of integrating traditional and virtual educational methods, can identify the key elements of effective blended learning strategies. This provides practical insights for educators and policymakers to increase the quality and efficiency of nursing education. By focusing on the specific needs and challenges of nursing education, it is possible to fill a gap in the existing literature and provide a detailed understanding of how to optimize blended learning to better prepare nursing students for the needs of modern healthcare. Therefore, this study aims to identify the key elements of blended learning in nursing education by examining relevant research.

Materials and Methods

Study design and setting

This study systematically reviews the essential components of blended learning in nursing education worldwide, addressing key research questions and following PRISMA guidelines (PRISMA Flow Diagram).[14] Two specialists independently screened all phases of the research.

Search strategy

In this systematic review, related keywords and their synonyms were determined by referring to Medical Subject Headings (MeSH), related texts, and expert opinions. Accordingly, the following keywords were used: nursing, teaching, learning, education, instruction, training, curriculum, blended, integrated, and hybrid.

Then, related studies were searched through the following strategy: (hybrid[tiab] OR blended[tiab] OR integrated[tiab]) AND (Education[mesh] OR education*[tiab] OR Learning[mesh] OR learning[tiab] OR instruction*[tiab] OR teaching[mesh] OR teaching[tiab] OR training[tiab] OR curriculum[mesh] OR curriculum[tiab]) AND (nursing[mesh] OR nursing[tiab]) AND 2010/01/01:2024/06/30[dp].

Medline, Embase, CINAHL, Cochrane Database, Scopus, Web of Science (WOS), ProQuest, and ERIC were searched. In addition, after identifying the final sources, their references were reviewed for further relevant studies.

Inclusion and exclusion criteria

Selection criteria included: 1) original articles, 2) all study types, 3) studies in English and Persian, 4) studies incorporating hybrid learning in nursing education, and 5) studies published from January 2010 to Jun 2024.

Articles were excluded if they met any of the following conditions: 1) Articles that were not accessible in full text, 2) articles that were not primary research studies (e.g., editorials, opinion pieces, letters, or conference abstracts), 3) studies that did not focus on blended learning or e-learning in nursing education, and 4) articles that did not meet the quality threshold based on the adjusted CASP checklist and JBI Critical Appraisal Checklist.

Study selection

A total of 11,862 records were retrieved. After the removal of duplicate records, 2682 unique items remained. Following the screening of titles and abstracts based on the eligibility criteria, 114 sources were retained. The full texts of these 114 articles were then evaluated, resulting in the selection of 16 studies for data collection after 98 studies were eliminated for failing to meet the study’s objectives and eligibility requirements. Throughout the title/abstract and full text screening stages, each research paper was compared to the inclusion and exclusion criteria, and those that did not fulfill the criteria were eliminated. Two reviewers independently made the resource selection, and any disagreements were resolved by consensus.

Qualification of articles

To critically evaluate the articles in this study, both the adjusted CASP (Critical Appraisal Skills Program) checklist for quantitative and qualitative studies and the JBI Critical Appraisal Checklist were utilized. The CASP checklist, designed by the JAMA Group in 1994, included 19 items.[15] The JBI approach to systematic reviews emphasizes pragmatism, aiming to include a summary of the best available evidence, not just randomized controlled trials.[16,17] Each article was reviewed, with responses categorized as “yes” if the criterion was met, “no” if it was not, and “can’t say” if the answer was unclear. For “can’t say” cases, a third researcher reviewed the article, and the three reviewers consulted together to decide on its inclusion. To determine quality, scores were classified as follows: 75% or above was considered good quality, 25–75% was average quality, and below 25% was poor quality. This classification was based on similar articles and expert consultation[18] [Table 1].

Table 1.

Quality assessment of the selected articles

Author/ Year		Quality Assessment Tool		Criteria Evaluated (Out of 10)		Risk of Bias		Comments
Bobbink et al. 2022[20]		JBI Critical Appraisal Checklist		Selection bias, Performance bias, Detection bias, Attrition bias, Reporting bias		Low		Minor reporting bias
Yu et al. 2021[21]		JBI Critical Appraisal Checklist		Selection bias, Performance bias, Detection bias, Attrition bias, Reporting bias		Low		Well-conducted with minor reporting bias
Grønlien. K. et al. 2021[22]		JBI Critical Appraisal Checklist		Selection bias, Performance bias, Detection bias, Attrition bias, Reporting bias		Medium		Some attrition bias
Alshawish, et al. 2021[23]		JBI Critical Appraisal Checklist		Selection bias, Performance bias, Detection bias, Attrition bias, Reporting bias		Medium		Performance bias noted
Porter et al. 2020[24]		CASP Qualitative Checklist		Selection bias, Data saturation, Researcher bias		Low		In-depth thematic analysis
Koch. et al. 2020[25]		CASP Qualitative Checklist		Selection bias, Data saturation, Researcher bias		Medium		Detailed but potential researcher bias
Sáiz-Manzanares, et al. 2020[26]		JBI Critical Appraisal Checklist		Selection bias, Data saturation, Researcher bias Selection bias, Data saturation, Researcher bias		Low		High methodological rigor
Moon, et al. 2019[27]		JBI Critical Appraisal Checklist		Selection bias, Performance bias, Detection bias, Attrition bias, Reporting bias		Low		High methodological rigor
Shorey S. et al. 2018[28]		CASP Qualitative Checklist		Selection bias, Data saturation, Researcher bias		Medium		Thorough thematic categorization
Sigaroudi, et al. 2016[29]		CASP Qualitative Checklist		Selection bias, Data saturation, Researcher bias		Medium		Detailed themes, moderate bias
Park, et al. 2016[30]		JBI Critical Appraisal Checklist		Selection bias, Performance bias, Detection bias, Attrition bias, Reporting bias		Medium		Positive results with moderate bias
Arving, et al. 2014[31]		CASP Qualitative Checklist		Selection bias, Data saturation, Researcher bias		Medium		Moderate thematic analysis quality
Stephens, et al. 2013[32]		CASP Action Research Checklist		Contextual relevance, Implementation fidelity		Medium		Good implementation details
Zolfaghari, et al. 2013[33]		CASP Action Research Checklist		Contextual relevance, Implementation fidelity		Medium		Relevant but with logistical issues
Rigby, et al. 2012[34]		CASP Qualitative Checklist		Selection bias, Data saturation, Researcher bias		Medium		Detailed but potential researcher bias
Hsu, et al. 2011[35]		JBI Critical Appraisal Checklist		Selection bias, Performance bias, Detection bias, Attrition bias, Reporting bias		Medium		Positive feedback with some biases

Data extraction

Data from each research study were extracted, including the first author’s name, publication year, study location, study design, sample characteristics, and hybrid education components. Data extraction was performed independently by two reviewers, and any discrepancies were resolved by consensus. A systematic approach was used to synthesize and summarize the data.[19]

Ethical considerations

The authors of the manuscript took great care to prevent any kind of plagiarism. The analysis’s findings were quite honest. The researchers avoided data fabrication. They never manipulated the data for their benefit.

Results

The initial searches returned a total of 11,862 records, as shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram [Figure 1]. Using Endnote X9, duplicate sources were eliminated, leaving 2682 unique sources. After scrutinizing the titles and abstracts based on the study’s goals and eligibility requirements, 114 sources remained. The full text of these 114 articles was examined in the next stage, resulting in the selection of 16 studies for data collection after 98 studies were eliminated for failing to meet the study’s objectives and eligibility requirements. Table 2 displays the features of the chosen studies.

Figure 1.

PRISMA flow diagram

Table 2.

Characteristics of the selected articles

Author/ Year		Reference		Country		Study design		Study sample		Results		Comments and conclusion
Bobbink et al. 2022		E-Learning and Blended-Learning Program in Wound Care for Undergraduate Nursing Students		Switzerland		Experimental		Undergraduate Nursing Students		In this study, the development of blended and e-learning units was informed by literature reviews and expert discussions, guided by the learning outcomes defined by the European Wound Management Association. The implementation extended over a period of 3 years, during which 14 learning units were developed and deployed, including 12 blended learning units and two e-learning units. Blended learning approaches encompassed flipped classrooms integrating asynchronous e-learning components, complemented by workshops facilitated by clinical wound care specialists.[20]		Blended and e-learning methods provide flexible, evidence-based learning modules, yet their curriculum effectiveness needs more study.
Yu et al. 2021		Effects of blended versus offline case-centred learning on the academic performance and critical thinking ability of undergraduate nursing students		China		Cluster Randomized Controlled Study		Second-Year Undergraduate Nursing Students		Experimental class students excelled in academic performance and critical thinking compared to control class students. Experimental class showed significant improvement in critical thinking self-confidence, while control class showed improvement in total score, truth-seeking, and systematicity.[21]		The study indicates the superiority of blended learning in enhancing academic performance and critical thinking skills. This suggests blended learning could be more beneficial than traditional offline methods in nursing education.
Grønlien. K. et al. 2021		A blended learning teaching strategy strengthens the nursing students’ performance and self-reported learning outcome achievement in an anatomy, physiology and biochemistry course		Norway		Quasi-experimental		The First Semester Of Nursing Bachelor Studies		Results indicated that students in blended learning outperformed those in traditional teaching on national exams, with Cohen’s d=0.23 effect size. Course evaluations showed support for blended learning, with students reporting improved understanding of expectations and satisfaction with the virtual environment. The study highlights digital resources as beneficial for enhancing teaching and student experience in higher education.[22]		Blended learning was positively received and effective, suggesting its potential to improve both academic performance and student satisfaction. This approach leverages digital resources to enhance educational outcomes.
Alshawish, et al. 2021		Comparison of blended versus traditional classrooms among undergraduate nursing students		Palestine		Quasi-experimental		Bachelor Of Science In Nursing Students		Blended teaching led to higher DREEM scores and student perceptions of learning and teachers, compared to traditional teaching. Total DREEM scores were positive for both groups. There was no difference in total course GPA or exam scores between blended and traditional learning. However, blended teaching resulted in higher assignment scores. Overall, students preferred the blended teaching method for a more positive educational experience.[23]		Blended learning was preferred over traditional methods, improving student perceptions of learning and teaching. Despite no difference in GPA or exam scores, the higher assignment scores and positive student feedback highlight the benefits of a blended approach.
Porter et al. 2020		The academic experiences of transitioning to blended online and digital nursing curriculum		Australia		Qualitative		Nursing Academic Staff		Three key themes identified: ‘Get Ready’ emphasizes academic staff’s need to be prepared for transition to BOLD, ‘Get Set’ focuses on managing content, ‘Go’ emphasizes ongoing evaluation during implementation phase.[24]		The study highlights the importance of preparation, content management, and ongoing evaluation in transitioning to blended learning. It underscores the need for thorough planning and continuous improvement for successful implementation.
Koch. et al. 2020		Undergraduate nursing students’ experiences and expectations of bioscience tutors in a blended learning curriculum		Australia		Qualitative descriptive study		Undergraduate Nursing Students		Two primary topics with corresponding secondary topics were recognized. The initial theme highlighted the significance of the instructor in bioscience, encompassing their attributes, knowledge, and application of learning. The second theme offered understanding of how students viewed effective and ineffective learning methods.[25]		Emphasizes the critical role of instructors in bioscience courses and the importance of their attributes and knowledge. Effective teaching methods significantly impact students’ learning experiences in a blended learning environment.
Sáiz-Manzanares, et al. 2020		Effectiveness of Blended Learning in Nursing Education		Spain		Quasi-experimental		Nursing Students		In blended learning environments, effective teaching design with 80% LMS interaction enhances learning outcomes and student behaviors. This approach, using hypermedia resources and real-time feedback, is particularly beneficial for nursing education, and machine learning techniques help in understanding and predicting student learning characteristics and identifying at-risk students.[26]		Integrating automated feedback and hypermedia resources in blended learning enhances nursing education by facilitating personalized learning, increasing motivation, and improving practical skills and collaboration.
Moon, et al. 2019		Nursing students’ knowledge, attitude, self-efficacy in blended learning of cardiopulmonary resuscitation		South Korea		Randomized Control Trial		Nursing Students		The results showed that the group receiving intervention had notably higher knowledge scores and emotional attitudes about CPR compared to the control group, while there were no differences in other outcomes.[27]		Blended learning positively influenced knowledge and emotional attitudes toward CPR. This supports the potential of blended learning to enhance critical emergency skills in nursing education.
Shorey S. et al. 2018		Experiences of nursing undergraduates on a redesigned blended communication module		Singapore		Qualitative		First Year Nursing Undergraduates		Six main themes and fifteen smaller themes were created. The six main themes consisted of: 1) A beneficial and interesting classroom environment, 2) useful Internet assignments, 3) significant evaluation, 4) respect for interprofessional training, 5) individual growth, and 6) general input and suggestions.[28]		The redesigned blended communication module was well received, highlighting the importance of a supportive classroom environment, useful Internet assignments, and significant evaluations. These elements contribute to the overall effectiveness of blended learning modules.
Emami Sigaroudi, et al. 2016		Understanding Doctoral Nursing Students’ Experiences of Blended Learning		Iran		Qualitative		Ph.D. Student Of Nursing		The study identified three main themes: “failure,” “synergy,” and “specific interaction” in the blended approach to medical education. Failure included administrative challenges and software malfunctions. Synergy highlighted the benefits of combining traditional and digital methods. Specific Interaction emphasized personalized learning experiences.[29]		Highlights both challenges and benefits of blended learning. Administrative issues and software problems need addressing, but the synergistic benefits and personalized learning experiences are significant advantages that support the continued use of blended learning in medical education.
Park, et al. 2016		Effects of Blended Cardiopulmonary Resuscitation and Defibrillation E-learning on Nursing Students’ Self-efficacy, Problem Solving, and Psychomotor Skills		South Korea		Quasi-experimental		Fourth-Year Nursing Students		Participants in the study saw improved problem-solving and nursing skills after exposure to a mix of online and traditional learning methods.[30]		Blended learning enhances problem-solving and practical skills in CPR and defibrillation training, demonstrating its effectiveness in improving critical skills in nursing education.
Arving, et al. 2014		Registered nurses’ thoughts on blended learning in a postgraduate course in cancer care--content analyses of web surveys and a focus group interview		Sweden		Content analyses of web surveys and a focus group interview		Oncology nurses		RNs valued blended learning, with web lectures providing flexibility. They emphasized the importance of interaction with teachers for knowledge acquisition. Seminars should prioritize evidence-based nursing knowledge and practical skills over memorization of facts.[31]		Flexibility and teacher interaction are key benefits of blended learning. The approach should focus on evidence-based knowledge and practical skills, enhancing the learning experience for postgraduate nursing courses.
Stephens, et al. 2013		Internationalising the nursing curriculum using a Community of Inquiry Framework and blended learning		UK		Action research		Nursing Students		Key themes from thematic analysis include operational issues, pastoral care, academic and peer support, and cultural awareness. Challenges in implementing blended learning tools and international placements were highlighted, emphasizing the importance of emotional support for students. Blended tools like Skype and weblogs fostered community, but further work is needed for cultural development.[32]		Identifies operational, pastoral, and academic support as critical elements for successful blended learning implementation. Emotional support and cultural development are essential, especially in international contexts. Blended tools can foster a sense of community among students.
Zolfaghari, et al. 2013		Developing a blended learning program for nursing and midwifery students in Iran: Process and preliminary outcomes		Iran		Action research		midwifery students		181 students (72.1%) and 17 instructors (28.3%) participated in the study. Students in BL had higher GPA and engagement than traditional in-person instruction. Most teachers favored BL for flexibility. Some students cited independence but lacked Internet access and computer skills. Teachers disliked designing BL courses.[33]		Blended learning led to higher GPAs and engagement, and was favored for its flexibility. However, challenges such as lack of Internet access and computer skills among students, and difficulties in course design for teachers, need to be addressed for optimal implementation.
Rigby, et al. 2012		The development and evaluation of a ‘blended’ enquiry based learning model for mental health nursing students: “making your experience count”.		UK		Qualitative		3rd year undergraduate mental health nursing students		The findings of the research indicate that combining in-person groups with an online learning element was the most suitable and efficient method of providing education that catered to the diverse learning preferences of students. Furthermore, students stated that they had a greater understanding of the significance of clinical oversight and their responsibilities as supervisees.[34]		Blended learning, combining in-person and online elements, effectively caters to diverse learning preferences and enhances understanding of clinical oversight and responsibilities, making it a suitable model for mental health nursing education.
Hsu, et al. 2011		Blended learning in ethics education: a survey of nursing students		Taiwan		A cross-sectional survey		Nursing students		57.8% of participants found the course ‘extremely helpful’ or ‘very helpful.’ The study revealed a strong correlation (r=0.43) between student satisfaction with blended learning and case analysis attitudes, showing potential for meaningful learning.[35]		High student satisfaction with blended learning in ethics education indicates its potential for meaningful learning experiences.

From the total of 16 studies included in the analysis, one was experimental, two were RCTs, four were quasi-experimental, six were qualitative, one was descriptive cross-sectional, and two were action research. Six of these studies were conducted in European countries, two in Australia, and the rest in Asian countries. The research samples included undergraduate nursing students in 12 studies, nursing doctorate students in one study, midwifery students in one study, and nurses working in wards in two studies.

From the review of studies, 64 blended learning components were identified. Analyzing the specified elements, pertinent components were categorized accordingly. Finally, through examining interconnected subjects, four core components – educational design, technology infrastructures, instructional techniques, and assessment techniques – were recognized. Also, four outcomes, academic performance, critical thinking ability, student satisfaction, and self-efficacy, and three influencing factors, instructor attributes, student attributes, and institutional support, were recognized.

Core components

These components form the foundation of the blended learning program. The core components are interlinked, indicating that a successful blended learning program in nursing education requires a comprehensive approach that incorporates all four elements [Figure 2].

Figure 2.

Conceptual framework for blended learning in nursing education

Educational design

Two subcomponents of “educational content” and “flexibility” were discovered for the “educational design” component of blended learning. The course’s material, the resources employed, the proportion of in-person and online activities, and the learning needs of the students all made up the educational content. The adaptability of the course material, the venue, and the timing were all taken into consideration.

Technological infrastructures

Among the things included in the technological infrastructure component were the hardware and software infrastructures and technological skills required for students, professors, and support staff to utilize virtual education services effectively.

Educational strategies

Teaching and learning strategies each include two subcomponents, according to educational strategies. The best ways to combine education and technology, effective teaching strategies, and how to guide and assist educational activities were all taken into account. According to educational strategies, teaching and learning techniques each include two subcomponents. The most effective strategies to incorporate technology into education and how to direct and support educational activities were all taken into consideration.

Evaluation methods

The components of evaluation techniques, including the evaluation of research and classroom activities, examination and assessment, performance feedback, and self-evaluation, were noted.

Influencing factors

These factors directly impact the effectiveness and implementation of the core components of blended learning. Key influencing factors include instructor attributes, student attributes, and institutional support, all of which play crucial roles in shaping the blended learning environment. Continuous support for students, such as mentorship, academic counseling, and effective time management techniques, is essential. Additionally, encouraging active participation and fostering a collaborative learning environment significantly enhances student satisfaction and learning outcomes.

Outcomes

Outcomes are the desired results that arise from the proper integration of core components and influencing factors. Outcomes are depicted at the bottom, illustrating that effective blended learning leads to improved academic performance, critical thinking ability, student satisfaction, and self-efficacy [Figure 2].

Discussion

Four components—educational design, technology infrastructures, instructional methodologies, and evaluation methods—have been identified as a consequence of the literature research. In a study, A Systematic Review of Systematic Reviews, Azim Ashraf et al.[36] presented a blended learning model where participants, the learning model, and topics were positioned at the three corners of a triangle, with outcomes, technology, and subjects and topics on the sides. While some aspects of their model align with the findings of the present study, many components identified here, such as technology infrastructure, learner design, and learner support, were not addressed in their model. Educational design is a cornerstone of blended learning. By implementing a blended learning strategy, educational institutions can deliver relevant instructional materials to qualified individuals in the appropriate context and at the right time. This approach allows for the examination of planned educational programs using effective methods. In line with this finding, Kintu et al.’s[37] results showed that certain learner characteristics and design features are significant predictors of student learning outcomes in blended learning.

A key advantage of blended learning is its utilization of various instructional materials, providing students access to diverse textual and audiovisual knowledge sources. Access to a variety of information sources enables students to gain a comprehensive understanding of complex topics or issues.[38] Effective instructional design in blended learning has been shown to result in improved student academic achievement.[23,39] Additionally, the adaptability of blended learning enables curriculum customization to meet students’ needs and provide accessibility to information and curriculum components at any time and location.[40] Toghyani et al.[41] claim that educational flexibility and content are crucial components of blended learning. Their study’s conclusions concur with those of the current study. However, they also view assessment as a component of educational design, and in this way, their research’s findings diverge from those of the current study.

Technology infrastructures play a crucial role in blended learning.[42] This includes telecommunication infrastructure systems, Internet service providers, Internet networks, software, and hardware components, like printers, data storage devices, multimedia scanners, Modems, and phone service, which are all examples of technological infrastructure. It is also important to take into account human infrastructures, such as technical and support staff and educational designers. These findings align with previous research on the importance of technology infrastructure in supporting blended learning initiatives.[43,44,45]

Instructional methodologies are another key element of blended learning. Everyone agrees that the development of teaching and learning strategies is one of the most important advantages of blended learning. To accommodate the varying requirements of pupils, blended learning incorporates a variety of teaching strategies. This approach allows learners to operate autonomously and confidently, develop skills, and engage in real-world settings. The development of effective teaching and learning strategies is recognized as one of the significant advantages of blended learning.[33] Ali et al.,[46] in a single case study design, demonstrated that despite initial doubts among professors, the adoption of blended learning is successful when supported by a well-justified strategy, investment in infrastructure, and continuous support for professors.

Evaluation methods are essential components of blended learning.[47] Blended education has the potential to significantly transform teaching and learning at higher education institutions when it is properly planned and supported.[48] This calls for certain guidelines, the most crucial of which is the ongoing evaluation of teachers, students, and other educational system components. The assessment procedure for blended courses should be revised in comparison to traditional methods based on the features and capabilities of the blended education curriculum.[49] Thus, it is essential to regularly assess students at various points throughout the learning process as well as after the program’s conclusion.[41]

The findings of the current research showed that influencing factors directly affect the effectiveness and implementation of the main components of blended learning. Key influencing factors include instructor characteristics, student characteristics, and institutional support, all of which play important roles in shaping the blended learning environment. This finding aligns with Kintu et al.’s study,[37] which identified key influencing factors, including student characteristics and institutional support, as crucial in shaping the blended learning environment. Ongoing support for students, such as coaching, academic advising, and effective time management techniques, is essential. Additionally, encouraging active participation and creating a collaborative learning environment significantly increase student satisfaction and learning outcomes.

Limitations and recommendations

This systematic review included a wide range of studies with various research designs (experimental, RCT, quasi-experimental, qualitative, descriptive cross-sectional, and action research), offering a broad and inclusive perspective on blended learning in nursing education.

However, this study does have some limitations. One of its weaknesses is the inclusion of solely English and Persian language publications, potentially excluding valuable insights from studies published in other languages. Additionally, the variability in study designs and methodologies made it challenging to synthesize findings and draw definitive conclusions across the reviewed studies. Some of the included studies had limited sample sizes, which may affect the generalizability and robustness of the conclusions. Additional research is needed to determine the impact of BL on reaching educational goals.

Conclusion

The findings underscore the importance of considering the components of blended education to enable the optimal implementation of blended learning programs in nursing education. Adjusting educational design, content, and resources to suit a virtual system is essential, along with providing alternative learning opportunities for students in virtual contexts. Attention should be given to providing appropriate platforms and circumstances for utilizing technological facilities, ensuring technical infrastructure supports the blended learning environment effectively.

Developing educational strategies that efficiently integrate presentation techniques, instructional models, and learning preferences is crucial. Utilizing simulator software and self-directed learning techniques can enhance student engagement and learning outcomes. Improving trainers’ capacity to provide feedback on learners’ progress is recommended to enhance evaluation procedures and ensure continuous improvement in teaching and learning.

Policymakers and educational managers have a pivotal role in creating a framework that integrates educational design, technology infrastructure, educational strategies, and evaluation methods. By considering these components, policymakers and educational managers can establish guidelines and frameworks to support the effective implementation of blended learning in nursing education, ultimately enhancing the quality of education and preparing future nurses for success in their profession.

Ethical approval and/or Institutional Review Board (IRB) approval

Not applicable.

Availability of data and materials

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

Consent to participate

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.