Article

15         June 2011, Vol. 3, No. 1  AJHPE

Introduction
The need to develop reflective practitioners in physiotherapy should 
in part be the role of higher education institutions. Various methods of 
learning can be used to promote this. According to Merrill1 there are four 
distinct phases of learning for a student that are evident in all methods of 
learning and these include ‘activation of prior experience, demonstration 
of skills, application of skills, and the integration of these skills into real-
world activities’. As part of the constructivist perspective of learning, 
more emphasis should be placed on the learner, thus allowing knowledge 
to be built by the learner and not only given by the instructor. 

Self-directed learning (SDL) is a method of instruction used increas-
ingly in adult education within higher education institutions.2 The authors 
define self-directed learning in terms of ‘the amount of responsibility the 
learner accepts for his or her own learning’. However, within this current 
era, there is another challenge for the educator. The generational differ-
ences will definitely influence the approach to learning. The develop-
ment of ICT has allowed for new approaches for delivering instruction in 
institutions of higher education. Thus we need to consider opportunities 
for learning using social media and e-learning.  Students also demand 

that our teaching presentations have structure and that the content being 
taught is evidence based. 

Within the broad definition of self-directed learning, the self-directed 
learner needs to take control and accept the freedom to learn what they 
view as important for themselves. The degree of control the learner is 
willing to take over their own learning will depend on their attitude, abili-
ties and personality characteristics.2 Postgraduate students are considered 
adult learners and should be encouraged to become self-directed learners 
as part of their training. This active guided learning tends to remain in 
memory and can be more easily recalled by the learner.3 However, in 
becoming self-directed learners, there is a need to understand the role of 
the facilitator as well as the role of the learner. 

Various studies have indicated the use of self-directed learning and 
education among health professionals such as doctors,4 dentists and 
nurses.5 In order to implement a programme or module using the self-
directed learning framework one needs to understand the role of the fa-
cilitator. Literature has highlighted the role of a facilitator in education 
and clearly identified that one of the six main roles of the teacher is to 
be a facilitator.6   According to Schwartz,7 a facilitator’s purpose is to 

Abstract
The use of information and communications technology (ICT) has 
become integral to health professions education worldwide.  The in-
corporation of online facilities and maintaining of the face-to-face 
element make blended learning the ‘best of both worlds’. Blogs can 
be used to create a relatively learner-centred environment that allows 
students to learn at their own pace. Though blended learning has been 
proved to be appropriate in higher learning institutions, it comes with 
challenges and opportunities. Our study intended to highlight the 
challenges and identify opportunities encountered by an evidence-
based practice (EBP) postgraduate class who used the blended learn-
ing model of learning. An action-based research methodology was 
utilised in this study. This involved data gathering, action planning, 
action taking and action evaluation. Data were gathered through the 
use of a blog that was accessed by all participants. They made com-
ments which were reflecting their perceptions on the model that was 
used for the course. The students gave consent to participate while 
permission from the physiotherapy head of department was also ac-
quired.  Deductive analysis was used for data analysis. The informa-
tion from the blog was extracted and converted into text files. Cod-
ing and analysis into opportunities and challenges as expressed by 
the participants was performed. Theoretical saturation through every 
reviewer’s agreement and satisfaction about the information was in-
cluded. The data consisted of 94 postings made of primary postings 
(22) and responses (72). All the authors acted as reviewers. Certainty 

was achieved by discussing any ambiguity in coding. Any necessary 
amendments were made. The participants reported to have experi-
enced some challenges pertaining to blended learning. The blog that 
was used as a media between students and the facilitator was inef-
ficient in some way. Some students could not access it when required 
and some resources in the blog were inaccessible. The wireless inter-
net connection mainly used in this model was not reliable. However, 
there were opportunities experienced by the learners. These included 
easy interaction between the learners and the facilitator at any time. 
The model also reduced instructor dependence and made the learn-
ers more responsible of their work. The blog appeared as a resource 
base for skills development. Timely feedback involving solving the 
problems students encountered during the course improved the com-
munication skills between the students and the facilitator. However, 
technology constraints involving the blog and the internet connection 
were overwhelming among the students while writing up the tasks al-
located to them. Despite the fact that students faced some challenges, 
facilitators of blended learning such as the interaction between the 
students and the facilitator of the course were motivating to keep the 
course interesting. While students experienced some opportunities 
about blended learning, its future rests on averting the challenges as-
sociated with it more, especially in developing countries. If the chal-
lenges reported would be addressed in developing countries, blended 
learning can be effective in building students’ engagement and reliev-
ing of overcrowded classrooms in higher learning institutions.    

Challenges and opportunities related to postgraduate evidence-based 
practice module using blended learning
JM Frantz, S Himalowa, W Karuguti, A Kumurenzi, D Mulenga, M Sakala 
Department of Physiotherapy, Univeristy of the Western Cape

Correspondence to: Professor JM Frantz (jfrantz@uwc.ac.za)



    Article

16         June 2011, Vol. 3, No. 1  AJHPE

increase a group’s effectiveness by helping it to improve its processes 
and structures. The facilitator assists the learning process of the student 
and the experience is intended to be collaborative. With the facilitator, 
learning shifts from ‘passive’ learning to ‘active’ learning. The facilita-
tor must understand that the student comes with prior knowledge and 
the method of instruction by the facilitator should guide the student to 
‘the goal of interdependence’.8 In addition, the facilitator realises that 
‘effective learning is possible when the role of the teacher is not that of a 
controller and deliverer of pre-packed knowledge’.9 Thus the shift from 
the teacher-centred to student-centred instruction is being encouraged. 
The challenge that arises is: What are the guidelines for the shift from 
lecturing to facilitating learning?

Even though university requirements at postgraduate level allows for 
learning to exist, actual personal learning is controlled by, and dependent 
on the individual according to adult learning principles.10 These principles 
highlight that real learning occurs in self-directed and problem-oriented 
processes for adults, and each individual has to realise a ‘need to know’ 
and be intrinsically motivated to learn. This motivation needs to be nur-
tured, and Knowles10 highlights six factors as sources of motivation; these 
include social relationships, external expectations, social welfare, personal 
advancement, stimulation and cognitive interest. To be a life-long learning 
health professional, self-directed learning should be an essential factor for 
effective learning. In self-directed learning the individual’s practical expe-
rience motivates and stimulates learning and can be linked to the process of 
evidence-based practice. This poses a challenge to the facilitator in ensur-
ing that the four critical elements of learning are adequately incorporated. 
These elements include motivation, reinforcement, retention and transfer-
ence. Limited information could be found linking self-directed learning, 
evidence-based practice and physiotherapists. 

A postgraduate course in evidence-based practice was revised from 
the use of face-to-face instruction to a more blended learning approach 
which utilised face-to-face instruction, online discussions as well as other 
social media technologies. A blog was used to allow students to share 
knowledge, reflect and debate. Blogs can be used to facilitate ‘small vir-
tual groupings of individuals interested in co-constructing knowledge 
around a common topic within a community of practice’.11 Refshauge 
& Higgs12 describe an experiential learning framework that employs 
peer-assisted learning as one that allows the learners to relay their experi-
ences, discuss their reflections and make conclusions after considering 
their own and their peers’ inputs before finally forming an improved view 
of the experience.

Thus the aim of this study was to highlight the challenges and op-
portunities experienced by the students regarding the incorporation self-
directed learning as a framework for learning the skills and methods of 
collecting and analysing the best evidence available to support practice.

Methods
The study involved five full-time MSc students undertaking an Evidence-
Based Practice (EBP) Module as part of their degree programme. All stu-
dents registered for the module participated in the study, and the lecturer 
acted as a facilitator. The students involved in the study were adult learners, 
with a BSc Honours in physiotherapy, and who had returned to higher edu-
cation after having had a gap of at least 2 years of physiotherapy practice. 
The mean years of clinical experience in the group were 6 years.

This study was a cross-sectional qualitative study. The comments on 
the blog served as a reflective journal throughout the module. The data 
consisted of 22 blogs (primary postings) and 72 blog comments (respons-

es to primary postings); these were added together to represent a total of 
94 blog postings.

Although the course was designed to make use of didactic teaching, 
a blended learning approach was used which included didactic teaching, 
group discussions and online activities. This was a small-scale study with 
a qualitative approach because the aim was to gather rich, detailed infor-
mation reflecting the participants’ viewpoints. This can be compared with 
the personal diary mode of data gathering in qualitative studies. Informed 
verbal consent of willingness to participate in the study was obtained. 
Permission was obtained from the head of department in which the stu-
dents were registered and the registrar of the training institution. Liberty 
to withdraw from the study by not contributing to the blog activities was 
not granted but contributions of those individuals would be excluded if so 
desired. However, in the current study, all blog posts were made available 
for use in the publication. 

Data analysis
Deductive analysis was chosen to analyse the data obtained from the 
blog. The blogs were extracted from the web and converted into text files. 
According to Tere,13 for an appropriate data analysis, one has to put the 
data in a format that will be easily analysed. Coding and analysis of the 
blog continued according to the challenges and opportunities mentioned 
by the participants. Theoretical saturation was achieved after every re-
viewer was satisfied with what he/she had included and agreed on by the 
other reviewers. All the authors acted as reviewers and any ambiguities 
in coding between investigators were discussed, reviewed and amended 
where necessary till certainty was achieved. 

Results
The aim of this study was to highlight the challenges and opportuni-
ties experienced by postgraduate students in incorporating self-directed 
learning as a framework for learning the skills and methods of collect-
ing and analysing the best evidence available to support practice. The 
information in the blog focused on various tasks and the results will be 
presented according to themes guided by the conceptual model of under-
standing self-directed learning. According to Song & Hill,14 ‘the online 
learning context impacts on self-directed learning personal attributes of 
resource use, strategy use, and motivation’. Within all of this there are 
opportunities and challenges as highlighted by the following quotes.

Skills development
 EBP module has allowed me to develop skills regarding the process 
of evidence-based practice as well as reflecting on what I do and how 
I do it. (Opportunity)

 Blended learning has been very interesting to me at the same time 
challenging. For me it is the ultimate learning process in the 21st 
century. While I appreciate the research skills that I’ve learnt 
through blended learning, the question that I keep on asking myself 
is: how are we going to transform this beautiful learning process 
back home? (Challenge)

Improved learning
 This course (EBP) came at a time when our knowledge on research 
was a key higher. However, our writing knowledge has been refined; 
our aspiration for further writing has been inspired ... I was able to 
learn, read and contribute at my own pace. (Opportunity)



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17         June 2011, Vol. 3, No. 1  AJHPE

 Understanding and finding the correct tools to score the methodolog-
ical quality [of an article] was another challenge as most of the tools 
aimed at assessing RCTs though there are limited tools that critically 
appraise other study designs which is commonly found in health pro-
fessionals research … others found this task easier and I felt pres-
sured to complete the task in order to contribute.  (Challenge)

Resources
The students were able to access each other’s ideas and perspectives on 
various topics through the blog. However, the blog had both challenges 
and opportunities as a resource.

 To my utter disappointment, it wasn’t to be because I was never able 
to log in. This was at times devastating because I was not able to 
post anything I wanted to share ‘my experiences’ with my colleagues. 
It made me trail behind sometimes and this was never good at all. 
(Challenge)

 The fact that we could share our ideas, opinions, challenges, infor-
mation and knowledge made it far more important and worthwhile 
than what I see on Facebook ... I could refer back to the comments 
and additional resources place on the blog. (Opportunity)

Strategies
Students made use of the blog as well as face to face discussions to im-
prove their skills. In addition the importance of the facilitator and feed-
back was also highlighted. 

 This process was somehow challenging, where sometimes I would 
write up any part of the article and feel I have done great but the facili-
tation and feedback from the lecturer really helped a lot. This assisted 
me in understanding immediately where necessary. (Opportunity)

 I also like the fact that we had to share our challenges throughout the 
way because one would feel that he/she is not the only one facing the 
challenges. Support from others helped me cope with the challenges. 
(Opportunity)

 The blog could at times keep the posted comments pending and there-
fore denying the bloggers the opportunity to read and respond on time. 
This was frustrating as I wanted immediate responses. (Challenge)

Task context
Students reported challenges and opportunities within the process of ev-
idence-based practice and finding information supporting their research 
question.

 Very little literature around Africa was found. This hampered my pro-
gress regarding the desired tasks. (Challenge)

 Some articles were difficult to review since there was a limitation 
in drawing out the specific conclusions of the study and research 
design. I struggled with this. (Challenge)

 The methodology phase has made me realise that teaching the theory 
relating to tools and techniques is not as effective as providing the stu-
dents with the opportunity to apply the tools themselves. (Opportunity)

 I found being able to refer to the outline of the tasks on the blog and 
the comments from others associated with it good as I could go back 
all the time when I did not understand. (Opportunity)

Discussion
Blended learning is a combination of any form of technology-facilitated 
learning and face-to-face instructor-led training.15 The traditional models 
of learning are being replaced by the emergence of new advanced technol-
ogies that provide the facilitators with an exceptional opportunity, creating 
blended learning environments that are highly interactive, meaningful and 
learner-centred.16 EBP is a movement within health professions education 
that allows professionals to identify, disseminate and promote the adoption 
of practices based on research. Designing a postgraduate EBP module is 
challenging, as it would be expected that the evidence base expands from 
pure intervention studies and RCTs to including evidence on contextual 
factors using qualitative research. How to best teach EBP has become a 
major point of discussion in many health professions but teaching concepts 
of EBP remains a challenge in professional education.13 In exploring effec-
tive pedagogies, educators have emphasised the benefits of applying the 
principles of adult learning theory to EBP modules. 

In the current study students highlighted the challenges and oppor-
tunities faced when allowed to incorporate the principles of self-direct-
ed learning in a module. The use of information and communications 
technology (ICT) has become integral to health professions education 
worldwide. Blogs can be used to create a relatively learner-centred envi-
ronment that allows students to learn at their own pace. This was evident 
in the current study when participants reflected on their experiences and 
indicated that they could continuously refer back to comments and tasks 
on the blog. In addition, participants also indicated that they could ‘learn, 
read and respond’ at their own pace. However, research has highlighted 
that there are concerns that developing countries lack the relevant infra-
structure and skill base to effectively incorporate ICT in education.17 Al-
though learners of today have tried to embrace technologies like blogging 
to enhance their learning in institutions, the students in the current study 
also highlighted their concern of how they would be able to effectively 
implement this method of teaching and learning in their home countries 
in Africa. Currently this challenge is also being highlighted in medical 
education in Africa.18 

Conclusion
Although blended learning can be used to adjust to the essential learning 
methods and overall learning environment of the student, it is still evident 
that challenges do exist with this method. The challenges related to blended 
learning that arose during the course include, but not limited to, technology 
constraints involving the blog and the internet connection. Despite the fact 
that students faced some challenges, the facilitators such as the interaction 
of the students and the facilitator providing feedback on students’ progress 
were motivating to keep the course interesting. The blog allowed a greater 
and timely feedback such as solving the problems the students encountered 
during the course and improved the communication and IT skills between 
the students and the facilitator. If the challenges reported would be ad-
dressed in developing countries, this type of learning can be effective in 
building students’ engagement in learning, relieving overcrowded class-
rooms found in most African countries. In all, there was a multitude of 
success to both the facilitator and students during this course.     

Implications for practice
Incorporation of blended learning in physiotherapy will lead to enhance-
ment of learning due to access to literature and reduction of dependency 
on facilitators, which is a characteristic of didactic learning and improved 
responsibility and autonomy over the learners’ work.



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18         June 2011, Vol. 3, No. 1  AJHPE

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