Nurse Education in Practice xxx (2014) 1e7
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
The diversity of Iranian nursing students’ clinical learning styles: A qualitative study Shahram Baraz, Robabeh Memarian*, Zohreh Vanaki Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 4 March 2014
Background: Numerous factors, including learning styles, affect the learning process of nursing students. Having insights about students’ learning styles helps promoting the quality of education. The aim of this study was to explore the Iranian baccalaureate nursing students’ learning styles in clinical settings. Methods: A qualitative design using a content analysis approach was used to collect and analyze data. Semi-structured interviews were conducted with fifteen Iranian baccalaureate nursing students selected using a purposive sample method. Findings: During data analysis, it was found that nursing students employed different clinical learning styles such as ‘thoughtful observation,’ ‘learning by thinking,’ and ‘learning by doing’. Conclusion: Students adopt different learning strategies in clinical practice. Designing teaching strategies based on students’ learning styles can promote students’ learning and maximize their academic and clinical practice success. Nursing educators, curriculum designers, and students can use the findings of this study to improve the quality of nursing education in both the classroom and clinical settings. Ó 2014 Elsevier Ltd. All rights reserved.
Keywords: Clinical learning styles Nursing in Iran Qualitative study Student nurses
Introduction Classrooms and clinical settings are different learning environments available to nursing students (Brown et al., 2011; McMeeken, 2008). In classrooms, the process of learning is usually structured; however, in clinical settings, the learning process takes place through unplanned activities and through direct contacts with patients and healthcare providers. Accordingly, students’ learning styles in these two learning environments are different (Cheraghi et al., 2008). Numerous factors, including learning styles, affect the process of learning in nursing students (Cowman, 1998). Educational researchers believe that having insights about students’ learning styles helps promoting the quality of education. Learning styles are individuals’ preferred methods of knowledge and skill acquisition and information organization. Therefore, students’ personal differences in learning styles are required to be considered during the teaching process to fulfill their educational needs (Felder and Brent, 2005; Vollers, 2008). Arthurs (2007) believed that nursing educators have difficulties in designing teaching strategies that are consistent with students’
* Corresponding author. Tel./fax: þ98 2182883856. E-mail address: [email protected] (R. Memarian).
learning styles. On the other hand, it is important to nursing educators to adopt different teaching-learning strategies to facilitate students’ learning and to improve their professional skills (Bailey and Tuohy, 2009). Background The term ‘learning style’ is originated from educational studies conducted in the 1970s. One of the reasons for the invention of this term is that learning styles have practical application particularly in the areas of teaching and learning. Subsequently, numerous studies were conducted on the application of learning styles in nursing (Snelgrove, 2004). To the best of our knowledge, most of these studies are quantitative in which standardized questionnaires such as the Kolb Learning Style Inventory and the Honey and Mumford Learning Style Inventory have been used for data collection (Ahadi et al., 2010; D’Amore et al., 2012; Fleming et al., 2011; Peyman et al., 2012; Rezaei et al., 2010). These selfreported questionnaires classify students into predetermined categories developed by teaching-learning theorists (Snelgrove, 2004). For example, the Honey and Mumford Learning Style Questionnaire (Honey and Mumford, 2000) categorizes people according to their learning styles as activists, reflectors, theorists, and pragmatists. Fleming et al. (2011) found that the preferred learning styles of Irish first- and fourth-year nursing students
http://dx.doi.org/10.1016/j.nepr.2014.03.004 1471-5953/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
2
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
were reflector and activist styles. Astin et al. (2006) also found that the dominant learning styles of American nursing students were reflector and theorist ones. On the other hand, the Kolb’s Learning Style Inventory (Kolb and Kolb, 2009) categorizes people as diverger, accommodator, converger, or assimilator learners. D’Amore et al. (2012) found that Australian first-year nursing students were mainly diverger and assimilator learners. Gyeong and Myung (2008) also reported that Korean nursing students were mainly accommodator learners. The dominant learning styles adopted by Iranian nursing students also have been reported to be converger and assimilator styles (Ahadi et al., 2010; Rezaei et al., 2010). Despite the abundance of quantitative studies on learning styles, there is an obvious gap in terms of the dimensions and students’ experiences of clinical learning styles. Moreover, the best learning styles and models are still unknown (Felder and Brent, 2005; Fleming et al., 2011). Additionally, studies on learning styles have many applications: 1. In clinical settings, nursing educators encounter students coming from different educational backgrounds; therefore, they need to know different learning styles of nursing students to be able to facilitate the teaching-learning process and to minimize clinical education weaknesses (Snelgrov, 2004). 2. Knowing different learning styles helps nursing educators improve the educational environment and the teacherestudent relationship (Gillespie, 2002). 3. Knowing different learning styles helps educational theorists develop more coherent teaching-learning theories in higher education (Samuelowicz and Bain John, 2001). 4. Nursing educators’ awareness of students’ learning styles leads to thoughtful educational planning, appropriate student evaluation, and promotion of teaching and learning (Hunt, 2006; Karimi Moonaghi et al., 2010; Rassool and Rawaf, 2008). Consequently, as few qualitative studies have explored the learning styles of baccalaureate nursing students, therefore, it was decided to fill the gap by conducting this study. The aim of this study was to explore learning styles of the Iranian baccalaureate nursing students in clinical settings. Methods Design This was a qualitative design using a content analysis approach and the research was conducted between May and December 2012. Qualitative approaches have an explorative nature and enable researchers to explore the complexity of phenomena happened to the healthcare providers, policy-makers, and clients (Tong et al., 2007). Participants A purposive sample was used to recruit fifteen baccalaureate nursing students. Having at least a two-semester experience of clinical practice and willingness to participate in the study were inclusion criteria to choose participants. To cover a wide range of viewpoints and experiences, the maximum variation sampling technique was applied (Strubert and Carpenter, 2003). Accordingly, we sampled from both genders and from second- to forth-year students. The study sample consisted of 3 second-year, six thirdyear, and six forth-year students. Moreover, out of the fifteen students recruited, six students were female. The participating students ranged in age from 18 to 24 years.
Data collection Semi-structured interviews were used for data collection. This method, compared with the quantitative data collection methods, leads to a more in-depth understanding of the intended phenomenon (Strauss and Corbin, 1998). The interview questions included but not limited to, 1. Would you please explain about how you learn to provide nursing care in clinical settings? 2. What and how did you learn in this and other previous courses of clinical training? and 3. Would you please explain your clinical experiences? Besides these open-ended questions, probing questions were used to delve into the participants’ learning experiences. At the end of each interview session, the participant was asked to add any supplementary information not addressed by the interviewer. Data collection process was continued until reaching data saturation (Green and Thorogood, 2004). In case of any ambiguities, follow-up interviews were conducted. Totally, nineteen personal face-to-face interviews were conducted with fifteen students. Eleven students were interviewed once and four students were interviewed twice. Interviews were held in an interview room located in the Nursing Department. The interview sessions lasted 30e90 min. We recorded the interviews by using a digital sound recorder. Immediately after each interview, the interview content was transcribed verbatim. Data analysis The data collection and data analysis processes took place concurrently. For analyzing the study data, the Morse & Field’s qualitative content analysis approach was employed (Morse and Field, 1995). Content analysis is a systematic coding and categorizing approach. In this approach, the collected data are examined carefully to identify the trends, patterns, and relations (Gbrich, 2007). At the beginning of the analysis, the transcribed text was read repeatedly to immerse in and gain a general sense of the interview content. Then, the content of each interview was broken to basic meaning units, the irrelevant pieces of data were discarded, and the text was coded line-by-line. Thereafter, we categorized the codes based on their similarities and differences into higher-level sub-categories and categories and put the developed sub-categories and categories under overarching themes. Table 1 shows how the theme ‘thoughtful observation’ was developed. Trustworthiness Trustworthiness is a key component of qualitative studies. If the reader of a study report is able to audit the data collection and analysis processes, the study is presumably trustworthy (Koch, 2006). In this study, the peer-checking method was used to establish the credibility of the analysis process. Accordingly, the researchers analyzed the interviews independently and compared the developed concepts, categories, and themes. In case of any disagreement, discussions were held to reach an agreement. Besides peer-checking, the member-checking method was used to establish the credibility of data. Accordingly, after the analysis of each interview, the participants were provided with a summary of data analysis process and findings and asked to check whether the developed concepts reflected their experiences or ideas. Finally, their additional points of view and suggestions were included in the analysis. Another criterion for trustworthiness was audit-
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
3
Table 1 The development of the theme ‘Active involvement’. Quotation
Sub-categories
Categories
Theme
I tend to learn by observation rather than by intervention. For instance, in case of procedures such as venipuncture, I, initially, observe carefully to learn. I do not ask them to assign the task to me. I observe repeatedly to learn. In ICU, I learned, from my instructor, how to insert a nasogastric tube. Initially, my instructor performed the procedure and I just observed and learned. Then, at the same day, I successfully inserted a nasogastric tube for another patient We had read, from the textbook, the procedure of removing surgical drains and tubes; however, I had never seen the procedure until a physician came and removed a drain and sutured the drain site. It was then that I learned the procedure and now, I can do it independently. On a bedside nursing round our instructor asked, ‘What will happen if you give an IV push of potassium chloride?’ We did not know the answer. He told us that in case of an IV push of potassium chloride, a cardiac arrest may happen. Such critical points, when highlighted repeatedly, will be imprinted on our minds forever I have also learned from physicians; for example, one day a physician was teaching his students how to manage a diabetic foot and when it should be amputated. The physician, together with his students, was deciding on the amputation of a female patient’s diabetic foot. I listened to their discussions carefully and learned how to manage a diabatic foot
Careful observation of nurses
Careful observation of role-models’ performance.
Thoughtful observation
trailing (Gbrich, 2007). In this regard, all the records of the study were kept for the purpose of audit-trailing.
Careful observation of clinical instructors Careful observation of physicians’ performance
Careful observation, listening, and reflection during nursing rounds
Reflective observation during clinical rounds
Careful observation, listening, and reflection during medical rounds
the drain site. It was then that I learned the procedure and now, I can do it independently (P.14, second-year student from a surgical placement).
Ethical considerations The Ethics Committee affiliated to Tarbiat Modares University approved the study. All the participants were informed about the aim of the study. They were assured that participation in the study is voluntary. Moreover, they were able to voluntarily withdraw from the study. We also guaranteed the confidentiality of their provided data and ensured them that their provided information will be published anonymously. Finally, we asked the participants to read and sign the study informed consent form. Results During data analysis, it was found that the students’ clinical learning styles fell into three main themes including ‘thoughtful observation,’ ‘learning by doing,’ and ‘learning by thinking’ (see Table 2). As follows, the meaning of each theme and subtheme has been reported using the participants’ direct quotations. Thoughtful observation This theme had two categories including ‘careful observation of role-models’ performance’ and ‘reflective observation during clinical rounds.’ Our participants had adopted learning styles such as careful observation of nurses, clinical instructors, and physicians’ performance as well as careful observation, listening, and reflection during nursing and medical rounds. The following quotation reflects learning through the observation of nurses’ caring behaviors: I tend to learn by observation rather than by intervention. For instance, in case of procedures such as venipuncture, I, initially, observe carefully to learn. I do not ask them to assign the task to me. I observe repeatedly to learn (P.2, fourth-year student from an ICU placement). Moreover, as physicians work in healthcare settings, our students referred to them as potential learning supports: We had read, from the textbook, the procedure of removing surgical drains and tubes; however, I had never seen the procedure until a physician came and removed a drain and sutured
Besides, almost all the participants mentioned that they promote their own learning by participating in medical rounds and listening to physicians’ discussions carefully. I have also learned from physicians; for example, one day a physician was teaching his students how to manage a diabetic foot and when it should be amputated. The physician, together with his students, was deciding on the amputation of a female patient’s diabetic foot. I listened to their discussions carefully and learned how to manage a diabetic foot (P.13, third-year student from an Endocrinology placement).
Table 2 The diversity of Iranian nursing students’ clinical learning styles. Sub-categories
Categories
Theme
Careful observation of nurses’ performance Careful observation of clinical instructors’ performance Careful observation of physicians’ performance Careful observation, listening, and reflection during nursing rounds Careful observation, listening, and reflection during medical rounds Cooperation with role models in implementing nursing procedures Active involvement in scientific debates Continuity in history taking and physical examination’ Continuity in implementing nursing procedures Assuming responsibility for patient care Self-reliance Individual accountability for doing clinical homework Facing problematic situations Facing challenging questions Having a sense of curiosity Questioning
Careful observation of role-models’ performance
Thoughtful observation
Reflective observation during clinical rounds
Active involvement
Learning by doing
Maintaining the continuity of learning
Assuming responsibility and being independent
Critical thinking
Learning by thinking
Inquisitiveness
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
4
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
Besides medical rounds, our participants also mentioned that they had learned a lot from nursing rounds held by their clinical instructors and classmates at patients’ bedside. These rounds had sensitized them to clinical notes and cases. On a bedside nursing round our instructor asked, ‘What will happen if you give an IV push of potassium chloride?’ We did not know the answer. He told us that in case of an IV push of potassium chloride, a cardiac arrest may happen. Such critical points, when highlighted repeatedly, will be imprinted on our minds forever” (P.1, fourth-year student from a Dialysis placement). Learning by doing This theme consisted of three categories: ‘active involvement,’ ‘maintaining the continuity of learning’ and ‘assuming responsibility and being independent.’ Active involvement After learning through ‘careful observation of role-models performance,’ our participants strived to promote their own learning through active involvement in implementing nursing procedures and class discussions. For example one student noted that: Infants are extremely sensitive and vulnerable; therefore, working with them is associated with fear and anxiety. However, our third-semester instructor helped us admit a full-term infant, give him at-birth vaccines, and control birth and primitive reflexes such as Moro, grasping, and rooting (P.12, fourthyear student from a Pediatric placement). The following quotation shows how the student promoted his learning through collaboration with a staff nurse: In that 10-day clinical training course, I was assigned to a staff nurse who involved me in all his tasks. For instance, when we were caring for a patient with CAD [Coronary Artery Disease], he asked me, ‘Do you know what CAD is?’ I gave him my answers and he added some more helpful notes. Moreover, he shared with me his first-hand clinical experiences; for example, he told me that he had seen the complications of a Ceftriaxone IV push given to a patient with CAD. He improved my knowledge in many areas of patient care (P.3, third-year student from a CCU placement) The following student reflects learning through active collaboration with peers: Our instructor asked us to work together on the dialysis machine. He asked us to help each other in learning. He told that he will evaluate us subsequently. We worked on the machine and learned how to set up, use, and disassemble it. Now, I can do it easily (P.11, fourth-year student from a Dialysis placement). On the other hand, the study participants cooperatively discussed, thought, and shared their clinical experiences about patients’ conditions. Such discussions and thinking had promoted their learning. Moreover, they mentioned that they had learned a lot from their instructors and peers through active participation in group discussions that tended to take place in their daily clinical class meetings:
Then, we began to talk together about interesting subjects. For instance, when we were in ICU, we discussed patients’ ABG [arterial blood gases] readings to diagnose their problems. We shared our knowledge and this helped me learn a lot (P.1, fourthyear student from an ICU placement).
Maintaining the continuity of learning Continuity reflects how our participants promoted their learning through making frequent contacts with patients for obtaining their health history. Our students explained that they, initially, build up an image of the patient’s main problem and then, start to make frequent contacts with him to understand his problem thoroughly: I tried to memorize and categorize information collected during history taking. Then, if another patient gave me the same information, I could guess his medical diagnosis easily.for example, I have taken health history from several patients having radiating chest pain and now I have a sound knowledge base about this heart condition (P.6, third-year student from a Cardiology placement). The study participants also mentioned that they facilitate their learning process through performing nursing procedures regularly: The more one does a task, the more fearless he becomes, the better he will do it later, and the lower his error rate will be (P.8, third-year student from a Hematology placement).
Assuming responsibility and being independent The study findings revealed that the more experienced students had greater tendency towards assuming responsibility for patient care. Moreover, self-reliance in performing nursing procedures, assuming responsibility for patient care, and individual accountability for doing clinical homework had promoted the students’ learning through increasing their knowledge, skills, self-confidence and clinical decision making: When I assume responsibility for providing care to a certain patient, I study about his medication and learn that his medication has certain side effects. For example, I understand that his medication is useful for the treatment of sepsis but increases his blood pressure. I need to know that this medication is contraindicated in patients with high blood pressure. Therefore, in the case-method approach to care, I have enough time to learn the prescribed medications, their side effects, and the way to minimize the side effects (P.5, fourth-year student from a CCU placement). In ICU, we had authority to intervene; for example, when a patient developed dysrhythmias, we had the authority to give him an antiarrhythmic agent. This type of professional autonomy eliminated the sense of being subordinate to physicians and therefore, increased our self-confidence (P.4, fourth-year student from an ICU placement). The study participants believed that accountability for doing clinical homework, such as designing educational posters and pamphlets, presenting case reports, planning and delivering patient education, and writing nursing care plans, compels them to study hard and to learn a lot. I like patient education because it compels me to gather basic information regarding patient’s condition, its signs and symptoms, complications, and management as well as essential self-
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
care activities. This is a comprehensive approach. It helped me cover that subject completely and learn effectively (P.3, Secondyear student from an Neurology placement).
Learning by thinking This theme also consisted of two categories including ‘inquisitiveness’ and ‘critical thinking.’ Inquisitiveness While collaborating with healthcare team members, the students strived to use their own sense of curiosity to promote their learning. Moreover, they asked instructors, peers, staff nurses, and even physicians the questions that had arisen out of their daily clinical practice. Another learning strategy adopted by the study participants was consulting with nursing textbooks or educational materials to find answer to their questions and to satisfy their curiosity: When I encounter an unusual case, I consult my books at night. For example, when we were in cardiac care unit, I did not know very well about cardiomyopathy and artificial heart valves; therefore, I consulted my books at night (P.12, third-year student from a Cardiology placement). When we were in CCU, I had difficulties in interpreting an electrocardiogram correctly; therefore, I asked my classmates to help me. They helped me and I learned a lot from them (P.15, third-year student from a Cardiology placement).
Critical thinking This category shows how nursing students promoted their learning through monitoring, critiquing, and avoiding nurses and physicians’ unsafe clinical practice. Moreover, the participants mentioned that their clinical instructors face them with challenging questions to promote their critical thinking and learning. For example one student noted that: Today, I cared for a patient who had received subcutaneous Heparin. I saw, with my own eyes, that his arm was badly bruised. Then, I remember that massaging the Heparin injection site is contraindicated; however, hospital personnel had massaged the site so much that it had been bruised badly. As a result, avoidance of massaging the Heparin injection site was imprinted on my mind for ever (P. 14, third-year student from a Neurology placement). This was important as the instructor was letting the student know about evidence-based practice. Discussion The aim of this study was to explore the Iranian baccalaureate nursing students’ learning styles in clinical settings. The findings revealed that the students adopted different styles to promote their learning. Adopting multiple learning styles helped the students to benefit from unfamiliar working and learning environments. Moreover, this ability turned them into more efficient, flexible, resourceful, and professional learners. This important finding is particularly applicable to curriculum planning and development (Felder and Brent, 2005; Fleming et al., 2011). The American Associates of Colleges of Nursing (1998; cited in Synder et al., 2000) noted that to promote students’ learning, nurse
5
educators should develop a standard curriculum that stimulates students’ creativity and helps them actively participate in the learning process. Understanding students’ learning styles helps nursing educators develop a flexible student-centered curriculum that enables students to use their learning styles effectively (Meehan-Andrews, 2009). It also enables nursing educators to create a supportive learning environment, which in turn facilitates students’ learning and enhances their professional development, and improves the quality of care (Marek, 2013). Nurse educators need to teach students how to adapt their own learning styles to different teaching strategies. Accordingly, students would be able to discover their own strengths and weaknesses, promote their learning in different learning environments, develop self-confidence, and display more independence in learning (Spoon, 1996). The study findings revealed that the students’ learning styles evolved over their four-year nursing course into styles such as accountability and self-reliance. Fleming et al. (2011) also reported that the fourth-year students’ learning styles are different from the learning styles adopted by the first- and second-year students. Kolb (1984; cited in Rassool and Rawaf, 2008) believed that brilliant learners get qualified professionally by adopting different learning styles in different environments. Similarly, previous studies report that many factors such as the course of study, course curriculum, evaluation criteria, pedagogic strategies, professional socialization during the nursing program, and the students’ developmental stage can affect the students’ learning styles (Fleming et al., 2011; Rassool and Rawaf, 2008; Sutcliffe, 1993). The study findings revealed that students promoted their learning through observing instructors, clinical staff nurses, physicians, and peers’ clinical practice. Working and interacting with role models helps students acquire mastery over professional skills. Role models socialize students professionally. They develop students’ professional identity, knowledge, and skills and help them transfer their knowledge to practice. In turn, they will be empowered to teach their skills to other students (Beth Perry, 2009). We also found that the students promoted their learning through careful observation, listening, and reflection during nursing and medical rounds. Clinical rounds provide a natural environment for learning patient-centered and evidence-based practice (Gardner et al., 2010). Nursing rounds, like medical rounds, are effective teaching-learning and case presentation strategies (Furlong et al., 2007). In these rounds, clinical instructor provides detailed explanations about the intended case, adds his personal clinical experiences, creates an environment for further class discussion, and promotes students’ critical thinking through asking challenging questions. In addition, according to Perry and Paterson (2005), students promote their own learning through making clinical notes. The study findings revealed that the students learned from their peers. Other studies also have referred to peers as a main source of learning (Roberts, 2008, 2009). Moreover, learning from peers has positive effects on students’ accountability, degree of self-reliance and collaboration, and personal development. It can improve their psychomotor, communication, and time management skills (Gerace and Sibilano, 2006; Glynn et al. 2006; Secomb, 2008). We found that the students also adopted assisted learning and self-reliance or independent learning as their preferred learning strategies. Brugnolli et al. (2011) reported the same findings. Moreover, Brugnolli et al. (2011) and Jackson and Mannix (2001) reported that students’ control over their learning and thinking processes is affected by their own attitudes and the amount of support received from instructors, peers, and other healthcare professionals. The researchers also believed that some students prefer more intensive supervision while other students prefer
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
6
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
reflective self-directed learning (Brugnolli et al., 2011; Jackson and Mannix, 2001). Another learning strategy adopted by our participants was maintaining the continuity of learning. Hartigan-Rogers et al. (2007) believed that the application of the acquired knowledge and skills to everyday practice is a learning strategy that facilitates students’ professional socialization. Active involvement was another learning strategy adopted by our participants. Keeling and Templeman (2013) believed that learning in collaboration with role models is an important strategy. Active involvement in clinical care positively affects students’ understanding of the clinical interventions and promotes their critical thinking and active learning. Moreover, students’ observation and perception of nurses’ professional and non-professional behaviors positively affect their learning (Keeling and Templeman, 2013). Brugnolli et al. (2011) also found that one of the most effective learning strategies adopted by students is their active or supervised involvement in clinical care. This learning strategy gradually improves students’ knowledge and skills because it enables them to observe role-models’ performance, listen to the provided explanations, implement nursing procedures in collaboration with other peers and staff nurses, and reflect on the implemented procedures. Baghcheghi et al. (2011) also believed that small group teaching enables students to discuss all the possible solutions to perceived problems. Critical thinking was another learning strategy adopted by nursing students in this study. According to Kaddoura (2011), critical thinking is one of the most effective learning strategies. Critical thinking promotes students’ learning, qualifies them for clinical practice, enables them to make accurate clinical judgments, and helps them develop professionally. Accountability was another learning strategy among our participants. It is mentioned that independent learning, accountability, and regular feedbacks promote students’ learning (Lee et al., 2002; Stark, 2003). Spouse (2003) found that nursing students’ academic achievement directly correlates with their degree of self-reliance, i.e. their distance from their instructors and mentors. Spouse (2003) has referred to self-reliant students as ‘flying solo.’ Our participants also believed that self-reliance promoted their learning. Bradbury-Jones et al. (2011) reported that students’ learning dependence negatively affects their professional knowledge, interest, and self-confidence. Our findings were in some ways different from the learning styles proposed by Honey and Mumford and Kolb. For example, almost none of our themes reflected Honey and Mumford’s ‘theorists’ and ‘activists’ learning styles. Moreover, our findings were in some ways similar to the learning styles proposed by Kolb such as learning by observing, thinking, and doing. However, we did not found any theme reflecting concrete experiencing. Conclusion According to the findings of this study, nursing students in Iran adopt different learning strategies to promote their learning. Clinical setting is an unstable learning environment wherein students are faced with unpredictable and stressful situations. In such an unstable environment, students’ intelligence and inquisitiveness play an important role in developing and adopting the most effective learning strategies. Moreover, clinical training and education should provide students with different training opportunities to enable them to develop and adopt innovative learning strategies in different clinical environments. In addition designing teaching strategies based on students’ learning styles can strongly promote students’ learning and maximize their academic success.
Implications The current study explored the nature of students’ learning strategies in Iran. Nursing educators, curriculum designers, and students in other countries however can use the study findings for improving the quality of nursing education and practice in their own clinical environments and higher education settings. Limitations In this study, we explored a group of Iranian baccalaureate nursing students’ learning styles in clinical settings. Therefore, the findings are not broadly transferable. Consequently, further studies are needed to explore different learning styles adopted by students worldwide and cross-country comparisons developed. References Ahadi, F., Abedsaidi, J., Arshadi, F., Ghorbani, R., 2010. Learning styles of nursing and allied health students in Semnan university of medical sciences. J. Med. Sci. Semnan 11, 141e147 (Persian). Arthurs, J.B., 2007. A juggling act in the classroom: managing different learning styles. Teach. Learn. Nurs. 2, 2e7. Astin, F., Closs, J.S., Hughes, N., 2006. The self-reported learning style preferences of female Macmillan clinical nurse specialist. Nurse Educ. Today 26, 475e483. Baghcheghi, N., Koohestani, H.R., Rezaei, K., 2011. A comparison of the cooperative learning and traditional learning methods in theory classes on nursing students’ communication skill with patients at clinical settings. Nurse Educ. Today 31, 877e882. Bailey, M.E., Tuohy, D., 2009. Student nurses’ experiences of using learning contract as a method of assessment. Nurse Educ. Today 29, 758e762. Beth Perry, R.N., 2009. Role modeling excellence in clinical nursing practice. Nurse Educ. Pract. 9, 36e44. Bradbury-Jones, C., Sambrook, S., Irvine, F., 2011. Empowerment and being valued: a phenomenological study of nursing students’ experiences of clinical practice. Nurse Educ. Today 31, 368e372. Brown, T., Williams, B., McKenna, L., Palermo, C., McCall, L., Roller, L., Hewitt, L., Molloy, L., Baird, M., Aldabah, L., 2011. Practice education learning environments: the mismatch between perceived and preferred expectations of undergraduate health science students. Nurse Educ. Today 31, 72e78. Brugnolli, A., Perli, S., Viviani, D., Saiani, L., 2011. Nursing students’ perceptions of tutorial strategies during clinical learning instruction: a descriptive study. Nurse Educ. Today 31, 152e156. Cheraghi, M.A., Salasli, M., Ahmadi, F., 2008. Factors influencing the clinical preparation of BS nursing student interns in Iran. Int. J. Nurs. Pract. 14, 26e33. Cowman, S., 1998. The approaches to learning of student nurses in the Republic of Ireland and Northern Ireland. J. Adv. Nurs. 28, 899e910. D’Amore, A., James, S., Mitchell, E.K.L., 2012. Learning styles of first-year undergraduate nursing and midwifery students: A cross-sectional survey utilising the Kolb learning style inventory. Nurse Educ. Today 32, 506e515. Felder, R.M., Brent, R., 2005. Understanding student differences. J. Eng. Educ. 94, 57e72. Fleming, S., Mckee, G., Huntley-Moore, S., 2011. Undergraduate nursing students’ learning styles: a longitudinal study. Nurse Educ. Today 31, 444e449. Furlong, K.M., D’Luna-O’Grady, L., Macari-Hinson, M., O’Connel, K.B., Perez, E.L., Pierson, G.S., 2007. Implementing nursing grand rounds in a community hospital. Clin. Nurse Spec. 21, 287e291. Gardner, G., Woollett, K., Daly, N., Richardson, B., Aitken, L.M., 2010. Innovation in clinical learning for the acute hospital environment: nursing grand rounds. Nurse Educ. Today 30, 737e741. Gbrich, C., 2007. Qualitative Data Analysis: an Introduction, first ed. SAGE Publications, London. Gerace, L., Sibilano, H., 2006. Preparing students for peer collaboration: a clinical teaching model. J. Nurs. Educ. 23, 206e209. Gillespie, M., 2002. Studenteteacher connection in clinical nursing education. J. Adv. Nurs. 37, 566e576. Glynn, L.G., MacFarlane, A., Kelly, M., Cantillon, P., Murphy, A.W., 2006. Helping each other to learn- a process evaluation of peer assisted learning. BMC Med. Educ. 6,18. Green, J., Thorogood, N., 2004. Qualitative Methods for Health Research, first ed. SAGE Publications, London. Gyeong, J.A., Myung, S.Y., 2008. Critical thinking and learning styles of nursing students at the baccalaureate nursing program in Korea. Contemp. Nurse 29, 100e109. Hartigan-Rogers, J.A., Cobbett, S.L., Amirault, M.A., Muise-Davis, M.E., 2007. Nursing graduates’ perceptions of their undergraduate clinical placement. Int. J. Nurs. Educ. Scholarsh. 4. Honey, P., Mumford, A., 2000. The Learning Styles Questionnaire: 80-item Version. Peter Honey Publications Ltd., Berks, UK. Hunt, S., 2006. Learning and Cognitive Styles, What are Learning and Cognitive Styles?. Available from: http://www.ilstu.edu.
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7 Jackson, D., Mannix, J., 2001. Clinical nurses as teachers: insights from students of nursing in their first semester of study. J. Clin. Nurs. 10, 270e277. Kaddoura, A.M., 2011. Critical thinking skills of nursing students in lecture-based teaching and case-based learning. Int. J. Scholarsh. Teach. Learn. 5, 1e18. Karimi Moonaghi, H., Dabbaghi, F., Oskouie, S.F., Vehviläinen-Julkunen, K., Binaghi, T., 2010. Teaching style in clinical nursing education: a qualitative study of Iranian nursing teachers’ experiences. Nurse Educ. Pract. 10, 8e12. Keeling, J., Templeman, J., 2013. An exploratory study: student nurses’ perceptions of professionalism. Nurse Educ. Pract. 13, 18e22. Koch, T., 2006. Establishing rigour in qualitative research: the decision trail. J. Adv. Nurs. 53, 91e103. Kolb, A.Y., Kolb, D.A., 2009. The learning way: meta-cognitive aspects of experiential learning. Simul. Gaming 40, 297e327. Lee, W.S.C., Cholowski, K., Williams, A.K., 2002. Nursing students’ and clinical educators’ perceptions of characteristics of effective clinical educators in an Australian University school of nursing. J. Adv. Nurs. 39, 412e420. Marek, G.I., 2013. Impact of learning style assessment on self-reported skills of students in an associate degree nursing program. Teach. Learn. Nurs. 8, 43e49. McMeeken, J., 2008. Physiotherapy educationdwhat are the costs? Aust. J. Physiother. 54, 85e86. Meehan-Andrews, T.A., 2009. Teaching mode efficiency and learning preferences of first year nursing students. Nurse Educ. Today 29, 24e32. Morse, J.M., Field, P.A., 1995. Nursing Research: The Application of Qualitative Approaches. Nelson Thornes, Cheltenham, UK. Perry, J., Paterson, B.L., 2005. Nursing rounds as a pedagogical strategy: anchoring theory to practice in gerontological nursing. Nurse Educ. Pract. 5, 63e69. Peyman, H., Sadeghifar, J., Alizadeh, M., Yaghoubi, M., Mohammad hassan nahal, M., Yamani, N., Delpisheh, A., 2012. Learning styles of first year nursing and midwifery students in Ilam University of medical sciences. Iran. J. Med. Sci. 11, 1350e1358 (Persian). Rassool, G.H., Rawaf, S., 2008. The influence of learning styles preference of undergraduate nursing students on educational outcomes in substance use education. Nurse Educ. Pract. 8, 306e314.
7
Rezaei, K., Koohestani, H.R., Ganjeh, F., Anbari, Z., 2010. Learning styles of first semester students in Arak University of Medical Sciences, 2008. Arak Med. Univ. J. (AMUJ) 12, 44e51 (Persian). Roberts, D., 2008. Learning in clinical practice: the importance of peers. Nurs. Stand. 23, 35e41. Roberts, D., 2009. Friendship fosters learning: the importance of friendships in clinical practice. Nurse Educ. Pract. 9, 367e371. Samuelowicz, K., Bain John, D., 2001. Revisiting academics’ beliefs about teaching and learning. High. Educ. 41, 299e325. Secomb, J., 2008. A systematic review of peer teaching and learning in clinical education. J. Clin. Nurs. 17, 703e716. Snelgrove, S., 2004. Approaches to learning of student nurses. Nurse Educ. Today 24, 605e614. Spoon, C.J., 1996. Impacts of Student Learning Style and Instructor Teaching style on Achievement of Adult Basic Skills Students. Georgia State University. Doctoral dissertation. Spouse, J., 2003. Professional Learning in Nursing. Blackwell Publishing, Oxford. Stark, P., 2003. Teaching and learning in the clinical setting: a qualitative study of the perceptions of students and teachers. Med. Educ. 37, 975e982. Strauss, A., Corbin, J., 1998. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Sage Publications, Park, CA. Newbury. Streubert, H.J., Carpenter, D.R., 2003. Qualitative Research in Nursing: Advancing the Humanistic Imperative, third ed. Lippincott, Philadelphia. Sutcliffe, L., 1993. An investigation into whether nurses change their learning style according to subject area studies. J. Adv. Nurs. 18, 647e658. Synder, M.D., Fitzloff, B.M., Fiedler, C.R., Lambke, M.R., 2000. Preparing nursing students for contemporary practice: restructuring the psychomotor skills laboratory. J. Nurs. Educ. 39, 229e230. Tong, A., Sainsbury, P., Craig, J., 2007. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int. J. Qual. Health Care 19, 349e357. Vollers, J.M., 2008. Teaching & learning styles. Int. Anesthesiol. Clin. 46, 27e40.
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
The diversity of Iranian nursing students’ clinical learning styles: A qualitative study Shahram Baraz, Robabeh Memarian*, Zohreh Vanaki Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 4 March 2014
Background: Numerous factors, including learning styles, affect the learning process of nursing students. Having insights about students’ learning styles helps promoting the quality of education. The aim of this study was to explore the Iranian baccalaureate nursing students’ learning styles in clinical settings. Methods: A qualitative design using a content analysis approach was used to collect and analyze data. Semi-structured interviews were conducted with fifteen Iranian baccalaureate nursing students selected using a purposive sample method. Findings: During data analysis, it was found that nursing students employed different clinical learning styles such as ‘thoughtful observation,’ ‘learning by thinking,’ and ‘learning by doing’. Conclusion: Students adopt different learning strategies in clinical practice. Designing teaching strategies based on students’ learning styles can promote students’ learning and maximize their academic and clinical practice success. Nursing educators, curriculum designers, and students can use the findings of this study to improve the quality of nursing education in both the classroom and clinical settings. Ó 2014 Elsevier Ltd. All rights reserved.
Keywords: Clinical learning styles Nursing in Iran Qualitative study Student nurses
Introduction Classrooms and clinical settings are different learning environments available to nursing students (Brown et al., 2011; McMeeken, 2008). In classrooms, the process of learning is usually structured; however, in clinical settings, the learning process takes place through unplanned activities and through direct contacts with patients and healthcare providers. Accordingly, students’ learning styles in these two learning environments are different (Cheraghi et al., 2008). Numerous factors, including learning styles, affect the process of learning in nursing students (Cowman, 1998). Educational researchers believe that having insights about students’ learning styles helps promoting the quality of education. Learning styles are individuals’ preferred methods of knowledge and skill acquisition and information organization. Therefore, students’ personal differences in learning styles are required to be considered during the teaching process to fulfill their educational needs (Felder and Brent, 2005; Vollers, 2008). Arthurs (2007) believed that nursing educators have difficulties in designing teaching strategies that are consistent with students’
* Corresponding author. Tel./fax: þ98 2182883856. E-mail address: [email protected] (R. Memarian).
learning styles. On the other hand, it is important to nursing educators to adopt different teaching-learning strategies to facilitate students’ learning and to improve their professional skills (Bailey and Tuohy, 2009). Background The term ‘learning style’ is originated from educational studies conducted in the 1970s. One of the reasons for the invention of this term is that learning styles have practical application particularly in the areas of teaching and learning. Subsequently, numerous studies were conducted on the application of learning styles in nursing (Snelgrove, 2004). To the best of our knowledge, most of these studies are quantitative in which standardized questionnaires such as the Kolb Learning Style Inventory and the Honey and Mumford Learning Style Inventory have been used for data collection (Ahadi et al., 2010; D’Amore et al., 2012; Fleming et al., 2011; Peyman et al., 2012; Rezaei et al., 2010). These selfreported questionnaires classify students into predetermined categories developed by teaching-learning theorists (Snelgrove, 2004). For example, the Honey and Mumford Learning Style Questionnaire (Honey and Mumford, 2000) categorizes people according to their learning styles as activists, reflectors, theorists, and pragmatists. Fleming et al. (2011) found that the preferred learning styles of Irish first- and fourth-year nursing students
http://dx.doi.org/10.1016/j.nepr.2014.03.004 1471-5953/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
2
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
were reflector and activist styles. Astin et al. (2006) also found that the dominant learning styles of American nursing students were reflector and theorist ones. On the other hand, the Kolb’s Learning Style Inventory (Kolb and Kolb, 2009) categorizes people as diverger, accommodator, converger, or assimilator learners. D’Amore et al. (2012) found that Australian first-year nursing students were mainly diverger and assimilator learners. Gyeong and Myung (2008) also reported that Korean nursing students were mainly accommodator learners. The dominant learning styles adopted by Iranian nursing students also have been reported to be converger and assimilator styles (Ahadi et al., 2010; Rezaei et al., 2010). Despite the abundance of quantitative studies on learning styles, there is an obvious gap in terms of the dimensions and students’ experiences of clinical learning styles. Moreover, the best learning styles and models are still unknown (Felder and Brent, 2005; Fleming et al., 2011). Additionally, studies on learning styles have many applications: 1. In clinical settings, nursing educators encounter students coming from different educational backgrounds; therefore, they need to know different learning styles of nursing students to be able to facilitate the teaching-learning process and to minimize clinical education weaknesses (Snelgrov, 2004). 2. Knowing different learning styles helps nursing educators improve the educational environment and the teacherestudent relationship (Gillespie, 2002). 3. Knowing different learning styles helps educational theorists develop more coherent teaching-learning theories in higher education (Samuelowicz and Bain John, 2001). 4. Nursing educators’ awareness of students’ learning styles leads to thoughtful educational planning, appropriate student evaluation, and promotion of teaching and learning (Hunt, 2006; Karimi Moonaghi et al., 2010; Rassool and Rawaf, 2008). Consequently, as few qualitative studies have explored the learning styles of baccalaureate nursing students, therefore, it was decided to fill the gap by conducting this study. The aim of this study was to explore learning styles of the Iranian baccalaureate nursing students in clinical settings. Methods Design This was a qualitative design using a content analysis approach and the research was conducted between May and December 2012. Qualitative approaches have an explorative nature and enable researchers to explore the complexity of phenomena happened to the healthcare providers, policy-makers, and clients (Tong et al., 2007). Participants A purposive sample was used to recruit fifteen baccalaureate nursing students. Having at least a two-semester experience of clinical practice and willingness to participate in the study were inclusion criteria to choose participants. To cover a wide range of viewpoints and experiences, the maximum variation sampling technique was applied (Strubert and Carpenter, 2003). Accordingly, we sampled from both genders and from second- to forth-year students. The study sample consisted of 3 second-year, six thirdyear, and six forth-year students. Moreover, out of the fifteen students recruited, six students were female. The participating students ranged in age from 18 to 24 years.
Data collection Semi-structured interviews were used for data collection. This method, compared with the quantitative data collection methods, leads to a more in-depth understanding of the intended phenomenon (Strauss and Corbin, 1998). The interview questions included but not limited to, 1. Would you please explain about how you learn to provide nursing care in clinical settings? 2. What and how did you learn in this and other previous courses of clinical training? and 3. Would you please explain your clinical experiences? Besides these open-ended questions, probing questions were used to delve into the participants’ learning experiences. At the end of each interview session, the participant was asked to add any supplementary information not addressed by the interviewer. Data collection process was continued until reaching data saturation (Green and Thorogood, 2004). In case of any ambiguities, follow-up interviews were conducted. Totally, nineteen personal face-to-face interviews were conducted with fifteen students. Eleven students were interviewed once and four students were interviewed twice. Interviews were held in an interview room located in the Nursing Department. The interview sessions lasted 30e90 min. We recorded the interviews by using a digital sound recorder. Immediately after each interview, the interview content was transcribed verbatim. Data analysis The data collection and data analysis processes took place concurrently. For analyzing the study data, the Morse & Field’s qualitative content analysis approach was employed (Morse and Field, 1995). Content analysis is a systematic coding and categorizing approach. In this approach, the collected data are examined carefully to identify the trends, patterns, and relations (Gbrich, 2007). At the beginning of the analysis, the transcribed text was read repeatedly to immerse in and gain a general sense of the interview content. Then, the content of each interview was broken to basic meaning units, the irrelevant pieces of data were discarded, and the text was coded line-by-line. Thereafter, we categorized the codes based on their similarities and differences into higher-level sub-categories and categories and put the developed sub-categories and categories under overarching themes. Table 1 shows how the theme ‘thoughtful observation’ was developed. Trustworthiness Trustworthiness is a key component of qualitative studies. If the reader of a study report is able to audit the data collection and analysis processes, the study is presumably trustworthy (Koch, 2006). In this study, the peer-checking method was used to establish the credibility of the analysis process. Accordingly, the researchers analyzed the interviews independently and compared the developed concepts, categories, and themes. In case of any disagreement, discussions were held to reach an agreement. Besides peer-checking, the member-checking method was used to establish the credibility of data. Accordingly, after the analysis of each interview, the participants were provided with a summary of data analysis process and findings and asked to check whether the developed concepts reflected their experiences or ideas. Finally, their additional points of view and suggestions were included in the analysis. Another criterion for trustworthiness was audit-
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
3
Table 1 The development of the theme ‘Active involvement’. Quotation
Sub-categories
Categories
Theme
I tend to learn by observation rather than by intervention. For instance, in case of procedures such as venipuncture, I, initially, observe carefully to learn. I do not ask them to assign the task to me. I observe repeatedly to learn. In ICU, I learned, from my instructor, how to insert a nasogastric tube. Initially, my instructor performed the procedure and I just observed and learned. Then, at the same day, I successfully inserted a nasogastric tube for another patient We had read, from the textbook, the procedure of removing surgical drains and tubes; however, I had never seen the procedure until a physician came and removed a drain and sutured the drain site. It was then that I learned the procedure and now, I can do it independently. On a bedside nursing round our instructor asked, ‘What will happen if you give an IV push of potassium chloride?’ We did not know the answer. He told us that in case of an IV push of potassium chloride, a cardiac arrest may happen. Such critical points, when highlighted repeatedly, will be imprinted on our minds forever I have also learned from physicians; for example, one day a physician was teaching his students how to manage a diabetic foot and when it should be amputated. The physician, together with his students, was deciding on the amputation of a female patient’s diabetic foot. I listened to their discussions carefully and learned how to manage a diabatic foot
Careful observation of nurses
Careful observation of role-models’ performance.
Thoughtful observation
trailing (Gbrich, 2007). In this regard, all the records of the study were kept for the purpose of audit-trailing.
Careful observation of clinical instructors Careful observation of physicians’ performance
Careful observation, listening, and reflection during nursing rounds
Reflective observation during clinical rounds
Careful observation, listening, and reflection during medical rounds
the drain site. It was then that I learned the procedure and now, I can do it independently (P.14, second-year student from a surgical placement).
Ethical considerations The Ethics Committee affiliated to Tarbiat Modares University approved the study. All the participants were informed about the aim of the study. They were assured that participation in the study is voluntary. Moreover, they were able to voluntarily withdraw from the study. We also guaranteed the confidentiality of their provided data and ensured them that their provided information will be published anonymously. Finally, we asked the participants to read and sign the study informed consent form. Results During data analysis, it was found that the students’ clinical learning styles fell into three main themes including ‘thoughtful observation,’ ‘learning by doing,’ and ‘learning by thinking’ (see Table 2). As follows, the meaning of each theme and subtheme has been reported using the participants’ direct quotations. Thoughtful observation This theme had two categories including ‘careful observation of role-models’ performance’ and ‘reflective observation during clinical rounds.’ Our participants had adopted learning styles such as careful observation of nurses, clinical instructors, and physicians’ performance as well as careful observation, listening, and reflection during nursing and medical rounds. The following quotation reflects learning through the observation of nurses’ caring behaviors: I tend to learn by observation rather than by intervention. For instance, in case of procedures such as venipuncture, I, initially, observe carefully to learn. I do not ask them to assign the task to me. I observe repeatedly to learn (P.2, fourth-year student from an ICU placement). Moreover, as physicians work in healthcare settings, our students referred to them as potential learning supports: We had read, from the textbook, the procedure of removing surgical drains and tubes; however, I had never seen the procedure until a physician came and removed a drain and sutured
Besides, almost all the participants mentioned that they promote their own learning by participating in medical rounds and listening to physicians’ discussions carefully. I have also learned from physicians; for example, one day a physician was teaching his students how to manage a diabetic foot and when it should be amputated. The physician, together with his students, was deciding on the amputation of a female patient’s diabetic foot. I listened to their discussions carefully and learned how to manage a diabetic foot (P.13, third-year student from an Endocrinology placement).
Table 2 The diversity of Iranian nursing students’ clinical learning styles. Sub-categories
Categories
Theme
Careful observation of nurses’ performance Careful observation of clinical instructors’ performance Careful observation of physicians’ performance Careful observation, listening, and reflection during nursing rounds Careful observation, listening, and reflection during medical rounds Cooperation with role models in implementing nursing procedures Active involvement in scientific debates Continuity in history taking and physical examination’ Continuity in implementing nursing procedures Assuming responsibility for patient care Self-reliance Individual accountability for doing clinical homework Facing problematic situations Facing challenging questions Having a sense of curiosity Questioning
Careful observation of role-models’ performance
Thoughtful observation
Reflective observation during clinical rounds
Active involvement
Learning by doing
Maintaining the continuity of learning
Assuming responsibility and being independent
Critical thinking
Learning by thinking
Inquisitiveness
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
4
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
Besides medical rounds, our participants also mentioned that they had learned a lot from nursing rounds held by their clinical instructors and classmates at patients’ bedside. These rounds had sensitized them to clinical notes and cases. On a bedside nursing round our instructor asked, ‘What will happen if you give an IV push of potassium chloride?’ We did not know the answer. He told us that in case of an IV push of potassium chloride, a cardiac arrest may happen. Such critical points, when highlighted repeatedly, will be imprinted on our minds forever” (P.1, fourth-year student from a Dialysis placement). Learning by doing This theme consisted of three categories: ‘active involvement,’ ‘maintaining the continuity of learning’ and ‘assuming responsibility and being independent.’ Active involvement After learning through ‘careful observation of role-models performance,’ our participants strived to promote their own learning through active involvement in implementing nursing procedures and class discussions. For example one student noted that: Infants are extremely sensitive and vulnerable; therefore, working with them is associated with fear and anxiety. However, our third-semester instructor helped us admit a full-term infant, give him at-birth vaccines, and control birth and primitive reflexes such as Moro, grasping, and rooting (P.12, fourthyear student from a Pediatric placement). The following quotation shows how the student promoted his learning through collaboration with a staff nurse: In that 10-day clinical training course, I was assigned to a staff nurse who involved me in all his tasks. For instance, when we were caring for a patient with CAD [Coronary Artery Disease], he asked me, ‘Do you know what CAD is?’ I gave him my answers and he added some more helpful notes. Moreover, he shared with me his first-hand clinical experiences; for example, he told me that he had seen the complications of a Ceftriaxone IV push given to a patient with CAD. He improved my knowledge in many areas of patient care (P.3, third-year student from a CCU placement) The following student reflects learning through active collaboration with peers: Our instructor asked us to work together on the dialysis machine. He asked us to help each other in learning. He told that he will evaluate us subsequently. We worked on the machine and learned how to set up, use, and disassemble it. Now, I can do it easily (P.11, fourth-year student from a Dialysis placement). On the other hand, the study participants cooperatively discussed, thought, and shared their clinical experiences about patients’ conditions. Such discussions and thinking had promoted their learning. Moreover, they mentioned that they had learned a lot from their instructors and peers through active participation in group discussions that tended to take place in their daily clinical class meetings:
Then, we began to talk together about interesting subjects. For instance, when we were in ICU, we discussed patients’ ABG [arterial blood gases] readings to diagnose their problems. We shared our knowledge and this helped me learn a lot (P.1, fourthyear student from an ICU placement).
Maintaining the continuity of learning Continuity reflects how our participants promoted their learning through making frequent contacts with patients for obtaining their health history. Our students explained that they, initially, build up an image of the patient’s main problem and then, start to make frequent contacts with him to understand his problem thoroughly: I tried to memorize and categorize information collected during history taking. Then, if another patient gave me the same information, I could guess his medical diagnosis easily.for example, I have taken health history from several patients having radiating chest pain and now I have a sound knowledge base about this heart condition (P.6, third-year student from a Cardiology placement). The study participants also mentioned that they facilitate their learning process through performing nursing procedures regularly: The more one does a task, the more fearless he becomes, the better he will do it later, and the lower his error rate will be (P.8, third-year student from a Hematology placement).
Assuming responsibility and being independent The study findings revealed that the more experienced students had greater tendency towards assuming responsibility for patient care. Moreover, self-reliance in performing nursing procedures, assuming responsibility for patient care, and individual accountability for doing clinical homework had promoted the students’ learning through increasing their knowledge, skills, self-confidence and clinical decision making: When I assume responsibility for providing care to a certain patient, I study about his medication and learn that his medication has certain side effects. For example, I understand that his medication is useful for the treatment of sepsis but increases his blood pressure. I need to know that this medication is contraindicated in patients with high blood pressure. Therefore, in the case-method approach to care, I have enough time to learn the prescribed medications, their side effects, and the way to minimize the side effects (P.5, fourth-year student from a CCU placement). In ICU, we had authority to intervene; for example, when a patient developed dysrhythmias, we had the authority to give him an antiarrhythmic agent. This type of professional autonomy eliminated the sense of being subordinate to physicians and therefore, increased our self-confidence (P.4, fourth-year student from an ICU placement). The study participants believed that accountability for doing clinical homework, such as designing educational posters and pamphlets, presenting case reports, planning and delivering patient education, and writing nursing care plans, compels them to study hard and to learn a lot. I like patient education because it compels me to gather basic information regarding patient’s condition, its signs and symptoms, complications, and management as well as essential self-
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
care activities. This is a comprehensive approach. It helped me cover that subject completely and learn effectively (P.3, Secondyear student from an Neurology placement).
Learning by thinking This theme also consisted of two categories including ‘inquisitiveness’ and ‘critical thinking.’ Inquisitiveness While collaborating with healthcare team members, the students strived to use their own sense of curiosity to promote their learning. Moreover, they asked instructors, peers, staff nurses, and even physicians the questions that had arisen out of their daily clinical practice. Another learning strategy adopted by the study participants was consulting with nursing textbooks or educational materials to find answer to their questions and to satisfy their curiosity: When I encounter an unusual case, I consult my books at night. For example, when we were in cardiac care unit, I did not know very well about cardiomyopathy and artificial heart valves; therefore, I consulted my books at night (P.12, third-year student from a Cardiology placement). When we were in CCU, I had difficulties in interpreting an electrocardiogram correctly; therefore, I asked my classmates to help me. They helped me and I learned a lot from them (P.15, third-year student from a Cardiology placement).
Critical thinking This category shows how nursing students promoted their learning through monitoring, critiquing, and avoiding nurses and physicians’ unsafe clinical practice. Moreover, the participants mentioned that their clinical instructors face them with challenging questions to promote their critical thinking and learning. For example one student noted that: Today, I cared for a patient who had received subcutaneous Heparin. I saw, with my own eyes, that his arm was badly bruised. Then, I remember that massaging the Heparin injection site is contraindicated; however, hospital personnel had massaged the site so much that it had been bruised badly. As a result, avoidance of massaging the Heparin injection site was imprinted on my mind for ever (P. 14, third-year student from a Neurology placement). This was important as the instructor was letting the student know about evidence-based practice. Discussion The aim of this study was to explore the Iranian baccalaureate nursing students’ learning styles in clinical settings. The findings revealed that the students adopted different styles to promote their learning. Adopting multiple learning styles helped the students to benefit from unfamiliar working and learning environments. Moreover, this ability turned them into more efficient, flexible, resourceful, and professional learners. This important finding is particularly applicable to curriculum planning and development (Felder and Brent, 2005; Fleming et al., 2011). The American Associates of Colleges of Nursing (1998; cited in Synder et al., 2000) noted that to promote students’ learning, nurse
5
educators should develop a standard curriculum that stimulates students’ creativity and helps them actively participate in the learning process. Understanding students’ learning styles helps nursing educators develop a flexible student-centered curriculum that enables students to use their learning styles effectively (Meehan-Andrews, 2009). It also enables nursing educators to create a supportive learning environment, which in turn facilitates students’ learning and enhances their professional development, and improves the quality of care (Marek, 2013). Nurse educators need to teach students how to adapt their own learning styles to different teaching strategies. Accordingly, students would be able to discover their own strengths and weaknesses, promote their learning in different learning environments, develop self-confidence, and display more independence in learning (Spoon, 1996). The study findings revealed that the students’ learning styles evolved over their four-year nursing course into styles such as accountability and self-reliance. Fleming et al. (2011) also reported that the fourth-year students’ learning styles are different from the learning styles adopted by the first- and second-year students. Kolb (1984; cited in Rassool and Rawaf, 2008) believed that brilliant learners get qualified professionally by adopting different learning styles in different environments. Similarly, previous studies report that many factors such as the course of study, course curriculum, evaluation criteria, pedagogic strategies, professional socialization during the nursing program, and the students’ developmental stage can affect the students’ learning styles (Fleming et al., 2011; Rassool and Rawaf, 2008; Sutcliffe, 1993). The study findings revealed that students promoted their learning through observing instructors, clinical staff nurses, physicians, and peers’ clinical practice. Working and interacting with role models helps students acquire mastery over professional skills. Role models socialize students professionally. They develop students’ professional identity, knowledge, and skills and help them transfer their knowledge to practice. In turn, they will be empowered to teach their skills to other students (Beth Perry, 2009). We also found that the students promoted their learning through careful observation, listening, and reflection during nursing and medical rounds. Clinical rounds provide a natural environment for learning patient-centered and evidence-based practice (Gardner et al., 2010). Nursing rounds, like medical rounds, are effective teaching-learning and case presentation strategies (Furlong et al., 2007). In these rounds, clinical instructor provides detailed explanations about the intended case, adds his personal clinical experiences, creates an environment for further class discussion, and promotes students’ critical thinking through asking challenging questions. In addition, according to Perry and Paterson (2005), students promote their own learning through making clinical notes. The study findings revealed that the students learned from their peers. Other studies also have referred to peers as a main source of learning (Roberts, 2008, 2009). Moreover, learning from peers has positive effects on students’ accountability, degree of self-reliance and collaboration, and personal development. It can improve their psychomotor, communication, and time management skills (Gerace and Sibilano, 2006; Glynn et al. 2006; Secomb, 2008). We found that the students also adopted assisted learning and self-reliance or independent learning as their preferred learning strategies. Brugnolli et al. (2011) reported the same findings. Moreover, Brugnolli et al. (2011) and Jackson and Mannix (2001) reported that students’ control over their learning and thinking processes is affected by their own attitudes and the amount of support received from instructors, peers, and other healthcare professionals. The researchers also believed that some students prefer more intensive supervision while other students prefer
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
6
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7
reflective self-directed learning (Brugnolli et al., 2011; Jackson and Mannix, 2001). Another learning strategy adopted by our participants was maintaining the continuity of learning. Hartigan-Rogers et al. (2007) believed that the application of the acquired knowledge and skills to everyday practice is a learning strategy that facilitates students’ professional socialization. Active involvement was another learning strategy adopted by our participants. Keeling and Templeman (2013) believed that learning in collaboration with role models is an important strategy. Active involvement in clinical care positively affects students’ understanding of the clinical interventions and promotes their critical thinking and active learning. Moreover, students’ observation and perception of nurses’ professional and non-professional behaviors positively affect their learning (Keeling and Templeman, 2013). Brugnolli et al. (2011) also found that one of the most effective learning strategies adopted by students is their active or supervised involvement in clinical care. This learning strategy gradually improves students’ knowledge and skills because it enables them to observe role-models’ performance, listen to the provided explanations, implement nursing procedures in collaboration with other peers and staff nurses, and reflect on the implemented procedures. Baghcheghi et al. (2011) also believed that small group teaching enables students to discuss all the possible solutions to perceived problems. Critical thinking was another learning strategy adopted by nursing students in this study. According to Kaddoura (2011), critical thinking is one of the most effective learning strategies. Critical thinking promotes students’ learning, qualifies them for clinical practice, enables them to make accurate clinical judgments, and helps them develop professionally. Accountability was another learning strategy among our participants. It is mentioned that independent learning, accountability, and regular feedbacks promote students’ learning (Lee et al., 2002; Stark, 2003). Spouse (2003) found that nursing students’ academic achievement directly correlates with their degree of self-reliance, i.e. their distance from their instructors and mentors. Spouse (2003) has referred to self-reliant students as ‘flying solo.’ Our participants also believed that self-reliance promoted their learning. Bradbury-Jones et al. (2011) reported that students’ learning dependence negatively affects their professional knowledge, interest, and self-confidence. Our findings were in some ways different from the learning styles proposed by Honey and Mumford and Kolb. For example, almost none of our themes reflected Honey and Mumford’s ‘theorists’ and ‘activists’ learning styles. Moreover, our findings were in some ways similar to the learning styles proposed by Kolb such as learning by observing, thinking, and doing. However, we did not found any theme reflecting concrete experiencing. Conclusion According to the findings of this study, nursing students in Iran adopt different learning strategies to promote their learning. Clinical setting is an unstable learning environment wherein students are faced with unpredictable and stressful situations. In such an unstable environment, students’ intelligence and inquisitiveness play an important role in developing and adopting the most effective learning strategies. Moreover, clinical training and education should provide students with different training opportunities to enable them to develop and adopt innovative learning strategies in different clinical environments. In addition designing teaching strategies based on students’ learning styles can strongly promote students’ learning and maximize their academic success.
Implications The current study explored the nature of students’ learning strategies in Iran. Nursing educators, curriculum designers, and students in other countries however can use the study findings for improving the quality of nursing education and practice in their own clinical environments and higher education settings. Limitations In this study, we explored a group of Iranian baccalaureate nursing students’ learning styles in clinical settings. Therefore, the findings are not broadly transferable. Consequently, further studies are needed to explore different learning styles adopted by students worldwide and cross-country comparisons developed. References Ahadi, F., Abedsaidi, J., Arshadi, F., Ghorbani, R., 2010. Learning styles of nursing and allied health students in Semnan university of medical sciences. J. Med. Sci. Semnan 11, 141e147 (Persian). Arthurs, J.B., 2007. A juggling act in the classroom: managing different learning styles. Teach. Learn. Nurs. 2, 2e7. Astin, F., Closs, J.S., Hughes, N., 2006. The self-reported learning style preferences of female Macmillan clinical nurse specialist. Nurse Educ. Today 26, 475e483. Baghcheghi, N., Koohestani, H.R., Rezaei, K., 2011. A comparison of the cooperative learning and traditional learning methods in theory classes on nursing students’ communication skill with patients at clinical settings. Nurse Educ. Today 31, 877e882. Bailey, M.E., Tuohy, D., 2009. Student nurses’ experiences of using learning contract as a method of assessment. Nurse Educ. Today 29, 758e762. Beth Perry, R.N., 2009. Role modeling excellence in clinical nursing practice. Nurse Educ. Pract. 9, 36e44. Bradbury-Jones, C., Sambrook, S., Irvine, F., 2011. Empowerment and being valued: a phenomenological study of nursing students’ experiences of clinical practice. Nurse Educ. Today 31, 368e372. Brown, T., Williams, B., McKenna, L., Palermo, C., McCall, L., Roller, L., Hewitt, L., Molloy, L., Baird, M., Aldabah, L., 2011. Practice education learning environments: the mismatch between perceived and preferred expectations of undergraduate health science students. Nurse Educ. Today 31, 72e78. Brugnolli, A., Perli, S., Viviani, D., Saiani, L., 2011. Nursing students’ perceptions of tutorial strategies during clinical learning instruction: a descriptive study. Nurse Educ. Today 31, 152e156. Cheraghi, M.A., Salasli, M., Ahmadi, F., 2008. Factors influencing the clinical preparation of BS nursing student interns in Iran. Int. J. Nurs. Pract. 14, 26e33. Cowman, S., 1998. The approaches to learning of student nurses in the Republic of Ireland and Northern Ireland. J. Adv. Nurs. 28, 899e910. D’Amore, A., James, S., Mitchell, E.K.L., 2012. Learning styles of first-year undergraduate nursing and midwifery students: A cross-sectional survey utilising the Kolb learning style inventory. Nurse Educ. Today 32, 506e515. Felder, R.M., Brent, R., 2005. Understanding student differences. J. Eng. Educ. 94, 57e72. Fleming, S., Mckee, G., Huntley-Moore, S., 2011. Undergraduate nursing students’ learning styles: a longitudinal study. Nurse Educ. Today 31, 444e449. Furlong, K.M., D’Luna-O’Grady, L., Macari-Hinson, M., O’Connel, K.B., Perez, E.L., Pierson, G.S., 2007. Implementing nursing grand rounds in a community hospital. Clin. Nurse Spec. 21, 287e291. Gardner, G., Woollett, K., Daly, N., Richardson, B., Aitken, L.M., 2010. Innovation in clinical learning for the acute hospital environment: nursing grand rounds. Nurse Educ. Today 30, 737e741. Gbrich, C., 2007. Qualitative Data Analysis: an Introduction, first ed. SAGE Publications, London. Gerace, L., Sibilano, H., 2006. Preparing students for peer collaboration: a clinical teaching model. J. Nurs. Educ. 23, 206e209. Gillespie, M., 2002. Studenteteacher connection in clinical nursing education. J. Adv. Nurs. 37, 566e576. Glynn, L.G., MacFarlane, A., Kelly, M., Cantillon, P., Murphy, A.W., 2006. Helping each other to learn- a process evaluation of peer assisted learning. BMC Med. Educ. 6,18. Green, J., Thorogood, N., 2004. Qualitative Methods for Health Research, first ed. SAGE Publications, London. Gyeong, J.A., Myung, S.Y., 2008. Critical thinking and learning styles of nursing students at the baccalaureate nursing program in Korea. Contemp. Nurse 29, 100e109. Hartigan-Rogers, J.A., Cobbett, S.L., Amirault, M.A., Muise-Davis, M.E., 2007. Nursing graduates’ perceptions of their undergraduate clinical placement. Int. J. Nurs. Educ. Scholarsh. 4. Honey, P., Mumford, A., 2000. The Learning Styles Questionnaire: 80-item Version. Peter Honey Publications Ltd., Berks, UK. Hunt, S., 2006. Learning and Cognitive Styles, What are Learning and Cognitive Styles?. Available from: http://www.ilstu.edu.
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
S. Baraz et al. / Nurse Education in Practice xxx (2014) 1e7 Jackson, D., Mannix, J., 2001. Clinical nurses as teachers: insights from students of nursing in their first semester of study. J. Clin. Nurs. 10, 270e277. Kaddoura, A.M., 2011. Critical thinking skills of nursing students in lecture-based teaching and case-based learning. Int. J. Scholarsh. Teach. Learn. 5, 1e18. Karimi Moonaghi, H., Dabbaghi, F., Oskouie, S.F., Vehviläinen-Julkunen, K., Binaghi, T., 2010. Teaching style in clinical nursing education: a qualitative study of Iranian nursing teachers’ experiences. Nurse Educ. Pract. 10, 8e12. Keeling, J., Templeman, J., 2013. An exploratory study: student nurses’ perceptions of professionalism. Nurse Educ. Pract. 13, 18e22. Koch, T., 2006. Establishing rigour in qualitative research: the decision trail. J. Adv. Nurs. 53, 91e103. Kolb, A.Y., Kolb, D.A., 2009. The learning way: meta-cognitive aspects of experiential learning. Simul. Gaming 40, 297e327. Lee, W.S.C., Cholowski, K., Williams, A.K., 2002. Nursing students’ and clinical educators’ perceptions of characteristics of effective clinical educators in an Australian University school of nursing. J. Adv. Nurs. 39, 412e420. Marek, G.I., 2013. Impact of learning style assessment on self-reported skills of students in an associate degree nursing program. Teach. Learn. Nurs. 8, 43e49. McMeeken, J., 2008. Physiotherapy educationdwhat are the costs? Aust. J. Physiother. 54, 85e86. Meehan-Andrews, T.A., 2009. Teaching mode efficiency and learning preferences of first year nursing students. Nurse Educ. Today 29, 24e32. Morse, J.M., Field, P.A., 1995. Nursing Research: The Application of Qualitative Approaches. Nelson Thornes, Cheltenham, UK. Perry, J., Paterson, B.L., 2005. Nursing rounds as a pedagogical strategy: anchoring theory to practice in gerontological nursing. Nurse Educ. Pract. 5, 63e69. Peyman, H., Sadeghifar, J., Alizadeh, M., Yaghoubi, M., Mohammad hassan nahal, M., Yamani, N., Delpisheh, A., 2012. Learning styles of first year nursing and midwifery students in Ilam University of medical sciences. Iran. J. Med. Sci. 11, 1350e1358 (Persian). Rassool, G.H., Rawaf, S., 2008. The influence of learning styles preference of undergraduate nursing students on educational outcomes in substance use education. Nurse Educ. Pract. 8, 306e314.
7
Rezaei, K., Koohestani, H.R., Ganjeh, F., Anbari, Z., 2010. Learning styles of first semester students in Arak University of Medical Sciences, 2008. Arak Med. Univ. J. (AMUJ) 12, 44e51 (Persian). Roberts, D., 2008. Learning in clinical practice: the importance of peers. Nurs. Stand. 23, 35e41. Roberts, D., 2009. Friendship fosters learning: the importance of friendships in clinical practice. Nurse Educ. Pract. 9, 367e371. Samuelowicz, K., Bain John, D., 2001. Revisiting academics’ beliefs about teaching and learning. High. Educ. 41, 299e325. Secomb, J., 2008. A systematic review of peer teaching and learning in clinical education. J. Clin. Nurs. 17, 703e716. Snelgrove, S., 2004. Approaches to learning of student nurses. Nurse Educ. Today 24, 605e614. Spoon, C.J., 1996. Impacts of Student Learning Style and Instructor Teaching style on Achievement of Adult Basic Skills Students. Georgia State University. Doctoral dissertation. Spouse, J., 2003. Professional Learning in Nursing. Blackwell Publishing, Oxford. Stark, P., 2003. Teaching and learning in the clinical setting: a qualitative study of the perceptions of students and teachers. Med. Educ. 37, 975e982. Strauss, A., Corbin, J., 1998. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Sage Publications, Park, CA. Newbury. Streubert, H.J., Carpenter, D.R., 2003. Qualitative Research in Nursing: Advancing the Humanistic Imperative, third ed. Lippincott, Philadelphia. Sutcliffe, L., 1993. An investigation into whether nurses change their learning style according to subject area studies. J. Adv. Nurs. 18, 647e658. Synder, M.D., Fitzloff, B.M., Fiedler, C.R., Lambke, M.R., 2000. Preparing nursing students for contemporary practice: restructuring the psychomotor skills laboratory. J. Nurs. Educ. 39, 229e230. Tong, A., Sainsbury, P., Craig, J., 2007. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int. J. Qual. Health Care 19, 349e357. Vollers, J.M., 2008. Teaching & learning styles. Int. Anesthesiol. Clin. 46, 27e40.
Please cite this article in press as: Baraz, S., et al., The diversity of Iranian nursing students’ clinical learning styles: A qualitative study, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.03.004
