Nursing students at a university — A study about learning style preferences

Nurse Education Today xxx (2014) xxx–xxx

YNEDT-02704; No of Pages 7

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Nursing students at a university — A study about learningstyle preferences

Karin Hallin ⁎Department of Nursing Science, Mid Sweden University, Östersund, Sweden

⁎ Corresponding author at: Department of Nursing ScÖstersund, SE-831 25, Sweden. Fax: +46 63 1656 26.

E-mail address: karin.hallin@miun.se.

Please cite this article as: Hallin, K., Nursing sdx.doi.org/10.1016/j.nedt.2014.04.001

s u m m a r y

Article history:

Keywords:CampusesLearning preferencesNursing educationPEPSSemesters

Background: In most adult education, teachers use methods that assume all students learn in the same way. Butknowledge of students' learning style preferences highlights the importance of adequate teaching and learningadaptation.Objectives: The aim of the study was to describe and compare final year nursing students' learning style prefer-ences in two campuses during three semesters. A further aim was to identify differences between learningstyle preferences and personal characteristics.Design: A descriptive cross-sectional study using the Productivity Environmental Preference Survey (PEPS)questionnaire was conducted at a Swedish rural university. Three semester groups with 263 nursing studentsparticipated in 2012–2013.

Introduction

Adult education assumes that students at universities and collegeshave developed efficient study skills and have acquired appropriatelearning strategies to adapt their learning to the lessons and tutoringmethods used by teachers. But this does not apply to all students. Stud-ies show the importance of teachers' adapting pedagogy and didacticsto students' preferences. When nursing students have studied withstrategies congruent to their learning style preferences they have beenmotivated, felt responsibility and achieved high grades (Billings andCobb, 1992). Furthermore, nursing students' satisfaction, anxiety andanger with teaching methods have significantly been related toteachers' reflections on students' perceptual preferences (O'Hare,

ience, Mid Sweden University,

tudents at a university— A stu

2002). Since earlier research with different questionnaires has shownthat learning styles vary widely between different groups of medicalstudents (Samarakoon et al., 2013), teaching students (Boström,2011), teaching and nursing students (Boström and Hallin, 2013) andrural and metropolitan nursing students (James et al., 2011), it is ofgreat interest to find out if nursing students differ to the same extentat the end of their education. The question is important as universityteachers, who collaborate within and across disciplines, mostly designteaching and learning strategies from one year to another withoutdeeper knowledge about individuals and groups.

Background

Learning style theories assume that allmay learn, though in differentways and at different levels. There are theories andmodels which focuson aspects such as talents, sensorymodalities, cognitive and/or learningand thinking processes (Evans andWaring, 2012). Kolb's Learning StyleModel (Kolb and Kolb, 2005), for example, is used for viewing how

dy about learning style preferences, Nurse Educ. Today (2014), http://

2 K. Hallin / Nurse Education Today xxx (2014) xxx–xxx

students process information,while the Dunn and Dunn Learning StylesModel (Dunn et al., 2000) views how students acquire information.Because of its practical usefulness, the Dunns' model is selected forthis study. The model is unique in the sense that it is built on multidi-mensional and instructional preferences that cover several proportionsof learning and teaching with practical and methodological support inthe research (Dunn and Griggs, 2007; Johansen, 2007). Fifty years ofworldwide research, both quantitative and qualitative, has shown thatit is widely usedwith children, adolescents and adults, and is very appli-cable to the education of health professionals (Dunn and Griggs, 1998).

The model consists of the Productivity Environmental PreferenceSurvey (PEPS) questionnaire, where the mean of the preference is anindividual's strengths and needs in learning new and difficult material(Dunn and Dunn, 1999). The term ‘learning style’ defines ‘the wayeach learner begins to concentrate on, process and retain new and diffi-cult information’ (Dunn et al., 1994, p. 12). The model categorizes theareas that may influence a person's learning style into elements of theenvironment and elements of emotional, sociological, physiologicaland perceptual strengths (Dunn and Griggs, 2007). Since the PEPScovers many preferences and provides information about patternsthrough which learning occurs, teachers will have a concrete basis forpedagogical and didactic choices. At the same time students can workon their own, providing a basis for lifelong learning.

About 400 doctoral dissertations and more than 500 scientificarticles indicate that the PEPS questionnaire is widely used, at over130 universities worldwide. But in Western settings and nursingstudents few studies on the Dunns' model have been published since2002. Just one study has focused on Swedish nursing students; a com-parative study which confirmed significant differences in learningstyle preferences between groups of teaching and nursing students(Boström and Hallin, 2013).

Because students in higher education are usually heterogeneous interms of personal characteristics, it is interesting to use the PEPS ques-tionnaire to investigate learning style preferences in different groupsof nursing students at the same academic level. This study starts withfinal year students, those with great experience of teachers' efforts todesign teaching and learning plans for specific professional aims.

Methods

The aim of the study was to describe and compare final year nursingstudents' learning style preferences in two campuses during threesemesters. A further aim was to identify differences between learningstyle preferences and personal characteristics.

Design

A descriptive cross-sectional pilot study was conducted with thePEPS questionnaire and nursing students in two campuses at a Swedishrural university during three semesters in 2012–2013. The study waspart of a larger project involving nursing students and high-fidelitypatient simulation at the end of education.

Participants and Settings

Convenience sampling was used and a total of 263 nursing studentsparticipated in the study, 209 women and 54 men. The students wererecruited from three semester groups at each of two campuses. Therespondent rate was 88.9%. All students were in their final semester ofa three-year bachelor of nursing program and studied with the samecurriculum. During nursing education the students had used variousteachingmethods, such as lectures, tutorials, computer-basedmethods,individual and group works, case studies and practical exercises, butwith a predominance of lectures.

Please cite this article as: Hallin, K., Nursing students at a university— A studx.doi.org/10.1016/j.nedt.2014.04.001

As shown in Table 1,which summarizes the students' characteristics,most participants were young; 80.6% were 21–30 years old and 19.4%were 31–48 years old. Concerning upper secondary school nearly half(46.4%) had a pre-university program; e.g. natural science, humanitiesor social program. Fewer (28.9%) had a vocational program: e.g. healthand care, child and recreational or hotel and tourism program. About aquarter (24.7%) had a specially designed program for the individual.Students with an assistant nurse graduation (22.1%) undertook eithera three-year vocational program in upper secondary school or a one-year course after upper secondary school. The students' care experiencebefore the nursing education varied: 19.5% had no health care experi-ence, 17.5% had less than one year's experience, while 63.0% had1–28 years' care experience (Table 1).

Measurements

Twoquestionnaireswere used; the PEPS for adults to identify learningstyle preferences (Dunn et al., 2000) and a questionnaire to identifypersonal characteristics. The PEPS consists of 100 questions relating to20 distinct learning style elements, each with a five-item Likert-typescale ranging from 1 (never) to 5 (always). The elements provide stu-dents and teacherswith information about different areas of preferences:

• Environmental preferences: sound, light, temperature, and furnituredesign.

• Emotional preferences: motivation, responsibility, conformity, persis-tence, need for externally imposed structure or opportunity to dothings independently.

• Sociological preferences: authoritative persons present, variation,learning alone, in pairs or as a part of a team.

• Physiological preferences: perceptual strengths such as auditory,visual, tactile or kinesthetic, time-of-day energy levels, need for intakeand/or mobility.

Auditory learners prefer hearing material and verbal instructionsrelated to practical examples while visual learners enjoy reading andwritten information, observation, pictures, flashcards and videos. Tactilelearners prefer hands-on-learning and write notes when they are inter-ested, while kinesthetic learners prefer the learning-by-doing approachand learn best through practical sessions, case studies or computer sim-ulation (Beischel, 2011; Hedin, 2006).

The PEPS is valued for having good reliability and validity (Griggset al., 1994). The reliability coefficients for each element typically fallinto the .75 to .88 range (Dunn et al., 1995), and a variety of constructvalidity evidence has been revealed in qualified international research(Dunn et al., 1995; Nelson et al., 1993).

Procedure

All information was given both in written and verbal form byteachers, and data were collected when the students were in the class-room. It took the students about 40 min to complete the two question-naires. Those who were not present were informed individually andwere invited to submit the answered forms to the current teacher.After data collection and result analysis the participants were e-maileda copy of the outcomes of the PEPS supplemented by a manual onhow the results should be interpreted. Although they were in the finalstage of their education, they should be able to use the results in furtherstudies.

Data Analysis

The responses of the PEPSwere computer processed to obtain scoresfor each individual on each subscale. The individual profile showed anaverage for each question on a 60-point scale andmarked each student'svalues as low (average 20–40),flexible (average 41–60) and high (aver-age 61–80). These values were calculated at the individual level and

Table 1Personal characteristics of 263 nursing students at two campuses during three semesters.

Variable Two campuses Three semesters including sixcourses

Total Comparisons between

CampusA

CampusB

Spring2012

Autumn2012

Spring2013

n = 263%

Campuses Semesters

n = 125 % n = 138 % n = 78 % n = 72 % n = 113 %

Gender Female 74.4 84.1 78.2 84.7 77.0 79.5 χ2 (1) = 3.75, χ2 (2) = 1.719Male 25.6 15.9 21.8 15.3 23.0 20.5 P = 0.053 n.s. P = 0.423 n.s

Age 21–22 Mean = 26,84 25.6 12.3 21.8 9.7 22.1 18.6 Mann–WhitneyU-test 7919.5Z = −1.150P = 0.250 n.s

Kruskal–Wallis testχ2 (2) = 1.238P = 0.538 n.s.

23–24 Median = 25,0 19.2 26.8 25.6 27.8 18.6 23.225–26 St. dev. = 5,27 16.8 19.6 11.5 22.2 20.35 18.327–30 Range = 28 (21–48) 19.2 21.7 20.5 20.8 20.35 20.531–48 19.2 19.6 20.5 19.4 18.6 19.4

Upper secondary school Pre-university program 45.6 47.1 50.0 43.1 46.0 46.4 χ2 (2) = 0.690,P = 0.708 n.s.

χ2 (4) = 2.706P = 0.608 n.s.Vocational program 31.2 26.8 28.2 34.7 25.7 28.9

Individual program 23.2 26.1 21.8 22.2 28.3 24.7Assistant nurse graduation Yes 24.8 19.6 19.2 23.6 23.0 22.1 χ2 (1) = 1.046 χ2 (2) = 0.523

No 75.2 80.4 80.8 76.4 77.0 77.9 P = 0.307 n.s P = 0.770 n.s.Care experience n = 124 % n = 138 % n = 78 % n = 72 % n = 112 % n = 262 % Mann–Whitney

U-test 8364.00Z = −0.315P = 0.753 n.s

Kruskal–Wallis testχ2 (2) = 0.776P = 0.678 n.s.

0 14.5 23.9 24.4 15.3 18.8 19.5b1 year 21.8 13.8 14.1 20.8 17.8 17.51–b3 years 34.7 31.1 34.6 31.9 32.1 32.83–b5 years 15.3 10.9 11.5 8.3 17.0 13.0≥5 (maximum 28 years) 13.7 20.3 15.4 23.6 14.3 17.2

3K. Hallin / Nurse Education Today xxx (2014) xxx–xxx

used for the inferential statistics. For further processing StatisticalPackage for Social Sciences (SPSS Inc., Chicago, IL, USA), version 21 forWindows was used and the level of significance was defined asP b 0.05 (two-tailed).

Descriptive statisticswere used to characterize the study sample andinferential statistics to test similarities and differences between groups.Students' learning style preferences were determined individually andcumulatively per university, campus and semester. The Pearson Chi-square test was used to compare nominal data. The Mann–Whitney U-test and Kruskal–Wallis test were used to compare ordinal, intervaland ratio data.

Ethical Considerations

The Ethics Committee at the university approved the study (dnr:2012/499). The students gave their informed consent and were assureda confidential process according to the principles of research ethics

Table 2Distribution of low, flexible, and high-preference scores for 263 nursing students.

Elementsa LowScale 20–40

FlexiScale

Noise level Prefers quiet 2 0.8 211Light Prefers dim 16 6.1 227Temperature Prefers cool 29 11.0 200Design Prefers informal 20 7.6 192Motivation Low 5 1.9 215Persistent Low 1 0.4 175Responsibility Low 29 11.0 209Structure Does not prefer 0 0.0 68Alone–peers Prefers alone 11 4.2 76Authority figure Does not want present 3 1.1 154Several ways Does not prefer 37 14.1 216Auditory Does not prefer 10 3.8 169Visual Does not prefer 42 16.0 200Tactile Does not prefer 12 4.6 170Kinesthetic Does not prefer 2 0.8 188Intake Does not prefer 23 8.7 184Morning Does not prefer 41 15.6 174Late morning Does not prefer 48 18.2 158Afternoon Does not prefer 38 14.4 149Mobility Does not prefer 6 2.3 199

a Items with Likert scales: 1 (never) to 5 (always).

(HSFR, 2002). There was no relationship of dependency between theresearcher and the participants.

Results

Comparison of students' personal characteristics between thegroups of campuses and semesters showed no significant differences(Table 1). Therefore, regarding personal characteristics, the studentgroups will in further comparisons be treated as one group.

Learning Style Preferences of Final Year Nursing Students

Table 2 shows distributions of low, flexible and high-preferencescores for each of the PEPS subscales for 263 nursing students. As canbe seen, most subscale scores fell essentially between 41 and 60, the‘flexible’ region of no strong preferences. Three students were flexiblein all of the 20 elements, and 260 students had two ormore preferences.

ble41–60

HighScale 61–80

% n % n

80.2 Prefers sound 50 19.0 26386.3 Prefers bright 20 7.6 26376.0 Prefers warm 34 12.9 26373.0 Prefers formal 51 19.4 26381.7 High 43 16.3 26366.5 High 87 33.1 26379.5 High 25 9.5 26325.9 Prefers 195 74.1 26328.9 Prefers with peers 176 66.9 26358.6 Wants present 106 40.3 26382.1 Prefers variety 10 3.8 26364.3 Prefers 84 31.9 26376.0 Prefers 21 8.0 26364.6 Prefers 81 30.8 26371.5 Prefers 73 27.7 26370.0 Prefers 56 21.3 26366.2 Prefers 48 18.2 26360.1 Prefers 57 21.7 26356.7 Prefers 76 28.9 26375.7 Prefers 58 22.0 263

Table 3Significant differences in the distribution of low, flexible and high-preference scores for nursing students of two campuses.

Elementsa LowDoes not preferScale 20–40

FlexibleScale 41–60

HighPrefersScale 61–80

CampusA n = 125 B n = 138

Comparisons between Campus A and Campus B

Campus Campus Campus

A % B % A % B % A % B % Total n Mann–Whitney U-testTactile 7.2 2.2 68.0 61.6 24.8 36.2 263 6842.5; Z = −2.913; P = 0.004b

a Items with Likert scales: 1 (never) to 5 (always).b Differences significant at P b 0.01.

There were some nursing students with scores below 40 and above60 on each of the learning style elements, indicating they would avoidor benefit from special accommodations to their learning style prefer-ences. Regarding the environmental elements, more students preferreda sound and formal furniture design to a quiet and informal design. Allthe students preferred structure but three-quarters showed a high pref-erence. Two-thirds highly preferred working with peers while some(4%) preferredworking alone; 40% highly preferred to have an authorityfigure present while 1.1% did not. Additionally, about 31% highly pre-ferred the auditory and/or the tactile, 28% the kinesthetic, 22% the mo-bility while 8% highly preferred the visual. Further, 33% rated highpersistent, 16% high motivation and 9% high responsibility. For theother preferences, the differences between the numbers of studentswho had no or high preferences were less distinctive (Table 2).

Comparison of Learning Style Preferences BetweenGroups of twoCampusesand Three Semesters

In relation to the students' learning style preferences, therewere fewsignificant differences between the groups. Comparing the two campusgroups, therewas one distinctive preference (Table 3);more students atcampus Bwere highly tactile (P= .004). Comparing the three semestergroups, there were two distinctive preferences (Table 4): most auditorystudents were in the group of autumn 2012 (P= .004),most visual stu-dents were in the group of spring 2012 (P = .028) and less visual stu-dents were in the group of 2013. Those three differences appeared tobe more group-affiliated than related to changes in time and place.

Learning Style Preferences Compared to Personal Characteristics

No significant differenceswere found between the elements of PEPS,the students' age and assistant nurse graduation (Table 5). Concerningupper secondary school, significantly more of those who had undertak-en a vocational program were auditory (P b .045) and preferred sound(P b .040), while more of those who undertook a special program forthe individual were visual (P b .049). Concerning care experiences,there were significantly more students in three of five groups whopreferred the visual (P b .047), but without any clear connection to

Table 4Significant differences in the distribution of low, flexible and high-preference scores for nursin

Elementsa Low— does not preferScale 20–40

FlexibleScale 41–60

High — prefersScale 61–80

Spring2012%

Autumn2012%

Spring2013%

Spring 2012Autumn 2012Spring 2013%

Spring2012%

Autum2012%

Auditory 6.4 4.2 1.8 67.9; 51.4; 69.9 25.6 44.4Visual 14.1 11.1 20.4 71.8; 81.9; 75.2 14.1 6.9

a Items with Likert scales: 1 (never) to 5 (always).b Differences significant at P b 0.01.c Differences significant at P b 0.05.

the quantity of experience. Concerning gender, there were a lot ofsignificant differences. The rank average showed relatively morewomen than men scored motivation highly (P b .005) and preferredhigh structure (P b .004), auditory (P b .008), tactile (P b .027) and kines-thetic (P b .010) methods. Likewise, relatively more women than menpreferred intake (P b .002) and mobility (P b .011). However, the resultsshould be viewedwith some caution as there were fewermen in relationto the number of women.

Discussion

The aim of the study was to describe and compare final year nursingstudents' learning style preferences in two campuses during three se-mesters. A further aim was to identify differences between learningstyle preferences and personal characteristics. As there were no signifi-cant differences between the groups of semesters and campusesconcerning the students' personal characteristics, the discussion willbe based on the view of 263 students.

Due to the difficulties educators have in satisfying students' desirefor different learning environments, such as dim and bright light, quietand sound, formal and informal design, food or beverage intake andtime of day, those aspects are left out of the discussion. However,when students become aware of their profiles they have the opportuni-ty to customize appropriate elements, especially in homeenvironments.

The results showed individual variations for all the elements.Relatively few scored “does not prefer” – more scored “prefer” – butmost of the students were “flexible” persons who had no or few strongpreferences. Those students who clearly markedwhat they preferred ordid not prefer had taken a position on special accommodations that fa-cilitate or impede their learning.With or without support, they strive toattain knowledge and skills in the easiest and quickest way. But thestronger the preferences are, the more important it is for teachers toprovide compatible instruction strategies (Griggs et al., 1994).

More troubling is the large number of flexible students. The conceptof flexibility is generally consistent with multimodal nursing and med-ical students using the VARK test, a questionnaire quite similar to thePEPS questionnaire regarding visual, aural, reading/writing and kines-thetic sensory modalities (AIKhasawneh, 2013; James et al., 2011;

g students of three semesters.

Total Comparisons between three semester groups

n Spring2013%

Spring n = 78Autumn n = 72Spring n = 113Total n

Kruskal–Wallis test

28.3 263 χ2 (2) = 10.858, P = 0.004b

4.4 263 χ2 (2) = 7.186, P = 0.028c

Table 5Significant differences between 263 nursing students' learning style preferences and their personal characteristics.

Elementsa

Low 20–40Flexible 21–60High 61–80

GenderWomen (W) n = 209Men (M) n = 54

Age21–22 n = 4923–24 n = 6125–26 n = 4827–30 n = 5431–48 n = 51

Upper secondary school1. Pre-university programn = 762. Individual programn = 1223. Vocational programn = 65

AssistantnursegraduationYes n = 205No n = 58

Care experiencea: 0 year n = 51b: b1 year n = 46c: 1 b 3 years n = 86d: 3 b 5 years n = 34e: 5–28 years n = 45

Mann–Whitney U-testP-value

Kruskal–Wallis testP-value

Mann–Whitney U-testP-value

Kruskal–Wallis testP-value

Noise level .404 .178 .040b ↑ in group 3 prefer sound .520 .389Light .059 .699 .620 .554 .623Temperature .663 .627 .316 .978 .557Design .714 .270 .911 .920 .395Motivation .005c ↑ W were .233 .465 .305 .903Persistent .151 .914 .533 .965 .626Responsibility .213 .496 .737 .745 .199Structure .004c ↑ W prefer .131 .863 .712 .246Alone–peers .458 .985 .248 .339 .355Authority figure .249 .615 .434 .137 .839Several ways .233 .050 .574 .741 .812Auditory .008c ↑ W prefer .740 .045b ↑ in group 3 prefer .389 .171Visual .733 .653 .049b ↑ in group 2 prefer .451 .047b ↑ in b,c,e preferTactile .027b ↑ W prefer .094 .085 .535 .997Kinesthetic .010b ↑ W prefer .528 .136 .267 .854Intake .002c ↑ W prefer .904 .081 .181 .214Morning .305 .119 .587 .423 .454Late morning .071 .738 .789 .611 .964Afternoon .104 .238 .708 .133 .631Mobility .011b ↑ W prefer .216 .251 .109 .873

a Items with Likert scales: 1 (never) to 5 (always). ↑ more.b Differences significant at P b 0.05.c Differences significant at P b 0.01.

Samarakoon et al., 2013). Unfortunately, while educators may believethat flexible andmultimodal students can easily adapt their learning re-gardless of teachingmethods, this is not the case. Students in suchmid-dle range adapt to teaching methods without any special requirementsas long they are interested in the topic. When not interested, they learnsuperficially and engage only their short-term memory (Dunn andGriggs, 2007). Thus, moderately interested flexible students need tohave two, three or four elements involved in learning before they aresatisfied (AIKhasawneh, 2013). It follows that the more flexible stu-dents are, the more important it is for teachers to arouse interest andmotivation in ongoing activities and set limits and rules for suitableworking. Based on the fact that just 16% of the studentswere highlymo-tivated and 9% highly responsible the teachers' biggest challenge lies insatisfying and influencing those students' internal motivation. Whenthe driving force comes from the inside (internal motivation), learnersenjoy challenges and try different ways to deal with the challenges.But the opposite effect occurs when the driving force comes from theoutside (external motivation)— for example, in order to impress some-one or receive a prize. Learners experience stresswhen confrontedwithteaching methods that are difficult to cope with (Hedin, 2006).

The results showed that even final year nursing students preferredhigh structure and having an authority figure present. Of course, all stu-dents, regardless of educational level, need clear goals and academicconditions where they know what is expected of them. However,when university students are at the end of their education and soon tobe autonomous registered nurses, it is surprising that so many greatlydesire the closeness and backing of authority figures. This is probablynot what university teachers expect. One plausible explanation maybe that as nursing is governed by laws and regulations and life anddeath situations, students want to receive immediate confirmation inthinking and acting with regard to patient safety. In addition, two-thirds preferred working with peers to a high degree, which shouldreduce their need for teachers, but apparently not enough.

The most thought-provoking result was the 8% who preferred vi-suals highly and the high proportion of ‘unvisuals’ (16%). The extent

to which the students took advantage of the literature is not known,but no one can waive reading and self studies. An interesting thoughtconnected to themajority of the young students comes from the resultsof Pettigrew et al. (2011), who found that older nursing students spentmore time per week studying than younger students. That is somethingon which teachers have to reflect.

Just about a third of the students highly preferred auditory, tactile,and/or kinesthetic methods. Those students were in the final stage ofa three-year nursing program and had a predominance of lecture expe-riences from all the aforementioned teaching and learningmethods, butoverall it is evident that students have found that those methods moreor less fit like a glove. According to Dale (1969), who 45 years ago con-cluded, the number of lectures should be reduced in favor of increasingother teaching methods. Dale found that after two weeks people re-member 10% of what they read, 20% of what they hear, 30% of what isdemonstrated but 90% of what is said and done in combination. Thisindicates and confirms the importance of using seminars, case studiesand scenario-based learning. Nevertheless, it is remarkable that it hastaken decades for the knowledge to make deeper impact at highereducation institutions.

In order tomeet individual needs in groups and keep their interest fora period of several hours, teachers should use multimodal interactive ap-proaches that change format every 40–50 min. According to Pettigrewet al. (2011), even university students' minds will start wandering after40 min of a lecture. Thus, most lectures in the end of nursing educationshould be replaced by strategies that promote interaction and participa-tion, critical reflections and feedback (cf. West et al., 2012). If the curricu-lum clearly outlines that the literature and case studies are discussed inworkshops it should encourage even ‘unvisuals’ to read and be prepared.

Unique individual characteristics appeared in the resultswhich haverepercussions on leadership in lecture halls. So, even if a group is large,students need teacherswhohave the ability to choosemethods that en-ergize and trigger each to work toward set goals. Besides clarifying thegoals, directives and guidelines, teachers need to possess the compe-tence to expand methodological repertoires to present subjects in an

efficient manner (Augustsson and Boström, 2012). Depending on thestudents, the context and the situated activity, there are four didacticareas that teachers have to consider initially: What should be taughtand why, how and to whom should it be taught? (Johansen, 2007). Asearly as 20 years ago, Billings and Cobb (1992) reported nursing stu-dents who, congruent to their learning style preferences, studied withinteractive strategies and clear instructions and became motivated,felt responsibility and achieved high grades.

Only three differences were found in learning style preferences be-tween the two campuses and the three semesters. Likewise therewere no differences in learning style preferences related to differentgroups of age and assistant nurse graduation. Overall the differences ap-peared to be more group-affiliated than to do with changes to the timeand place. Nevertheless, comparing gender, there were a lot of surpris-ingly significant findings; comparatively more women than men werehighly motivated, auditory, tactile and kinesthetic and preferred struc-ture andmobility. Since some of those results are contrary to the resultsof the VARK test, where no relationships to gender were found (Jameset al., 2011), nursing teachers should take into account possible differ-ences in men's and women's study approaches. Anyway, the degree towhich previous education has influenced the outcome of the presentstudy is not known, although significantly more auditory students un-dertook a vocational program in upper secondary school, and signifi-cantly more visual students undertook a special individual program.That calls formore research onwhether various upper secondary schoolprograms affect nursing students' learning styles.

Study Limitations

The central strengths of this studywere the results generated from awell proven questionnairewith high reliability and validity that is easilyapplicable to nursing education (Dunn et al., 1995; LaMothe et al., 1991;Nelson et al., 1993). The response rate was high (88.9%), and data wereselected from two campuses and a number of students at the same levelof education.

There were someweaknesses that limit the ability to generalize. Thestudy was conducted at a single rural university with final semesternursing students, and as with all surveys, the results should be seen assnapshots. A multi-method design with students from several universi-ties and education levels would have strengthened the results. Howev-er, the intention was to perform a pilot study and generate a basis forfurther research.

Implications

The PEPS questionnaire gives both students and teachers good infor-mation about individual and group-related learning style preferences.Since learning styles tend to change over time, teachers need to investi-gate groups on a recurrent basis, but the frequency required can bediscussed. James et al. (2011) suggests surveying each year, but accord-ing to the results of the present study two tests would be enough in athree-year period. Therefore, if teachers estimate a student groupbased on the results of the most recent survey, they will be able toplan for two or three semester courses ahead.

To achieve success it is of utmost importance that teachers whomeet and guide the same student groups set aside time to discuss notonly the students' but their own learning style preferences before theyjointly decide content, didactic, pedagogy and behavioral strategies. Asstudents' and teachers' learning styles may differ, teachers should beaware of their own preferences and answer the PEPS questionnaire too.

Implicitly, higher education requires students to select learning toolsthat suit and improve them best. On the other hand, high-quality teach-ing is affected by a lot of factors that influence deep learning and stu-dents' internal motivation (Hedin, 2006). A good start is to providestructure with clear goals complemented bymotivational expectations,and thereafter make use of critical friends to determine the kind of

varying interactive pedagogical and didactic methods required as wellas opportunities for communication, collaboration and self-regulation.

Further Studies

To get an idea of whether there are trends in the new nursing stu-dents' learning styles, for example in relation to those who havegrown up in a technological home and in different school environments,further studies are needed. It is also interesting to ask about universitystudents' family circumstances and the degree to which nursing stu-dents work alongside full-time studies. Another interesting approachwould be to combine the PEPS with additional learning style question-naires, e.g. the questionnaire used in Kolb's Learning Style Model andtheVAK test. Triangulated quantitative and qualitative studies are need-ed, too. At the university where the study was conducted, the results ofthis pilot study will be important for further pedagogical developmentin a high-fidelity patient-simulation project.

Conclusions

Nursing students and nursing educators strive to adapt learning andteaching methods, but they usually do so without mapping. The PEPSquestionnaire is a multidimensional and instructional tool in order toinvestigate students' learning styles preferences.

The results showed that there were more or less heterogeneousresults with regard to what final year nursing students preferred anddid not prefer. However, themajority were ‘flexible’, and if not interestedin the topic, they are the learners who largely call for teachers' supportand motivation-enhancing guidance. Holistically there are complex cir-cumstances that characterize teachers' leadership and students' learning,but these are not impossible to handle for skilled teachers and for stu-dents who know their needs. Based on the results, most tuition shouldbe varying and interactive, discussed and confirmed between teachersand students and between cooperating teachers.

The few differences in students' learning style preferences betweenthree semester groups during a 1.5-year period indicated that twolearning style tests should be enough over three years of nursing educa-tion. In such a range students could work on their own as a basis forlong-term learning.

The PEPS questionnaire provides a good basis for learning and teach-ing in colleges and universities. As there are few studies involving nurs-ing students and the PEPS questionnaire, the results will be helpful as areference for further surveys at rural and metropolitan universitiesregionally, nationally, and internationally.

Acknowledgments

This studywas conducted as a part of fund fromMid SwedenUniver-sity. Grateful thanks to all nursing students who agreed to participate inthe study.

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