Nurse Education in Practice 14 (2014) 170e175

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

A prospective cohort study examining the preferred learning styles

of acute care registered nurses
Judy McCrow a, b, *, Andrea Yevchak c, 1, Peter Lewis a, b, 2
a
Institute of Health and Biomedical Innovation, Brisbane, Queensland, Australia
b
School of Nursing, Queensland University of Technology, Queensland, Australia
c
School of Nursing, The Pennsylvania State University, University Park, PA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: This paper reports on the preferred learning styles of Registered Nurses practicing in acute
Accepted 29 August 2013 care environments and relationships between gender, age, post-graduate experience and the identied
preferred learning styles.
Keywords: Methods: A prospective cohort study design was used. Participants completed a demographic ques-
Learning styles tionnaire and the Felder-Silverman Index of Learning Styles (ILS) questionnaire to determine preferred
Registered nurse
learning styles.
Acute care
Results: Most of the Registered Nurse participants were balanced across the Active-Reective (n 77,
Education
54%), and Sequential-Global (n 96, 68%) scales. Across the other scales, sensing (n 97, 68%) and visual
(n 76, 53%) were the most common preferred learning style. There were only a small proportion who
had a preferred learning style of reective (n 21, 15%), intuitive (n 5, 4%), verbal (n 11, 8%) or global
learning (n 15, 11%). Results indicated that gender, age and years since undergraduate education were
not related to the identied preferred learning styles.
Conclusions: The identication of Registered Nurses learning style provides information that nurse
educators and others can use to make informed choices about modication, development and
strengthening of professional hospital-based educational programs. The use of the Index of Learning
Styles questionnaire and its ability to identify balanced learning style preferences may potentially yield
additional preferred learning style information for other health-related disciplines.
2013 Elsevier Ltd. All rights reserved.

Introduction
Front line healthcare providers in acute care settings must
maintain an understanding of evidence-based practices and ad-
vances in healthcare delivery (Dyson et al., 2009; Ibrahim and
Mahran, 2010). The majority of these providers are Registered
Nurses (RNs) who participate in continuing education to meet the
demands of their role (Wood, 2006). In previous research
continuing education is cited as being a key determinant of high
* Corresponding author. School of Nursing, Queensland University of Technology,
Victoria Park Road, Kelvin Grove, QLD 4059, Australia. Tel.: 61 7 3882 4585;
fax: 61 7 3138 5941.
E-mail addresses: j.mccrow@qut.edu.au, judymcr@bigpond.com (J. McCrow),
amy139@psu.edu (A. Yevchak), p.lewis@qut.edu.au (P. Lewis).
1
The Pennsylvania State University, School of Nursing, 201 Health and Human
Development East, University Park, PA 16802, USA.
2
School of Nursing, Queensland University of Technology, Victoria Park Road,
Kelvin Grove, QLD 4059, Australia.
quality patient care delivery (Ibrahim and Mahran, 2010) and can
consequently impact patient outcomes and healthcare costs.
Despite the need for RN continuing education, there are several
barriers to their participation in hospital-based education
including, but not limited to, competing demands for time and
effort, difculty obtaining education outside of the clinical arena,
and the nancial burden of providing education for healthcare
services (Brown et al., 2009; Meyer et al., 2007). These issues span
international clinical settings, highlighting the need for the most
effective methods to be in place when developing and imple-
menting education for RNs and other health disciplines across the
globe. In this paper hospital-based education or hospital-based
continuing education refers to activities aimed at improving clin-
ical knowledge or performance, whether the activities are done for
staff development or for contact hour credits.
Matching teaching activities with learning styles is one method
that may address identied learning barriers. Research demon-
strates that learning is more effective if education is provided in a
way that suits individuals learning style (Chai, 2006; Jen-Hwa Hu

1471-5953/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nepr.2013.08.019
 J. McCrow et al. / Nurse Education in Practice 14 (2014) 170e175
Fig. 1. Scoring example, across two domains for each of the four scales of the Felder-Silverman Learning Style Questionnaire. Adapted from Felder, R.M., and Soloman, B.A. (n.d.)
et al., 2007). Therefore, an understanding of RNs learning style is
important so that time efcient and cost effective hospital-based
educational models are developed in a way that will ensure bet-
ter information comprehension and meet RNs needs.
Learning styles are individual preferences for taking on new
skills and knowledge, and processing information (Felder and
Spurlin, 2005; Palermo et al., 2009). There has been an extensive
exploration of the learning styles of undergraduate nursing stu-
dents (Smith, 2010). Others have investigated the learning styles of
RNs enrolled in post-graduate education, including midwifery and
masters level programs (James et al., 2011; Smith, 2010). A
noticeable gap in the literature is studies exploring practicing
acute care Registered Nurses preferred learning styles. In addition
to this gap little is known about the impact of gender, age and
years since completion of undergraduate education on these RN
learning style preferences (James et al., 2011). Some research
suggests that learning styles may differ across gender and age,
while others have found no clear difference (Molsbee, 2011; Seiler,
2011; Ward, 2009).
Ongoing education is a mandatory requirement of national
nursing registration, within Australia, and therefore a crucially
important element of RNs practice (Australian Health
Practitioner Regulation Agency, 2011). In support of this
requirement and the need to ensure competency of healthcare
staff, hospitals offer ongoing education sometimes referred to as
staff development (Ibrahim and Mahran, 2010). An under-
standing of RNs learning styles may benet hospital-based ed-
ucators as it can provide guidance to education program
development that suits RNs requirements and consequently
improve knowledge uptake. In turn, this knowledge uptake may
improve practice and inuence safe patient outcomes (Sayers,
2012). The purpose of this paper is to report on the learning
styles of RNs working in acute healthcare facilities in Australia. It
will answer the following questions:
1. What are the preferred learning styles of acute care Registered
Nurses?
2. Is there a relationship between gender, age, and years since
post-graduate education with learning style preferences of
acute care Registered Nurses?
Methods
A prospective cohort study design was used to explore the
learning styles of RNs working within acute care hospital
environments.
171
Participants
The study was undertaken in three acute care hospitals in
South-East Queensland, Australia. The RN volunteer participants
were recruited over six months via study information sessions held
in each facility. An estimated total of 1250 RNs were employed in
these acute care facilities during study recruitment. Because of shift
work, including night duty, not all RNs were able to attend the
study information sessions. Of all RN staff approximately 16% (205)
attended the sessions and 175 (85% response rate) agreed to
participate. Of these, 142 RNs completed the questionnaires and
were included in the nal analysis. The RNs were employed in a
variety of clinical settings including surgical, medical, orthopedic,
critical care and emergency departments.
Instruments
All RNs completed a participant demographic questionnaire and
the Felder-Silverman Index of Learning Styles (ILS) questionnaire to
determine preferred learning styles. Previous nursing research has
utilized a variety of learning style instruments such as the Honey
and Mumfords Learning Styles Inventory, Myers-Briggs Type In-
dicator (Chinese version), Kolb Learning Style Inventory and the ILS
to understand preferred learning styles of nurses (Astin et al., 2006;
DAmore et al., 2012; Fleming et al., 2011; Li et al., 2008; Rassool and
Rawaf, 2008; Smith, 2010). This study chose the ILS.
Although not used extensively in nursing research, the ILS tool
was chosen for several reasons, including: it can be easily self-
administered; there is no cost for use; its extensive use in other
professions and its acceptable reliability using Cronbachs coef-
cient alpha across the four scales (a .55e.77) (Cook, 2005; Cook
and Smith, 2006; Litzinger et al., 2007). However, the major
reason for selecting this tool was its ability to allow learners to be
balanced across learning style domains or have a moderate to
strong preference for one domain. Identication of no strong
preference for specic learning style (balanced) provides additional
relevant information for hospital-based education. For example,
when there is no strong preference for a particular learning style
domain educators have added exibility in the creation and
implementation of educational programs as they can use varied
formats whilst still meeting the needs of the students.
The ILS was originally developed to deliver some insights into
teaching and learning in engineering education and was based on
Kolbs theory of experimental learning (Felder and Silverman, 1988;
Hsieh et al., 2011). It is used in other disciplines such as education,
medicine and science (Arora et al., 2011; Cook et al., 2007; Hsieh
et al., 2011; Palou, 2006; Sabry and Baldwin, 2003; Zhang and
172 J. McCrow et al. / Nurse Education in Practice 14 (2014) 170e175

Lambert, 2008). The ILS has successfully been used to guide Table 1
educational model development in science, information technol- Demographic data of the participants (N 142).

ogy, agriculture and vocational education and training courses Demographic variables n %
(Fazarro et al., 2009; Perantoni, 2010; Smith, 2005; Tsoi, 2009). Gender
Consequently, it is likely that it could be used to guide nursing staff Female 126 89
development and continuing education. Male 16 11
The ILS is a 44 item forced response questionnaire designed to Total 142 100

provide scores on four hypothesized learning scales. Each of the Age groups
responses are either a or b and the scales are: Active-Reective, 20e29 years 34 24
Sensing-Intuitive, Visual-Verbal, and Sequential-Global learning 30e39 years 32 23
40e49 years 42 30
style domains and represent four group classications (Christou 50 years and older 28 20
and Dinov, 2010; Cook, 2005). Total 136* 97

Highest qualication
1. Information processing: active (like doing things and active Hospital certicate (RN) 23 16
discussion particularly in groups) versus reective (like to work Baccalaureate degree (RN) 96 68
alone, think through process before taking action) Post-graduate certicate 7 5
2. Information perception: sensing (prefer facts, data and learning Post-graduate diploma 10 7
Masters 4 3
through practical and real world applications) versus intuitive Total 140* 99
(prefer ideas and theories)
Years since completion of undergraduate studies
3. External information channel: visual (like pictures, diagrams,
10 years 69 49
owcharts and reading books) versus verbal (prefer speaking 10e19 years 32 22
and hearing information) 20e29 years 23 16
4. Understanding process: sequential (like step-by-step pro- >29 years 18 13
cedures) versus global (prefer to learn in large steps and grasp Total 142 100

the whole picture) (Christou and Dinov, 2010; Felder and Note. *Missing data.
Soloman, (n.d.); Hawk and Shah, 2007)

In interpreting the study results it should be considered that the
ILS utilizes four scales as shown in Fig. 1 and each scale has two
specic domains (e.g. active and reective). From the ILS emerging
learning style preferences that may be either balanced across the
corresponding learning domains or a moderate or strong prefer-
ence to one or the other domain will appear. For example, a score
ranging from 1 to 3 implies the learner is balanced across both
domains alternatively a score ranging from 5 to 11 implies a
moderate to strong preference to that particular domain (Felder
and Soloman, (n.d.)).
In the majority of studies ILS results are reported by combining
learning style preferences on each side of the four domain scales
and reporting the two-groupings for example, active or reective
preferred learning style (Willems, 2011). Others have grouped the
moderate and high preferences together leaving four groupings
(moderate/strong and mild) across the four domains; for example
moderate-strong active, low active, moderate e strong reective
and low reective (Brown et al., 2009). Given we were interested
in identifying learning styles of RNs to help guide future staff
development education it was important to also identify learners
who did not clearly indicate a distinct preference for either domain
(balanced). We utilized a three-grouping method of scoring as
performed by Crutsinger and colleagues, where scores falling in the
mild preference section of the scale (3a to 3b) were classied as
balanced across that learning preference scale and 5a to 11a and 5b
to 11b were categorized as a preference for each corresponding
learning style domain (Crutsinger et al., 2005).
Ethical approval
The study was approved by the relevant human research ethics
committees. All participants provided written consent.
scale was nominally grouped to depict either a balanced or a spe-
cic preference across each domain (three-grouping method). To
answer question one, percentage counts were used to describe the
distribution of learning styles for the study participants. Age and
years since graduation were each grouped into four categories as
shown in Table 1. Fishers Exact Tests were used to test the hy-
pothesis that there was a relationship between each of the three
learning style domains (e.g. active, reective or balanced) of each
scale (e.g. active-reective) and gender, age categories and years
since graduation categories.
Results
The sample included 142 RNs with a mean age of 40 years
(S.D 11.6, range 20e68). Most participants were female (89%),
with a slightly higher percentage of them being in the 40e49 year
age group as shown in Table 1. The sample comprised a diverse range
in years since completion of undergraduate studies (1 year to 48
years) with a median time of 10 years. Approximately 70% of the
sample self-reported a Baccalaureate degree in nursing as their
highest qualication and 15% reported having post-graduate quali-
cations. Other characteristics of the sample are displayed in Table 1.
Preferred learning style of acute care RNs
The distributions of preferred learning styles of the RN partici-
pants across each of the four scales are reported in Fig. 2. The
majority were balanced across the domains of; active and reective
(n 77, 54%), and sequential and global learning (n 96, 68%). A
small proportion of the RNs had a preferred learning style of
reective (n 21, 15%), intuitive (n 5, 4%), verbal (n 11, 8%) or
global learning (n 15, 11%).

Data analysis Impact of demographic factors on learning styles

Data analyses were performed using the Predictive Analytics Gender

SoftWare (PASW) version 18.0. Descriptive data analyses were Although there were some differences in the proportion of
undertaken to examine demographic variables. Each learning style males and females within each of the preferred learning style
 J. McCrow et al. / Nurse Education in Practice 14 (2014) 170e175
Fig. 2. Distribution of preferred Learning Styles domains among the RNs (N 142).
domains no statistically signicant associations between learning
style preference and gender were found (p .12e.82) (see Table 2).
Age
Age was obtained by designation into one of four categories for
age. As depicted in Table 2, there were similar numbers of regis-
tered nurses (24%) in the younger 20e29 years age group as the
30e39 years age group (23%) and the over 49 years age group (24%).
The study identied slightly more RNs in the 40e49 years age
group (30%). When investigating relationships between the
different age groups and each learning style domain no statistically
signicant associations were found (p .13e.95) (see Table 2).
Experience
Years since completion of undergraduate education was
grouped into three categories as shown in Table 2. Nearly half of the
sample had less than ten years experience since completion of
undergraduate nursing education, with 28% having between ten
and twenty years experience and approximately 23% having more
than 20 years since completion of undergraduate nursing educa-
tion. This study reports no statistically signicant associations be-
tween years since completion of undergraduate studies and
preferred learning style domains (p .32e.97) (see Table 2).
Discussion
Registered nurses need to meet the demands of an ever-
changing environment to improve clinical care and patient out-
comes. Hospital-based education is important in assisting RNs
meet these demands. In the present study of RNs in three acute care
facilities in Australia, the learning style preferences were through
visualization and receiving information in a sensory stimulating
format. These ndings were similar across gender, age groups and
years since completion of undergraduate nursing education. Our
ndings can be used to inform hospital-based education. Tailoring
the education to RNs learning styles can improve the uptake and
dissemination of the information learned in clinical practice.
Irrespective of gender, age or experience our ndings show that
sensing and visual are preferred learning styles of RNs and this is
consistent with results from international studies of undergraduate
students. For example, a Chinese study found undergraduate
nurses had preferences for sensing (86%) and visual (76%) learning
and two studies undertaken in Taiwan established sensing learning
to be one of the most common learning style preferences among
173
the nurse participants (Li et al., 2011; Li et al., 2008; Zhang and
Lambert, 2008).
We found a high proportion of RNs to be balanced across the
Active-Reective and Sequential-Global learning style domains.
These results are difcult to compare to previous ndings because
of the limited use of the ILS in nursing research and the one pre-
vious study using this tool utilized a two-grouping method of
analysis as opposed to our three-grouping method. This prior study
identied more nurses to prefer global as opposed to sequential
learning and reective rather than active learning (Zhang and
Lambert, 2008). Potentially the use of two-groupings in prior
studies may have missed valuable ndings in relation to learners
who do not clearly indicate a distinct preference for either domain
(balanced). Our ndings may support the choice of three-grouping
analyses as it provides a more accurate reection of the spread of
learning style preferences, which includes those who dont have
strong preferences for particular learning style domains.
Although this study used a different learning style question-
naire, previous studies using the Honey and Mumford question-
naire have identied reector as the most frequently preferred
learning style for undergraduate nurses. Rassool and Rawaf (2008)
found that reector (n 48, 46%) was the most preferred learning
style of undergraduate nursing students in the UK. In contrast, only
15% (n 21) of our sample of RNs had a reective preferred
learning style. Similarly, Fleming et al. (2011) identied reector as
the most preferred learning style of rst and nal year under-
graduate nursing students and activist as the least preferred.
However, consistent with our ndings they found that there was no
dominant learning style preference across this scale, in the nal
year group. A nurse with no dominant learning style or balanced
across the learning style domain may be more responsive to
different educational presentations (Fleming et al., 2011). An un-
derstanding of specic learning style preferences as well as indif-
ference preferences (balanced) will provide additional information
to guide hospital educators in creating more targeted approaches to
learning for all students not just students in one specic learning
style domain.
The similarities between previous ndings investigating the
learning styles of undergraduate nursing students and our ndings
investigating practicing RNs learning styles may exist because there
are specic types of individuals drawn to the nursing profession.
The slight differences may be reective of changing learning style
preferences as a nurse progresses from undergraduate student to
practicing RN level and consequent exposure to real world contexts.
174 J. McCrow et al. / Nurse Education in Practice 14 (2014) 170e175

Table 2
Associations between learning style preferences and gender, age and experience (N 142 RNs).

Characteristic Characteristic Learning style preferences

subgroups
Active-Reective Sensing-Intuitive Visual-Verbal Sequential-Global

Act n (%) Balance Ref n (%) Sens n (%) Balanced Int n (%) Vis n (%) Balanced Ver n (%) Seq n (%) Balanced Glo n (%)
n (%) n (%) n (%) n (%)

Gender Male (n 16) 5 (31) 8 (50) 3 (19) 11 (69) 3 (19) 2 (13) 10 (63) 4 (25) 2 (13) 1 (6) 13 (81) 2 (13)
Female (n 126) 39 (31) 69 (55) 18 (14) 86 (68) 37 (29) 3 (2) 66 (52) 51 (41) 9 (7) 30 (24) 83 (66) 13 (10)
P-value .82 12 .34 .26
Fishers exact .48 4.04 1.95 2.62

Age 20e29 years (n 34) 11 (32) 21 (62) 2 (6) 24 (71) 9 (27) 1 (3) 22 (65) 10 (29) 2 (6) 6 (18) 24 (71) 4 (12)
30e39 years (n 42) 12 (38) 16 (50) 4 (13) 20 (63) 11 (35) 1 (3) 18 (56) 9 (28) 5 (16) 7 (22) 23 (72) 2 (6)
30e49 years (n 42) 11 (26) 20 (48) 11 (26) 27 (64) 12 (29) 3 (7) 19 (45) 22 (52) 1 (12) 8 (19) 28 (67) 6 (14)
50 years (n 34) 7 (25) 18 (64) 3 (11) 22 (79) 6 (21) 0 13 (46) 12 (43) 3 (11) 7 (25) 18 (64) 3 (11)
P-Value .26 .75 .13 .95
Fishers exact 7.61 3.62 9.51 1.86

Year since <10 years (n 69) 22 (32) 37 (54) 10 (14) 48 (70) 19 (28) 2 (3) 41 (60) 24 (35) 4 (6) 15 (22) 46 (67) 8 (12)
completion 10e20 years (n 40) 13 (33) 22 (55) 5 (13) 26 (65) 12 (30) 2 (5) 18 (45) 17 (43) 5 (13) 5 (13) 31 (78) 4 (10)
of undergraduate >20 years (n 33) 9 (27) 18 (55) 6 (18) 23 (70) 9 (27) 1 (3) 17 (52) 14 (42) 2 (6) 11 (33) 19 (58) 3 (9)
study P-Value .96 .97 .54 .32
Fishers exact .69 .82 3.15 4.72

Note: Totals may not equal 100% because of rounding.

Our ndings imply that hands-on, factual, visual and group
learning may be the best learning approaches for RNs and conse-
quently evolving technologies may offer suitable learning modal-
ities. Not surprising technologies such as human patient
simulations (HPS) are being incorporated in nursing education and
research ndings are showing some positive outcomes however,
published research in this eld is restricted (Alinier et al., 2006;
Shinnick et al., 2011). It is claimed that HPS provide hands-on
practical learning in a safe effective environment by allowing
nurses to apply theoretical knowledge to practical experiences
through experimental laboratory activities, which supports our RNs
preferred learning style preference results (Fountain and Alfred,
2010).
Currently there is an evolving body of evidence supporting the
use of technology in undergraduate nursing education however its
use in clinical environments is still in early investigative stages
(Spiva et al., 2012). Given we have found similar learning style
preferences in a sample of Australian practicing Registered Nurses
to those found in undergraduate populations, hospital-based edu-
cators may utilize undergraduate research ndings to guide
educational implementation in that setting. However, some caution
must be exercised as other characteristics such as environments
and learning context may be different and potentially inuence
learning. Additionally, despite the fact that we found many simi-
larities in learning style preferences to those found in undergrad-
uate nursing populations we did nd results that we couldnt
compare. For example, a previous study used a two-group method
of scoring (global or sequential) and consequently our ndings of
balanced learning style preferences across the global and
sequential domains were not comparable. Further research is
required to investigate learning styles of health-related disciplines
including RNs using three grouping analyses of the ILS. The
balanced learning style preference may potential yield additional
information for educators.
Limitations
determined by geographically location and willingness to partici-
pate. However, the study does include a diverse sample of prac-
ticing RNs from different clinical areas. Another potential limitation
was that there has been little research using the ILS questionnaire
in nursing and medical populations. However, this was not seen as
problematic by the authors as the tool was used to investigate the
learner not the setting.
Conclusion
Currently there is a lack of information regarding RNs preferred
learning styles, but we have some similar ndings to studies
investigating undergraduate nursing students. We identied that
the majority of RNs were balanced across the active-reective and
sequential-global scales. This information suggests that RNs are not
reliant on either particular style. However across other scales, the
RNs in this study preferred learning through sight and physical
sensation rather than abstract theoretically orientated methods.
We have also discovered that very few of the RNs preferred to learn
through reective processes or through system-orientated (global)
processes.
It is understandable that these methods of learning are
preferred by a large number of RNs given the requirements of
professional nurses and the clinical work environment they are
continuously exposed to. This research adds to the identied gap in
knowledge needed to allow nurse educators and others to make
informed choices about how ongoing hospital-based education is
provided to RNs. Importantly, with the predominant learning styles
of RNs identied, modication, development and strengthening of
professional educational programs can be undertaken. These pro-
grams should be designed to strengthen visual and sensing content
format to address the needs of RNs. We know that education cannot
be provided in a way that meets the needs of all learners and
engaging these preferred learning styles does not imply major
restructuring of educational resources. Rather it provides guidance
to emphasis on specic educational formats.

Limitations to this study include, the sample was self-selecting Conict of interest statement
RNs practicing in acute care hospitals and they may be different in
interests and work and educational experiences to those working in All authors state that there are no conicts of interest. No
other areas of nursing. The study sites and participants were nancial interests.
 J. McCrow et al. / Nurse Education in Practice 14 (2014) 170e175
Acknowledgments
We would like to thank the registered nurses involved in this
study for their voluntary participation and support.
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