Learning styles of nurse anesthesia students related to level in a master of science in nursing program

Learning styles of nurse anesthesia students related to level in a master of science in nursing program LINDA SHERBINSKI, CRNA, MSN Springfield, Illinois To alleviate the shortage of anesthetists, nurse anesthesia programs are expanding and new programs are being developed while they simultaneously move into the master's degree framework. Students' learning style preferences can provide valuable information for educators engaged in facilitating and enhancing learning. This study identified the learning styles of nurse anesthesia students enrolled in 12 programs that confer a master of science in Nursing degree in relation to the students' gender and level in an anesthesia program. Learning profiles were determined by scores on the Learning Style Inventory (Kolb, 1985). A personal data sheet was used to elicit the students'demographic characteristics. Surveys were administered to a sample of 264 nurse anesthesia students, with 164 usable responses (62.8%). Results indicated a preference for the assimilator learning style (37.2%). A statistically significant relationship between learning style and level in an anesthesia program was found (chi-square = 11.14, df = 3, P<.05). Whereas students who had completed fewer than 12 months in an anesthesia program showed no dominant preference for a learning style, students who had completed more than 12 months were predominantly distributed in two learning style categories: assimilators (40.0%) and convergers (38.8%). No statistically significant relationships were identified between learning styles and gender. Key words: Learning styles, master of science in nursing anesthesia students, nurse anesthesia education. Introduction A significant number of certificate anesthesia programs have closed for a variety of reasons, including financial and clinical site difficulties that have been reflected by a decrease in the number of nurse anesthesia graduates from 1,063 in 1978 to approximately 600 in 1989, contributing to the national shortage of anesthetists. To counter this shortage, the AANA proposes to open new programs, expand existing programs, and encourage collaboration between universities and healthcare facilities. The endeavors to alleviate the shortage might best be accomplished by establishing new programs within the graduate level and moving the existing certificate programs to the graduate level, which is the current trend of nurse anesthesia programs.' The AANA has projected that, by January 1, 1998, nurse anesthesia programs will be in the master's framework.' In 1989, 60% of the 93 programs were at the graduate level. 2 * Fourteen of the 93 pro- *In 1993, 85% of the 94 accredited nurse anesthesia education programs offered a master's degree. February 1994/ Vol. 62/No. 1 39

grams were incorporated into graduate schools of nursing that confer a master of science in Nursing (MSN) degree. Nursing students have been reported to be among the most frequently studied groups of health professionals in regard to learning styles; however, studies of learning styles of anesthesia students have been scarce and studies of graduate nursing students' learning styles were absent. 3-6 Learning style has been defined as the process by which individuals organize information and experiences. 7 They are based on experiential learning theory, which assumes that students learn best, as demonstrated by their motivation and achievement, if they are taught in the style they prefer. 8 It is postulated that each profession demonstrates a particular learning style and, with repetition of that style, learners will assimilate that profession's learning style norm. 8 The identification of learning styles can be a useful tool to facilitate and enhance learning for students. To meet the demands of the current shortage and to expedite the AANA's goal of increasing the number of graduates, new programs will open and existing programs will eventually move to the graduate level. The identification of students' learning styles appears to be an important element in facilitating these plans of action. The better that educators and students understand learning preferences, the more effective the teaching-learning process can become. 9 There have been reports that men and women have different learning style preferences, a factor that may have important implications in nurse anesthesia. The 10% increase in male nurse anesthetists-from 27% in 1979 to 37% in 1989-clearly demonstrates the need to include this important variable.' To meet the demands of the current shortage and to expedite AANA's goal of increasing the number of graduates, the identification of nurse anesthesia students' learning styles is an important element in implementing these plans of action as quickly and efficiently as possible. Experiential learning theory Experiential learning theory (ELT) considers learning to be a lifelong process of adaptation. ELT has its basis in the disciplines of social psychology, philosophy, and cognitive psychology. It defines learning as "the process whereby knowledge is created through the transformation of experience."' 0 The experiential learning model makes two basic assumptions: (1) "People learn from the immediate, here-and-now experience, as well as from concepts and books," and (2) "People learn differently; that is, according to their preferred learning styles."' 0 ELT has the advantage of combining experience, perception, cognition, and behavior, thereby integrating behavioral and cognitive theories." The characteristics of ELT are as follows: 1. Learning is best conceived as a process, not in terms of outcomes. 2. Learning is a continuous process grounded in experience. 3. The process of learning requires the resolution of conflicts between dialectically opposed modes of adaptation to the world. 4. Learning involves transactions between the person and the environment. 5. Learning is a process of creative knowledge. 10 Learning style types The Learning Style Inventory (LSI) is an instrument designed to identify an individual's learning style preference and correlates with the experiential learning model. The model depicts learning as a four-stage cycle, correlating experience with concepts. The four stages of the learning cycle are (1) concrete experience, (2) observations and reflections, (3) formation of abstract concepts and generalizations, and (4) testing the implications of concepts in new situations.' 0 The learning styles identified by Kolb are accommodator, assimilator, converger, and diverger. * Accommodator emphasizes concrete experience and active involvement. This learning style is characterized by active doing and risk-taking. * Assimilator emphasizes inductive reasoning and the ability to create models based on theoretical principles. The dominant abilities of the assimilator are abstract conceptualization and reflective observation. This learning style is characterized by an interest in abstract concepts and less interest in people. * Converger emphasizes problem-solving, decision-making, and the practical application of ideas. This learning style relies predominantly on abstract conceptualization and active experimentation. It is characterized by deductive reasoning and a preference for dealing with technical tasks and problems rather than people. * Diverger emphasizes concrete experience and reflective observation. This learning style is characterized by the ability to imaginatively adapt by observation rather than direct action.' 0 Methodology * Design and sample. This investigation was a 40 Journal of the American Association of Nurse Anesthetists

nonexperimental, descriptive study that focused on the relationship between learning styles, gender, and level in an MSN anesthesia program. The learning styles were determined by the scores obtained on the LSI. The sample consisted of 12 MSN programs. Two hundred sixty-four students comprised the population of the 12 participating programs, of which 166 first- and second-year students participated. The LSI, developed by David Kolb in 1976 and revised in 1985, has its theoretical basis in ELT. The instrument is a 12-item, rank-order questionnaire designed to measure an individual's learning preferences. The individual is instructed to arrange in rank order of preference four endings for each of 12 sentences, indicating the number 4 for the ending that best describes "how you learn best or is most indicative of yourself," to the number 1 for the ending that appears to be the "least like the method you learn or least like yourself." Each sentence ending is designed to form one of four columns which correspond to the four stages of the learning cycle that Kolb identified: column 1-concrete experience, column 2- reflective observation, column 3-abstract conceptualization, column 4- active experimentation. The 12 numbers in each column are added together to obtain raw scores. Two additional combination scores indicate the extent to which the individual emphasizes abstraction over concreteness. 10 The raw scores of column 1 are subtracted from those of column 3, and the raw scores of column 2 are subtracted from those of column 4. These scores are then plotted on the corresponding vertical and horizontal axes of the scoring grid. The point of intersection represents the individual's preference for one of the four learning styles. The LSI is reported to have good internal reliability, as measured by Chronbach's alpha,.87 to.93 (n = 236, P<.001).8 The combination scores, which are used to indicate learning style type, show almost perfect additivity (1.0) when Tukey's test was used. The Spearman-Brown split-half reliability shows results of.71 to.85, (n = 268, P<.001).10 Normative profiles and standardized percentile scores were based on a sample of 1,446 adults between the ages of 18 and 60. The normative study showed differences between men and women in the abstract-concrete grouping. Men (59%) demonstrated a preference for abstraction over concreteness compared to women (41% of the sample). Pearson product-moment correlations were carried out on the sample of 1,446 adults, and negative correlations between active experimentationreflective observation (r = -33) and abstract conceptualization-concrete experience (r = -42) were revealed. These negative correlations demonstrate the desired effect, that the instrument is measuring different learning styles. 10 The LSI has been reported to be valid. 8.10 In observing that individuals are fairly accurate selfperceivers, Smith and Kolb noted that selfdescription is "one of the most powerful perspectives on behavior.., self-descriptions can be more valid for some activities than other descriptions."' 10 The LSI has undergone testing in several areas and settings, including medical, educational, and managerial training. The validity of the LSI and Kolb's four stages, based on ELT, has been tested by numerous authors, who concluded that Kolb's four diverse learning styles can be identified. 8 ' 11-15 * Personal data sheet. This was a four-item questionnaire developed by the investigator to elicit demographic data. The items surveyed the participant's age, gender, level in an anesthesia program, and the number of years of critical care experience as a professional nurse prior to anesthesia school. * Procedure. Permission to conduct this study was obtained from the Institutional Review Board at Duquesne University, Pittsburgh, Pennsylvania. Permission to implement the study was obtained from the program directors of the nurse anesthesia MSN programs. The instrument packets, instructions, consent forms, and return envelopes were sent to the program directors who had agreed to participate in the study. First- and second-year anesthesia students were asked for their voluntary consent by the participating program directors. The anesthesia students who elected to participate were read a cover letter by their program director that explained the purpose of the study and informed them that their responses to the Kolb LSI and the personal data sheet would remain confidential. The LSI was coded to correspond to the personal data gathered, and the individual participants' names were in no way identified with this data. Each school that participated was identified by a school code, and each was sent its own aggregate results to compare with the total sample. Results * Demographic variables. The majority of students (69.3%) were between the ages of 26 and 35 years of age (Table I). The second largest group of students were between the ages of 36 and 45 years of age. Students between the ages of 41 and 45 years of age represented the smallest group (4.2%). Of the nurse anesthesia students in this sample (n = 166), 109 (65.7%) were female, and 57 February 1994/ Vol. 62/No. 1 41

Table I Distribution of nurse anesthesia students by age Age in years Number Percentage 21-25 15 9.0 26-30 58 35.0 31-35 57 34.3 36-40 29 17.5 41-45 7 4.2 Total 166 100.0 (34,3%) were male. There was an even split in distribution for the percentages of males and females in the first and second year of the anesthesia programs surveyed. There were 50.5% females in the first year and 49.5% females in the second year. No statistically significant relationships were identified between gender and learning styles. Eighty-five (51.2%) of the nurse anesthesia students were enrolled in the first year, and 81 (48.8%), were enrolled in the second year of an anesthesia program. The majority of students (53.2%) had between 1 and 4 years of critical care experience prior to entering an anesthesia program (Table II). The next largest group (28.8%) had between 5 and 8 years of experience. The students with the most experience, 9 years or more, represented the smallest group (18.0%). Table II Distribution of nurse anesthesia students by years of critical care experience Years experience Number Percentage 1-2 42 25.4 3-4 46 27.8 5-6 29 17.4 7-8 19 11.4 9-10 12 7.2 Greater than 10 18 10.8 Total 166 100.0 * Statistical results. All four learning styles were identified in the nurse anesthesia students enrolled in the 12 MSN programs (Table III). The predominant learning style identified in this sample (37.2%) was the assimilator style, which emphasizes reflective observation and abstract conceptualization. The converger learning style was the next most frequently occurring style, with 51 students (31.1%) in this category. The converger style em- Table III Learning styles of nurse anesthesia students Learning style Number Percentage Accommodator 30 18.3 Converger 51 31.1 Diverger 22 13.4 Assimilator 61 37.2 Total 164 100.0 Two of the subjects scores were eliminated from the data related to learning styles. The two students were included in the demographic data, therefore the total is 166 for demographic characteristics. phasizes active experimentation and abstract conceptualization. The accommodator learning style was the third most frequently occurring style, with 30 (18.3%) in this category. The accommodator style emphasizes concrete experience and active experimentation. The diverger learning style occurred least frequently in this study with 22 students (13.4%) in this category. The diverger style emphasizes concrete experience and reflective observation. All four learning styles were identified in both men and women in the sample of MSN students (Table IV). The percentages which represented the distribution of the four learning styles for males and females were similar. The diverger learning style had a difference of 1.4% between men and women. The greatest difference between men and women was represented by the accommodator learning style with 11.4%, which was not statistically significant. It can be concluded from the findings shown in Table IV that there is no statistically significant relationship between gender and Kolb's learning style types. There were 84 students in the first year and 80 Table IV Relationship of learning styles and gender Learning style Accommodator Diverger Converger Assimilator Total Males Number Percentage 6 7 21 22 56 10.7 12.5 37.5 39.3 100.0 - w-v Chi=square = 3.94, df = 3, P>.05 Females Number Percentage 24 15 30 39 108 22.2 13.9 27.8 36.1 100.0 42 Journal of the American Association of Nurse Anesthetists

Table V Relationship between leeming styles and level in an aneshe-la program Program year - - -qw- ---- F - -- First year (n = 84) 23 Second year (n = 80) 7 Chi-aquare = 11.14, df = 3, P<.05 Accommodator Number % 27.4 8.8 Diverger Number % 12 10 14.3 12.5 Learning styles Converger Assimilator Number % Number % 20 31 23.8 38.8 29 32 34.5 40.0 students in the second year of the sample. A statistically significant relationship was revealed by the chi-square analysis (Table V), when learning styles of the first-year students were compared to the second-year students' learning styles. The learning styles of the first-year students were spread over the four learning styles, in contrast to those of the second-year students, whose distribution predominantly fell into two of the learning style categories. Chi-square analysis revealed a statistically significant (P<.05) relationship between learning style type and level in an anesthesia program. Discussion The data indicated that all four learning styles were represented in the sample, with 61 subjects (37.2%) demonstrating a preference for the assimilator style. Students whose dominant learning style is assimilator tend to display abstract conceptualization and reflective observation. They are inclined to excel at inductive reasoning and the creation of models and theories. They tend to be goal setters and systematic planners. They have the ability to assimilate disparate observations into integrated, rational explanations. This learning style is focused less on people and more focused on ideas and abstract concepts.' 6 The converger learning style occurred in 51 nurse anesthesia students (31.1%). Convergers' strengths lie in their ability to solve problems, make decisions, and use deductive reasoning. The accommodator learning style occurred in 30 nurse anesthesia students (18.3%); accommodators' major strengths lie in doing things, getting involved, taking risks, and getting things done.' 1 The least preferred learning style, diverger, was identified in 22 nurse anesthesia students (13.4%). Divergers' strengths are reported to be imagination and understanding people; a diverger could be described as a "people person."' 0 The identification of the assimilator as the predominant learning style in nurse anesthesia students is in contrast to the results reported by Ramsborg and Holloway in 1985, who concluded that the predominant learning style for the firstand second-year anesthesia students was the accommodator. In 1981, the accommodator learning style was reported to be the predominant style among anesthesiologists and anesthesia residents. 171 The difference in the identification of a predominant learning style for nurse anesthesia students may be the result of a variety of factors. Currently, a baccalaureate degree is required for admission to anesthesia programs, but it was not an admission requirement in the early 1980s. The literature suggests that baccalaureate preparation may have influenced the students' learning style preference. 10 This study may reflect the trend toward placement of nurse anesthesia programs in a master's curriculum. This study included only MSN anesthesia students who are exposed to an environment in which practicing anesthetists are being encouraged to pursue higher education. The two studies that yielded contrasting results were conducted in the early 1980s and may not reflect the trend toward placement of anesthesia programs in the master's framework. The differences in these findings may be related to the trend toward higher education for students and practicing anesthetists. The normative profile study of the LSI concluded that nursing students demonstrated a preference for the accommodator style.' 0 However, nurse anesthesia students may not fit this category, because their backgrounds put considerable emphasis on the sciences and technical skills. The majority of nurse anesthesia students (53.2%) had between 1 and 4 years of critical care experience that enhances technical skills. Differences in learning styles have been reported when comparing undergraduate and graduate students in the same major. 8 Anesthesia students may not fit this typical picture, because they are required to have work February 1994/ VoL 62/No. 1 43

experience as well as an undergraduate degree before entering the graduate program. There were no statistically significant relationships between learning styles and gender. This finding is in contrast to the normative profile study on the instrument. 8,10 "15 Gender has not been a variable that has been frequently investigated; therefore, it is difficult to compare and contrast results. The studies with contrasting results were conducted in the '70s and '80s, which may not reflect the attitudes of the student population of the '90s. This study revealed a statistically significant relationship between length of time in a program and learning style preference. The learning style types of the first-year students were distributed over the four learning styles. The second-year students' learning style preferences were predominant in two learning style types, convergers and assimilators. There was no relationship between age or years of critical care experience before entering an anesthesia program and learning style preference. This suggests that experience in the practice of nurse anesthesia might be responsible for the predominant learning style preference held by the second-year students. These findings appear to be consistent with ELT; that is, individuals assimilate the learning styles of the profession to which they are exposed, and learning styles are based on experience. 10 The second-year students had greater than 12 months' experience in nurse anesthesia compared to the first-year students, who had less than 12 months' experience. Perhaps, in accordance with ELT, the learning styles of these students may have changed toward one of the predominant styles, based on their experiences in the program and their exposure to practicing anesthetists for whom higher education may also be an influential factor. Implications for education The AANA has a goal of opening new programs and expanding existing programs into the master's framework. The identification of a predominant learning style and the statistically significant relationship between learning styles and level in an MSN program may enhance the design of curricula for the new or expanding programs that are moving to the graduate level. Appropriate teaching strategies may be used to enhance students' ability to learn didactically and clinically. Faculty may be able to make adjustments to meet students' needs by altering their teaching approach to accommodate the types of learners who enter their programs. Students may be able to make adjustments in their learning styles if they have a better understanding of how they learn best. The identification of assimilator as the predominant learning style among nurse anesthesia students enrolled in MSN programs has important implications for educators, because abstract conceptualization and reflective observation are the dominant characteristics of this style. Those who have abstract conceptualization as a dominant ability put a priority on thinking and are concerned with general theories that use logic, ideas, and concepts; their concern is with understanding general areas rather than unique, specific areas. 16 Such individuals learn best by thinking and prefer to act on the basis of their understanding of a situation. They see the instructor as a communicator of information, with preferred learning situations being clear and well structured when presented with new ideas These individuals prefer to read theories and to study alone. 10 Reflective observation as a dominant learning ability is manifested in the individual's ability to focus on understanding the meaning of ideas and situations by observation. Such individuals emphasize understanding rather than practical applications. 16 They are concerned with understanding how things happen rather than what works in a particular situation. Their emphasis is on reflection and understanding things, as opposed to action. Reflective observers have a tendency to rely on their own thoughts to form opinions after observation as a dominant ability. Their preferred learning situation involves lectures, where the individual may take an observer role to see different perspectives. These individuals prefer objective tests, with a dominance in reflective observation, but they may have difficulty with practical applications or applied solutions. 10 Efforts directed at structuring lectures to guide these individuals through the critical thinking process may be helpful in enhancing their ability to make applications. Discussions have also been recognized to give students the opportunity to apply principles, concepts, and theories and, in the process, transfer their learning to new and different situations or practice the use of critical thinking. 8 The utilization of journal clubs in nurse anesthesia programs might be an excellent way to enhance critical thinking and promote focused discussions. Several medical schools have developed a special problem based learning curriculum which emphasizes small group discussions to enhance critical thinking, problem solving abilities, motivation, and the students' recognition of learning needs. 19 ' 20 The number of MSN programs has approximately doubled since this study was conducted and 44 Journal of the American Association of Nurse Anesthetists

the trend toward all graduate level anesthesia programs is now at 85%.21 Utilization of this data may be extremely valuable to promote problem solving and critical thinking as we rapidly approach all graduate level programs. REFERENCES (1) Annual Report of the President, 1989. 56th AANA Annual Meeting in Boston, Massachusetts. Special Supplement. AANA NewsBulletin. 1989;43(10):11-15. (2) Jordan L, Maree S. Challenges facing the education of nurse anesthetists. AANA Journal. 1988;56:305-307. (3) Barris R, Kielhofner G, Bauer D. Learning preferences, values, and student satisfaction.jallied Health. 1985;14:13-23. (4) Christensen M, Lee C, Bugg P. Professional development of nurse practitioners as a function of need motivation, learning style, and locus of control. Nurs Res. 1990;28:51-56. (5) West RF. A construct validity study of Kolb's learning style types in medical education. Journal of Medical Education. 1982;57:794-796. (6) DeCroux VM. Kolb's learning style inventory: A review of its applications in nursing'research. JNursEduc. 1990;29:202-207. (7) Laschinger HL, Boss MW. Learning styles of nursing students and career choices. fadv Nurs. 1984;9:375-380. (8) Kolb DA. Learning Style Inventory: Technical Manual. Boston, Massachusetts: McBer. 1976. (9) Ramsborg GC, Holloway RL. Learning style analysis: A comparison of CRNA clinical instructors and student nurse anesthetists. AANA Journal. 1985;53:439-444. (10) Smith DM, Kolb DA. User's Guidefor the Learning Style Inventory. Boston, Massachusetts: McBer. 1986. (11) Arndt MJ, Underwood B. Learning style theory and patient education. Journal of Continuing Education. 1989;2:28-31. (12) Marshall JC, Merritt SL. Reliability and construct validity of alternate forms of the learning style inventory. Educational and Psychological Measurement 1985;45:931-937. (13) Marshall JC, Merritt SL. Reliability and construct validity of the learning style questionnaire. Educational and Psychological Measurement. 1986;46:257-262. (14) Sims RR, Veres JG, Watson P, Buckner KE. The reliability and classification stability of the learning style inventory. Educational and Psychological Measurement. 1986;46:753-760. (15) Merritt S, Marshall JC. Reliability and construct validity of ipsative and normative forms of the Learning Style Inventory. Educational and Psychological Measurement 1984;44:463-472. (16) Kolb DA. Experiential Learning as the Source of Learning Development. Englewood Cliffs, New Jersey, Prentice-Hall. 1984. (17) Baker JD, Marks WE. Learning style analysis in anesthesia education. Anesthesiology Review. 1981 ;8:31-34. (18) DeYoung S. Teaching Nursing. New York: Addison-Wesley Nursing. 1990. (19) Kaufman A. Commentary on "Making doctors-a new approach." Teaching and Learning in Medicine. 1989;1:67. (20) Barrows HS. Problem-based, self-directed learning. JAMA. 1983;22:3077-3080. (21) Council on Accreditation of Nurse Anesthesia Education Programs. Official Council Listings. AANA Journal. 1993;61:630-638. AUTHOR Linda Sherbinski, CRNA, MSN, received her bachelor of science in Nursing from Alfred University, New York, and her master of science in Nursing Education from Duquesne University, Pittsburgh. Pennsylvania. As a graduate student, she was the recipient of a research award grant and excellence in nursing, scholarship and professional commitment award from Sigma Theta Tau, Epsilon Phi Chapter. She is a graduate of the University Health Center of Pittsburgh School of Anesthesia and has held university faculty positions in an anesthesia program. Ms. Sherbinski is currently an anesthetist at Memorial Medical Center, Springfield, Illinois, and a clinical instructor for the Bradley/Decatur Nurse Anesthesia Program. ACKNOWLEDGMENTS The author gratefully acknowledges the support and guidance of Kathleen Gaberson, RN, PhD, throughout the entire research process. The author also would like to acknowledge the research award grant from Sigma Theta Tau, Epsilon Phi Chapter. February 1994/ Vol. 62/No. 1 45