Journal of Nursing Education

Development of Strategies to Identify the Learning Needs of Baccalaureate Nursing Students

Elizabeth Kelly, PhD, MS, RN



Meeting the learning needs of nursing students today requires a shift in paradigms and the use of multimethods of teaching. This article describes case-control research undertaken to measure the effects of learning strategies on the final grades of first semester junior level, baccalaureate nursing students. The strategies used and how the students learned to use the strategies are presented. Research results did not provide statistical significance because of the small sample size. However, several trends related to ethnicity, student age, and the content of nursing courses were found. These findings suggest the need for further nursing education research in the areas of information processing and the use of learning strategies within academic and clinical settings.



Meeting the learning needs of nursing students today requires a shift in paradigms and the use of multimethods of teaching. This article describes case-control research undertaken to measure the effects of learning strategies on the final grades of first semester junior level, baccalaureate nursing students. The strategies used and how the students learned to use the strategies are presented. Research results did not provide statistical significance because of the small sample size. However, several trends related to ethnicity, student age, and the content of nursing courses were found. These findings suggest the need for further nursing education research in the areas of information processing and the use of learning strategies within academic and clinical settings.

The decrease in student academic success is most disturbing. More students are attending college but a greater number are dropping out because of academic failure. This has brought forth an increased interest in the study of the student learning process. Results from these studies have aided in the development of learning strategies, many of which relate to information gathered from learning style research.

The development and use of learning strategies for nursing students reflects a number of changes occurring within the nursing profession. These changes include a shift to a more diverse student population. Nursing students into the 21st century will represent more ethnic groups. More men will also be entering the profession (Farrell, 1988) which will also be impacted by the demographic shifts taking place in this country. Carty and Bednash (1988) add that the new nursing students bring with them a desire for more autonomy and a different career orientation. They will also have the challenge of expanding technology and a changing health care delivery system.

Hegyvary (1992) wrote that the current diversity the profession is experiencing can provide an opportunity for developing new ways of thinking within nursing education. No longer can narrowly defined, dichotomized prescriptions of theory in nursing education be regarded as the standard. What is needed (Hegyvary, 1992) are multimethods, multiparadigm approaches to developing and implementing nursing education theory.

The study presented here was conducted using multimethods and multiparadigms. The KoIb Learning Style Inventory (LSI) (1985) was used to determine the styles of 57 baccalaureate nursing students in a case control study. Kolb's four learning styles are diverger, assimilator, converger, and accommodator. The diverger learns through concrete experience. The strength of this learner is problem-solving, decision-making and practical application of ideas. If used too much the diverger cannot make decisions. When used too little, ideas and problems are not recognized.

The assimilator learns through reflection and observation. This learner is best with a wide range of information that the student puts into concise, logical form. If used too much, the assimilator develops no practical application. When used too little, this person is unable to learn from mistakes.

The converger learns through abstract conceptualization. These students are best at finding practical uses for ideas and theories. If used too much, the learner makes hasty decisions, When used too little, a lack of focus and scattered thoughts can result.

The accommodator learns through activities. These students are task oriented and learn through trial and error. If used too much, meaningless activities develop. When used too little, work is not directed toward goals and plans become impractical.


The development and use of learning style information included research into learning strategies. The change in student mix has caused this research to take place within academic settings, beginning in the late 1970s.

Smith and Haverkamp (1977) studied how learning occurs in adults and explored the meaning of learning and its implication for adult education in order to expand the theoretical base and guide further research. Ford (1981) reviewed and compared three different research studies that qualitatively measured effective learning. He concluded that a high level of awareness of one's own cognitive process may greatly contribute to successful course performance. With higher levels of awareness, the learner can exercise greater control of the learning environment through curriculum course selection.

Dillon and Schmeck (1983) described the learning styles and learning strategies of college students. They regarded learning style as a predisposition adaptable to learning strategies. Learning strategies, however, are patterns of information-processing activities used to prepare for an anticipated test of memory.

Weinstein and Meyer (1985) presented learning strategies taken from cognitive psychology. The goal of the strategies was to influence the learner's motivational or affective state through the way a learner selects, acquires, organizes and integrates new knowledge. In 1991, Weinstein and Meyer wrote that the field of cognitive psychology investigates how thoughts and mental processes influence other conditions and behaviors. Involved in these conditions are information processing and memory- both long and short term. For information to move along the memory continuum, the information must connect and be organized in the memory file. One year later, Weinstein and Van Meter Stone (1992) found that general models of education that focus only on increasing knowledge did not achieve their goal. This was shown by the increasing rate of students experiencing academic failure. They wrote that the difference between a novice learner and an expert learner is not simply that an expert learns or knows more, but that the expert has organized and integrated the knowledge better, using more effective and efficient strategies for accessing and using knowledge.



First semester, junior level, baccalaureate nursing students were offered the opportunity to learn more about their learning styles and their learning needs. Fifty-seven students of the 92 who volunteered for the study were matched with students from one year earlier, for the purpose of analyzing the effects of the learning strategy intervention. All 57 agreed to complete the KoIb LSI (1985) and attend four one-hour meetings, once a week for 4 weeks Each participant signed an informed consent form for release of their first semester final grades to the researcher. The purpose of the research was to measure the effect of combining the information students knew about their individual learning style with the use of learning strategies applicable to nursing education. Using the case-control design, the students from the study groups were matched with controls according to ethnicity, admitting grade point average (GPA), and age. The study subjects were then matched on the three characteristics with students who had taken the same three courses one year earlier (n=57). Final grades from the two groups on the three courses were then analyzed using a paired t-test.

For the combined groups (?7=114) 88% were Caucasian, 9% were Black, and 3% were Asian. By age group, 37% were between 19-29 years, 47% were between 30-39 years, and 16% were over 40 years of age. By admitting GPA, 35% had the lowest GPA range of 3.00-3.39, 39% were in the middle range, 3.40-3.79, and 26% were the highest range, 3.80 to 4.00. The two groups matched the national trend in student nursing population with increasing numbers of ethnic minorities and older students.

Of the 57 students in the study group, 19.3% were diverger learners, 36.8% were assimilators, 19.3% were convergers, and 24.6% were accommodators. This group's learning style differed from Kolb's research of nursing learning styles, that identifies nurses as diverger learners. Other researchers have identified nursing students' learning styles as either diverger or accommodator (Hodges, L.C., 1988; Hodges, S.A., 1988; Laschinger, 1984, 1986; O'Kell, 1988). Only Highfield (1988) found the largest percentage of assimilators.


The learning strategies designed to support each of the learning styles were derived by the researcher from a variety of research sources on learning strategies (Biggs, 1979; Dansveau et al., 1979; Dillon & Schmeck, 1983; Miller, Alway, & McKinley, 1984). The strategies were selected to relate to the strengths of each learning style, to be interactive with the other learning styles and to connect with the overall circular learning process. This learning process was designed to show students that academic knowledge has active linkage with application knowledge found in the clinical area. The purpose of connecting learning styles with learning strategies to support academic and applied knowledge was to outline, for new nursing students, the types of learning processes they would be experiencing each semester. An educational psychologist, a specialist in learning strategies, was consulted for theory and applicability of the strategies to the learning styles. Following are the strategies:

For the diverger the SQ3R system (survey-questionread-recite-review) was used (Dillon & Schmeck, 1983). This strategy directs the learner to survey the assignment by first using the broad topic outline of the reading. Then the student raises questions about the information before beginning to read the material. This is followed by a brief recitation of what the student read. Finally the student reviews the reading to seek answers to the questions he/she had raised. This strategy works especially well with classroom assignments.

In the clinical area, the student would gather as much data as possible about the patient and the patient's condition, question what information is available, seek other information if needed and then review the additional information in light of the first questions raised. Periodic review of all information in either the academic setting or in the clinic keeps the student alert to changes in patient information.

For the assimilator, the strategy selected connects with SQ3R. Connecting the strategies shows the unity and flow of information, and provides a more stable sense of learning for the student, rather than a division of information for each portion of the circular learning process. Questions from the SQ3R served as the bridge to the next learning strategy, MURDER. This acronym stands for mood, understanding, recall, digest, expand, review. This strategy begins by developing a mood of relaxation for learning, with the goal of understanding the important or difficult ideas extracted from the concrete information. To support the development of understanding, use of recall of previous information is developed. Then the new as well as the previous information is digested. Expanding that information through more question-answer combinations is undertaken. Finally, a review of the information for possible errors or mistakes completes the process (Dans veau et al., 1979).

In the clinical area this learning strategy is useful because it allows the student the opportunity to reflect on the concrete information that has been collected. Through reflection, the learner can recall previous experiences and question if the information obtained needs to be expanded, thereby avoiding hasty decisions.

For the converger (Biggs, 1979) SOLO (structure of observed learning outcome) was selected. From the MURDER strategy the expansion of information occurs by connecting to the outcome components of the total learning process. This strategy has five parts: prestructure, unistructure, multistructure, relational, and extended abstract, which adds depth to understanding. At the prestructure, no relationship is identifiable for the learner between the task and the patient. An example is learning to give a patient a bath. At this level the student focuses on completion of the task only. Concern for the patient or what the bath may mean to the patient is not considered. At the unistructure level, the student identifies one relevant item from the task that relates to the patient. In the example, the student at this level wants to keep the patient clean. At the multistructure level, the bath becomes relevant to several possible needs of the patient, cleanliness, skin care, privacy. At the relational level, the learner identifies and relates a large number of relevant factors about the patient and the bath, such as skin condition, psychological needs, self-care needs, and independency-dependency for the patient. While the student is processing all of this information, the learning capacity to remove conflict between several issues emerges. The student develops a concept of the total task, i.e., bathing, as it applies to the patient. The final level of SOLO is extended, abstract. This is when theoretical issues emerge. This would not be a useful learning tool for a beginning nursing student.

Using this learning strategy in the clinical area would expose the student to the various levels of information needed to begin outlining the level of care needed.

With the accommodator, a strategy that connected with the deep processing of information learned was used (Miller, Alway, & McKinley, 1984). It is characterized by taking time to look for differences and between the information and the task, then converting the main ideas and the supporting details into a plan. From this depth of understanding, a plan of action can be set forth. Finally, before action, critical analysis is needed to compare and contrast the various ideas that relate to the details of the situation. This is all undertaken before a systematic and detailed organization of the plan and its implementation is begun. Using this strategy in the clinical area involves the developmental processing of a plan of care for a patient.


At the first meeting of each group the LSI was completed and learning style results were explained. These results were presented as a guide for what the individual could use in relation to his/her learning needs as a nursing student. At the end of the first session students were offered guidelines based on questions from each of the learning styles (Figure 1). These guidelines formed the bases of journals the students were encouraged to keep. Writing journals, using the circular pattern of thinking, encouraged the students to begin to think and draw on their learning experiences. The entries were voluntarily shared by the students at the beginning of the following sessions.

During the second session, students were offered examples of how their learning style information could be related to the learning strategies, useful in both the academic and clinical experiences. The students were also offered a diagram of how they could adopt the circular model to their academic assignments. Examples were also taken from their assigned readings. In addition, learning strategies were related to test-taking skills and study habits (Figure 2).


FIGURE 1Learning Experience Journal


Learning Experience Journal

Because students expressed a great deal of anxiety about their forthcoming clinical experiences, the third session was spent using examples of patient-related tasks they would undertake. Examples such as bathing, range of motion, and taking vital signs were offered to show how knowing one's learning style, its strengths and weaknesses, could contribute to good, sound clinical judgment and decision-making. A guide to the clinical experience based on the Kolb circular model was offered the students at the end of the third session (Figure 3).

The students were instructed to bring a list of questions, experiences, opinions that they had derived from the three previous meetings to the fourth meeting. During the last meeting students focused on the questions they brought as well as case studies of some of the issues and problems they might face academically and clinically. How to read and answer test questions and test-taking issues were again discovered to concern the students. Knowing how to use the nursing process was the focus of the clinically related questions.


At the end of the study, grades from the two groups were analyzed using a paired t-test. Results revealed that there was no significant difference in the final grades of the students with highest GPAs in either group. The differences in groups by final grade appeared when ethnicity and level of admitting GPA were considered, but the difference was not statistically significant because the number of students was too small (n=14). One course, Fundamentals of Nursing, proved to be a measure of success or failure for the young ethnic minority students (Black and Asian) with the low GPAs. Students of ethnic minorities, admitted with low GPAs who were successful in the course work, had higher scores in the three classes than did their matched controls.

There was a difference among the grades of the three courses: Pharmacology, Introduction to Nursing, and Fundamentals of Nursing. There was not a statistically significant difference between the two groups in the first two courses. In Fundamentals of Nursing, however, the control group had a higher GPA than the study group (case X=84.9; control X=86.7). A possible explanation is that the Fundamentals course may require a different type of learning. It is the first nursing course in the curriculum that concentrates entirely on the application of nursing care to a patient with a particular health need related to the human physiological processes. The course also requires a nursing response to caring for that patient. Test questions reflect the nursing response to situations and require general knowledge to be applied to specific situations rather than simple recall of facts upon which the first two courses were focused.

FIGURE 2Guidelines for a Nursing Course Learning Strategy


Guidelines for a Nursing Course Learning Strategy

FIGURE 3Learning Strategy Guidelines for Clinical Experience


Learning Strategy Guidelines for Clinical Experience

Knowing that the study group had a majority of reflective thinkers may offer an explanation for the difference in the course results between the two groups. Reflective thinkers' strengths are in defining problems and in planning. Their weakness is in practical application. The Fundamentals course tests for this. This issue clearly needs further study. Further conclusions cannot be drawn from this study because there was no information concerning the learning styles of the control group.

Six students who participated in the study made grades lower than C in the Fundamentals course. The six students were ethnic minorities, Blacks or Asians, and had the lowest range admitting GPAs. This sub-group was also younger (X=25 years) than the mean age of the study population (X=31.7 years). Williams (1988) found that age was a positive path coefficient for students who transfer to a nursing program and that the older students were the more likely to complete the program.


The results of this study indicate that nursing education deals with several different education issues. Two national nursing organizations have recently addressed these. The National League for Nursing (NLN) (1993) outlined a "vision of nursing education." The American Association of College of Nursing (AACN) (1993) issued a "nursing education agenda for the 21st century." One issue addressed by the AACN is academic failure of students who have had previous academic success. Another issue refers to non-traditional students related to personal history, personal characteristics such as age or cultural diversity.

The NLN's (1993) vision for nursing education calls for a "reorientation of professional education and innovative response to problems rather than mastery of archaic content." (p. 9). Weinstein and Van Meter Stone (1992) would support this statement. Their research found that general education models that focus only on increasing knowledge are not achieving their goal. This has been supported by the increasing rate of students experiencing academic failure. They wrote that knowledge develops in various stages. One person does not simply know more than another. Rather, they suggest, knowledge must be organized and integrated. This can be achieved through more effective and efficient strategies for accessing and using knowledge.

A starting point for the "innovative response to problems" is to identify, in depth, who is entering the nursing profession. Andrews (1992) wrote that one-fourth of the US population will represent culturally diverse groups by the end of the 20th century. These will be the future nursing students as well as the population who will receive a large portion of the nursing care. Seidl and Sauter (1990) wrote that the new non-traditional nursing student can be identified not only by age, sex, and experience in higher education, but also by learning style and study habits. Johnson (1989) suggested that one way to successfully meet the learning needs of culturally diverse nursing students was through consideration of learning style. This means that the student would have a greater understanding of her/his own learning needs. This new perspective would encourage the student to relate his/her learning style to the learning approaches needed in nursing. The result would be more active student involvement in their learning. Nursing faculty could facilitate students' learning by undertaking academic and clinical teaching that accommodate students' learning styles. Garcia-Otero and Teddlie (1992) found that students who knew their own learnifig styles and how they processed information had more! confidence to begin transferring their knowledge to clinical practice.

Hailett, Hughes, Atkinson, and Williams (1993) reported that nursing introduction courses should assess the learning styles of beginning nursing students. Both the teacher and students can use this information to enhance each student's learning experience. Hailett and colleagues (1993) also found that there was a relationship between course GPA and learning style. Their research found that the accommodator learning style had the most difficulty with the courses. They suggest that accommodators receive study group assistance or tutoring to enhance the chance of successful completion of the program.

Laschinger (1992) suggested that a reflective learning strategy be included more in beginning nursing courses in order to enhance abstract learning. Hailett and colleagues (1993) likewise suggest that more abstract concepts and reflective observation skills be introduced early into the nursing curriculum. Their suggestions parallel the strategy sessions presented in this research. The reflection portion of circular thinking is a part of the assimilator learning process; the abstract portion is similar to the converger process.

In keeping with strategies that develop the "art of thinking" (NLN, 1993, p. 9), Curry, Wergin, and Associates (1993) argued the importance of using reflective thinking. Borrowing from Schon's (1987) work, their writings suggest several different strategies that encourage reflective thinking, for example questioning. Using case studies to uncover various aspects of patient care involves reflection and analytical thinking. Wales, Nardi, and Stager (1993) used a guided design to develop reflective learning strategies. Using case studies or scenarios, the teacher and students work through various levels of information. The authors found that this also involved the students more in their own learning.

In addition to reflective thinking found in this study, a learning log was used. The students were asked to keep a log of their personal learning experiences throughout the semester. They were also offered outlines of how to use a circular thinking pattern in the form of a log for their academic and clinical work (Figures 2 and 3). Sedlak's (1992) research with first semester students in the clinical setting also included the use of a log. Results of the log were analyzed to determine how the students were learning.

Using the log for both the classroom and the clinic helped to overcome the separation of the two learning environments. Doll (1993) suggests that the separation of curriculum into classroom/clinical, or theoretical/practical, be replaced by a curriculum that pays attention to complexity, self-organization, and multiplicity. McCaugherty (1991) combined classroom with clinical experience using a reflective model. Use of the model revealed that nursing students were more active in their educational process and demonstrated more knowledge and confidence when giving patient care.

Trigwell and Prosser (1991a & b) reported two studies that looked at nursing students' perceptions of their learning. The first study of (N=122) first year nursing students found that students' perceptions of the nursing courses had more influence on the students' course outcome than did the use of a learning strategy. The second study considered the students' perceptions of the learning environment. Results of this study indicated that a student's perception of superficial teaching correlated with a heavy workload, rote learning, and a learning environment that lacked encouragement, stimulation, or responsiveness to students. Sherbinski (1994) and Sedlak (1992) suggest that nurse educators need to be more imaginative and creative in their use of learning and teaching strategies.


Whether the instructor employs knowledge of a student's learning style, reflective thinking, or the use of learning logs, learning strategies for current nursing students appear to be highly effective in terms of academic success and combining or linking classroom and clinical learning experiences. However, further research in this area needs to focus on beginning nursing students. The students should then be tracked as they progress through the program. Tracking the students would provide continuity of information about how students learn different types of materials during different learning situations. Such longitudinal studies could also provide important information for the development of a variety of teaching strategies related to the student's progression through the various learning experiences. Implications for this approach point toward making learning both situational and life long. Resources with which to guide this goal may be found in such publications as the AACN (1993) position statement.


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