Wen designing courses for distance education, ducators face not only the usual challenges of ccommodating learner preferences and choosing appropriate strategies for helping students understand course content, but also the necessity of choosing suitable distance delivery methods. For distance education to be effective and learning experiences to be meaningful, it seems reasonable to match delivery methods with student preferences and course content.
In recent years, a broader range of delivery methods, such as synchronous and asynchronous computer-based technologies, video teleconferencing, CD-ROM, and satellite are being combined with more traditional printbased, audio tape, and audio teleconferencing. As a result, distance educators and learners have more choices depending on personal inclination, experience, and technical availability. For example, persons comfortable with computers may choose computer-based methods in contrast to novice computer users who may still fear technology. Audio conferencing might appeal to those who enjoy listening to and interacting with others verbally in real time, while video teleconferencing could suit learners who value a visual dimension.
Using learning approaches based on students' learning preferences, need's, and Ufe styles, and choosing delivery methods that are more suitable for certain content makes sense, although it is challenging. Teaching interactive skills through discussion and practice, or factual material through individual study and repetition are examples. Unfortunately, there are few studies comparing students' learning styles with general preferences for learning content using distance methods. The purpose of this paper is to present a study that assessed distance learning style preferences, delivery preferences for different content, and achievement of students enrolled in a primary health care nurse practitioner program (PHCNP) in Ontario, Canada.
DESCRIPTION OF THE PROGRAM
The PHCNP program, funded by the Ministry of Health in Ontario in 1995, comprises five courses leading to a post-baccalaureate certificate. It is delivered though a consortium of all 10 provincial universities that offer nursing education. The focus of this intensive 12-month practice-based program is to prepare registered nurses (RNs) to assume expanded roles that include diagnosing and treating common illnesses, ordering specific diagnostic tests, and prescribing medications. Nurses living in rural and urban regions of the province may complete the program on a full-time or part-time basis in English or French.
Delivery methods used in the program include printbased modules, audio teleconferencing, video teleconferencing (used primarily with French offerings), audio and video tape, Internet-based computer-conferencing, and CD-ROM. One university in the consortium is responsible for distance delivery of the theory portions to all others. Face-to-face tutorials and clinical practice placements occur at students' home universities in three of the five courses (Health Assessment and Diagnosis, Therapeutics, and Integrative Practicum).
Although literature on distance education is extensive, there is, as noted previously, a paucity of research that compares multiple delivery methods and student learning preferences in one distance delivery program. In most studies, one or two technologies have been described: audio teleconferencing (Biner, Welsh, Barone, Summers & Dean, 1991; Cragg, 199Ia), video teleconferencing (Shomaker & Fairbanks, 1997), computer conferencing (Andrusyszyn, Iwasiw & Goldenberg, 1998; Cragg, 1994; Schutte, 1996), CD-ROM (Andrusyszyn et al., 1999), and print-based or correspondence (Cragg, 199Ia).
In Carter's (1996) review of distance education literature about media, technologies, and their effect on student learning, most distance educators did not believe technological methods of course delivery influenced learning. Other studies have shown no significant differences in student results among technologies (Russell, 1999). Apparently, decision-making about which technology to use in distance learning should involve not only technological considerations, but personal choice, values, and beliefs as well (Bates, 1995).
Greater satisfaction and achievement was evident in Biner et al.'s (1997) investigation of undergraduates (ra = 288) when fewer students participated in the audio teleconferencing groups. Shutte (1996) found achievement scores of undergraduate social statistics students randomly assigned to a virtual classroom to be 20% higher than in those who studied face-to-face. In Cragg's (1994) study of seven post-RN students' experiences with asynchronous computer-conferencing, class discussions were high quality once the technology was mastered. The medium fit students' learning and life style needs. Similarly, Andrusyszyn, Iwasiw, & Goldenberg (1998) considered students' work excellent after they had completed a portion of their course using Internet-based computer-conferencing. Students described the medium as liberating, empowering, and convenient.
Cavanagh and Coffin (1994) reviewed research from the last 20 years, much of which involved nurses, on matching learning preferences and teaching styles in traditional environments. They concluded that while only some investigators found improved motivation for learning occurred when matching teaching methods with learning preferences, multiple approaches to teaching and learning theory and practice was advisable.
Finally, preferences for global and analytic ways of processing information were surveyed in a sample of 35 senior baccalaureate nursing students (Van Wynen, 1997). Diverse methods of processing information from highly global (66%) to highly analytical (34%) were reported. The responses of 50% of the group indicated they learned best by listening, while the remaining half "demonstrated a mixture of tactile, kinesthetic, and visual perceptual strengths" (p. 46). In addition, 40% responded that they liked to learn with their peers, and 60% preferred to work in pairs or individually. Van Wynen recommended teaching methods to complement learning styles, since academic achievement purportedly increases when students are taught in ways that are congruent with their cognitive processing style.
In summary, there is little literature that addresses the influence of multiple delivery methods on learning style preferences, delivery preference for content, and achievement. The purpose of the study, therefore, was to determine if there was a relationship among student choice of distance delivery methods, their preferred learning style, program content, and achievement.
A descriptive correlational design was used to examine the relationships among learning preference, preference for delivery method, and academic achievement. À questionnaire was designed by the researchers, each of whom has expertise in distance education, thereby assuring content validity. During its development, a focus group was held with four students in the program to identify areas of confusion or difficulty. Subsequently, the questionnaire was revised and pilot-tested with 25 students.
The questionnaire included items about demographics and how participants preferred to learn information. The latter questions were based on common learning-style categories. Twelve learning preferences were included involving a combination of bipolar and paired comparison item formats. Single bipolar items were used to determine preference for: (a) considering the big picture versus focussing on the details; (b) having a learning plan set by others versus setting one's own learning plan; and (c) focusing on theoretical concepts versus focusing on concrete examples. Additionally, three paired comparison items addressed preferred learning group size (on my own, in smaller groups, in larger groups). As well, six preferred styles of processing new learning were matched in a paired comparisons rating format (i.e., hearing, reading, discussing, observing, doing, and reflecting), and placed on a bipolar scale with other relevant learning preferences that resulted in all possible combinations of pairs. The score for a hearing-learning style would be the mean of the five comparisons between: (a) hearing and reading; (b) hearing and discussing; (c) hearing and observing; (d) hearing and doing; (e) and hearing and reflecting. This scoring process was repeated for each of the other learning preferences.
The questionnaire included additional items about the participante' previous experience with seven distance delivery methods and whether they had "adapted or converted" any of these to suit their personal learning needs while Ui the program. Respondents were also asked to rate 28 program content areas based on how they "would have liked" to learn the material, given what they knew about various delivery methods. Each content area was considered against seven distance methods using 5-point rating scale ranging from highly undesirable (1) to highly desirable (5). Narrative comments throughout the questionnaire were encouraged. Researchers also sought permission to access students' grades by requesting inclusion of student numbers from those who agreed. Following analysis of the questionnaire data, interviews were conducted with 6 randomly selected respondents using a semistructured, open-ended, interview guide to obtain reactions to and interpretations of results.
The nonprobability, convenience sample was drawn from 125 English speaking students enrolled in one or all of the five courses of the PHCNP program from September 1996 to August 1997. The 4 students who participated in the focus group during the development of the questionnaire were not included in the final mailing. AB there were no major changes between the pilot test and the final versions of the questionnaire, 19 responses (of 25 in the pilot-test) were included in the final sample. A total of 86 (71%) questionnaires were analyzed. Return of the questionnaires indicated consent. Student numbers were voluntarily provided by 59 individuals (68.6%).
The majority of participants were female (96.3%), and most (82.5%) were between the ages of 31 and 50. The mean number of years since completing their highest (pre-NP program) level of education was 11.21 with a range of 6 months to 29 years. Nearly two thirds lived less than 50 kilometers from their home university, but 25% resided 100 or more kilometers away. Of the participants, 58 (69% of valid responses) indicated they were studying part-time while 26 (31%) were full-tune. In addition to their course work, 83 (96.5%) participants indicated having additional work, family, or other responsibilities.
Except for print-based and video-taped (VCR) learning materials, participants had little prior experience with the seven distance methods used in the program. They were least familiar with the "high tech" methods, the majority never having used computer conferencing (81.4%), CD-ROM multimedia instruction (67.4%), Internet-based learning materials (69.8%), video teleconferencing (78.8%), and televised courses (68.6%).
Each of the bipolar learning preference items was measured on a 5-point scale with a midpoint score of "3" indicating no preference (can't decide). A series of 2-tailed ttests were conducted to compare the observed mean scores for these bipolar items against an "expected" mean score of 3.0. Respondents showed a statistically significant preference for considering the big picture (M = 3.31, t = 2.02, p <.05) rather than focusing on details. Although there were exceptions, they tended to prefer setting their own learning plans (M = 2.65, t = -2.30, p <.05) and most strongly preferred to learn new things by focusing on concrete examples compared to theoretical concepts (M = 1.99, t = -7.86, p <.001) (Table 1).
Paired comparison items were used to obtain additional measures of learning preferences involving two or more constructs. Estimates of preferred learning group size were determined using paired comparisons between three possible preferences (learning things on my own, in smaller groups, or in larger groups). Reliability estimates were not run because of the small number of items for each learning preference scale. A repeated measures ANOVA showed a significant overall difference between the three group size preferences CF[2,81] = 89.95, p <.001). Bonferroni adjusted post hoc comparisons indicated no differences (p >.05) between the means for learning on my own and in smaller groups. Both of these preferences were found to have significantly larger (p <.001) mean values than the in larger groups (Table 1).
The final six learning preferences, arranged in a paired comparisons format, involved ways that individuals prefer to process new learning (i.e.: hearing, reading, discussing, observing, doing, and reflecting). Cronbach alpha reliabilities for each of the five-item learning preference scales were: hearing: ∝.566; reading: ∝.537; discussing: ∝. 560; observing: ∝.325; doing: ∝.658; and reflecting: ∝.748. A repeated measures ANOVA showed a significant overall difference between the six preferences (F[5,59] = 77.257, p <-001). Bonferroni's adjusted post hoc comparisons indicated that mean scores for hearing, reading, and reflecting did not differ significantly (p >.05); however, the mean scores for remaining variables did differ significantly from these three preferences and from each other (Table 1).
Pearson's correlations calculated to examine patterns of relations between the 12 learning preference items resulted in 22 statistically significant correlations (Table 2). There were significant negative correlations (p <.01) between the three preferred learning group size variables. A preference for learning on my own was negatively related to having a learning plan set for me (r = -.30, p <.01) and positively related to a preference for learning new things by reading them (r = .26, p <.05>. Preferences for learning in smaller groups was positively related to a preference for learning new things by discussing them (r = .31, p <.05), and preferences for learning in larger groups was positively related to having a learning plan set for me (r = .25, p <-05) and learning new things by hearing them (r = .27, p <.01).
Mean Scores for Learning Preference Items According to Group Size, Learning Style, and Sensory Channels
In addition to the relationships indicated above, the three bipolar learning preference items (big picture vs. details; having a learning plan set for me vs. setting my own learning plan; and a focus on theoretical concepts vs. concrete examples) were found to be related to other learning preferences. A preference for focusing on the big picture versus details was negatively related to a preference for learning new things by reading them (r = - .29, p <.05), and positively related to a preference for learning new things by reflecting on them (r = .29, p <-01). Preferences for having a learning plan set for me versus setting my own was negatively related to preferences for theory (r = -.22, p <.05) and a preference for learning new things by doing them (r = -.31, p <.01), and positively related to a preference for learning new things by hearing them (r = .32, p <.01). Finally, a preference for theory versus concrete examples was negatively related to preferences for learning new things by observing them (r = -.26,p <.05), and positively related to preferences for reflecting on new learning (r = .21, p <.05).
Intercorrelations among the remaining set of paired comparison items (hearing, reading, discussing, observing, doing, and reflecting) yielded seven significant relationships, all of which were negative. These correlations were between (a) hearing and discussing; (b) hearing and doing; (c) reading and doing; (d) reading and reflecting; (e) discussing and observing; (f) discussing and doing; and (g) observing and reflecting (Table 2).
Preferences for Delivery Methods
Participants rated each of seven delivery methods according to how desirable they perceived each method was for a specific program content area. Ratings ranged across the entire scale from 1 (highly undesirable) to 5 (highly desirable) (see Table 3 for several examples). Individual respondents preferred different methods for each specific content area, despite similar overall group preferences for the various delivery methods. Many respondents added written suggestions such as "depending on what level of expertise you have achieved, your learning needs (preference) varies. In reality you need each medium at various times."
Repeated measures ANOVA's were calculated on the mean ratings for each content area with preferences for distance methods. In each pair, an overall difference in delivery preferences was found for each content area (all p <.001) indicating that, at a minimum, the highest and lowest ratings for each method differed significantly within each content area. Print-based materials were always rated among the most preferred methods and audio tapes were always among the least preferred. This was also clearly supported in the written comments. However, there was some variability in the ratings for other methods in relation to the content area pairings. For example, video teleconferencing received the highest mean rating for counseling, goal setting with clients as partner, crisis management, interdisciplinary teams and collaboration, political action, and transcultural issues. Similarly, video tape received the highest mean rating for physical assessment.
A Pearson's correlation matrix was produced between learning preference items and preferences for distance methods collapsed across content areas. A partial correlation matrix summarizing the relationships between learning preference items and mean preferences for distance methods is in Table 4. Few significant correlations were found between these sets of items. For example, preferences for audio teleconferences and the use of instructional video tape bore no relationships to the learning preference items.
Correlations Between Learning Preference Hems
Among the few significant findings, overall preferences for computer-conferences were negatively related to a preference for learning new things by observing them (r = -.33, p <.05). Print-based material preferences were negatively related to preferences for discussing (r - -.31, p <.05) and doing (r = -.27, p <.10). Preference for audio tape was positively related to a preference for acquiring new learning by hearing (r = -.42, p <.05), and CD-ROM preferences were positively related to a preference for focusing on the big picture (r = .33, p <05). Finally, video teleconference preferences (a method not used in the current program) were positively related to preferences for focusing on theory (r = .35, p <.05) and learning new things by reflecting on them (r = .29, p <.05).
Six English-speaking women participated in the qualitative interviews. All but one were in the process of completing the program part-time, while one had just finished. Participants received the questions ahead of time to permit reflection before the interview. Content analysis methods were used to analyze the interview data.
Mean Ratings for Delivery Method Preferences by Selected Content Area
Correlations Between Learning Preference Kerns and Mean Preferences for Distance Modalities
Several of these participants mentioned that, without distance delivery, it would have been impossible to complete the program. What was helpful were course materials, computer conferencing and the Internet, CD-ROM, and the interaction and contact with colleagues through so many networks. They suggested that theoretical/factual content (e.g., pathophysiology) could be mastered by reading print-based course materials, CD-ROM, Internet web sites, and through computer conferencing. Reading was thought to be a useful way to learn procedures or skills, but laboratory or clinical practice was essential for mastering these. Tutorial sessions were important for practicing in groups. Print-based materials were considered very useful, providing the foundation for learning in a flexible, portable, and familiar way.
No relationship was found in the quantitative results between choosing print-based material and preference for learning by reading. Most interview participants were surprised at this and suggested there may have been confusion about the question, the interpretation, or the meaning of terms. One participant offered that people may find reading useful, but don't really like doing it. Significant negative correlations were found in the quantitative data between reading and reflecting and between observing and reflecting. This was puzzling to the researchers and interview participants who proposed the following explanations: (a) definitions of reflection varied; (b) volume of reading to be done was overwhelming so participants saw reading and reflecting as separate processes; (c) reading and reflecting happened simultaneously; (d) the question in the questionnaire was misunderstood; (e) the questionnaire was long and by the end, people had been in a hurry to finish; (f) participants may have been linear rather than intuitive thinkers; (g) and reflection may not be a conscious act, while reading and observing are concrete, task-oriented activities.
There is no one answer to the question of what determines preferences for distance education delivery methods. Students make choices about how they prefer to learn based on a combination of life circumstances, approaches to learning, specific types of content and experiences with technology. For many participants who lived considerable distance from their home university, convenience was preferred over distance method or learning style. Self-direction in using materials and timing of learning were also important. Students wanted to choose when to fit learning into their day.
Participants' written comments described a variety of approaches to sequencing of activities not captured in the questionnaire. For example, they suggested an order in which they learned best: read first, then discuss and observe, do, and lastly reflect. These approaches are important to students and teachers for planning the use of materials and timing of activities. In the quantitative data, the majority indicated they learned best by doing. There was a statistically significant difference between doing, observing, and discussing. These approaches also differed significantly from solitary activities such as reflecting, reading, and hearing, which did not differ significantly from each other. This contrasts with Van Wynen's (1997) finding in which 50% of her sample learned best by listening. Program differences may account for this discrepancy, that is: undergraduate baccalaureate versus post-baccalaureate advanced practice. Furthermore, it is logical that these students would prefer doing, followed by observing, and discussing, since they were enrolled in a program to increase knowledge and hands-on skills for a new professional role. Designers of distance education programs at all levels should consider including more opportunities for group activity and hands-on practice. If this is not possible, virtual reality could be considered as an alternative complementary strategy, bearing in mind that preferences for computers were not highly rated by these participante.
The significant negative correlation between: (a) reading and reflecting, and (b) observing and reflecting, was puzzling. This may be explained by the different definitions and interpretations of reflection held by participants. Perhaps the intensity of the program may have contributed to a perceived lack of time for reflection on readings and observations.
The positive relationship between learning new things by reflecting on them and (a) seeing the big picture versus details and (b) preferences for theory versus concrete examples; and the negative relationship between (a) seeing the big picture versus details and (b) reading, seemed reasonable. This is consistent with Van Wynen's (1997) work where 66% of participants were highly global and 34%, highly analytical, One should attend to broader, global, and more contextual issues by taking time to reflect on them, not just read about them, which may or may not include critical reflection. It also underscores the importance of comprehending practical applications of theoretically driven knowledge.
Students' preference for learning on their own or in small groups through discussion was compatible with the following components of the program: self-study, computer-conference discussion, group meetings for audio teleconferences, tutorials, practice labs, and clinical placements (60% of Van Wynen's  participants preferred working on their own or in pairs). As expected, a preference for learning on their own was negatively related to having others determine their learning plan. These were self-directed, adult learners with life and professional experiences, as well as personal and professional learning needs. However, preferences for learning in larger groups being positively related to having a learning plan set for them was somewhat unexpected. Learners may be less comfortable with self-direction when in larger groups. They may expect or be accustomed to a more teacher-centered approach when in larger groups. This could also account for the positive relationship between having a learning plan set for them and learning new things by hearing them. Hearing is an approach to learning that is more customary in large groups. The positive relationship between learning by hearing and learning in large groups was anticipated.
Delivery methods with highest mean ratings for specific content areas were print-based materials, CD-ROM, video teleconferencing, and video tape. Video teleconferencing was preferred over other methods for learning about relationships and goal setting with clients and families, crisis management and counseling, interdisciplinary collaboration, dealing with ethical dilemmas and transcultural issues, as well as political action and health policy. The link with each of these content areas is communication; hence, simultaneously seeing and hearing complex communication in action through video teleconferencing is plausible.
The fact that print-based materials were preferred for content dealing with terminology, critical thinking, research utilization, complementary therapies, health-illness and community assessment, ordering and interpreting lab tests, pharmacotherapeutics, and learning about the nurse practitioner role, could be because of their presence in the literature. However, one should question how the nurse practitioner role could best be learned through print. Discussion through video teleconferencing or computer conferencing would seem more effective. These distance delivery methods support the exchange of ideas and deliberation of issues, processes critical to understanding and embracing the role these students would soon be assuming. Close communication and association with peers undergoing similar professional socialization to a new role "could provide the students with support when they had problems, or be a sounding board for the new ideas they were discovering" (Cragg, 1991b, p. 259).
It was fitting that CD-ROM was perceived as being best suited for health-history taking and pathophysiology. This medium blende sound, graphics, text, animation, and interactive exercises. Although specifically developed for pathophysiology, the delivery method may be equally effective for history-taking. Video tape, most preferred for learning physical assessment, provided opportunities to observe and listen, pause, and repeat (the tape) where necessary. Computer-conferencing and audio tape as least preferred delivery methods deserve explanation. Computer-conferencing was never or rarely used by 95% of participants prior to the program, so it is possible that learning to use the method, when combined with their other learning needs, was too difficult. This method requires some technical expertise and making sense of multiple messages can be overwhelming to new learners (Harasim, 1990). For computer-conferencing to be effective, both educators and students need to be well oriented. User comfort and competence can rise dramatically with use over time (Andrusyszyn, et al., 1999). Audio tape was used primarily by those who had missed a class; however, the quality of the tapes was poor, in addition to which this is a solitary activity, stimulates only one sensory channel, and takes concentration to listen and learn.
An interesting finding was that when learning preferences and chosen delivery method were incongruent, students modified their learning habits to master the content. By using strategies such as printing computer case studies, taping materials, and forming learning groups, they were better able to match material with their learning preferences.
Finally, although one purpose of this investigation was to compare success in courses with preferences for distance delivery methods, the grades achieved by participants in all courses were too similar to identify meaningful differences. These highly motivated students had succeeded in their assignments and exams whether or not the method used matched their preferences.
LIMITATIONS, IMPLICATIONS, AND RECOMMENDATIONS FOR FUTURE RESEARCH
Since this study involved students in only one program who were fairly homogeneous in gender, educational level, and age, many of whom were reflecting on the first use of a given distance delivery method, generalizations can only be made with caution. Follow-up with students experienced in learning through distance education methods, who take courses from professors experienced in facilitating distance learning through various media, might reveal if preferences stem from inherent qualities of the delivery method or from professors' effective use of unique features. Furthermore, investigating students in other programs might uncover additional information about whether these preferences are characteristic of a given program or group of students.
Because computer-conferencing was new to almost all participants, replication of this study should be considered with students familiar with this method and/or who are computer literate. This could differentiate preferences based on content and learning from those related to inexperience with the method and the necessity of mastering the technology as well as course content.
Finally, refinement of the instrument to increase item reliability is needed. In addition, the process of reflection should be clearly defined in order that participants interpret this term similarly. Since students suggested sequences preferred for undertaking learning activities, adding a question about preferred sequencing would be valuable.
The variation in student responses about which methods are appropriate for specific content indicates that no single approach suits all students or all content. Therefore, making provision for student choice of methods should be considered whenever possible. While reliance on a particular approach may be appropriate for a specific learning outcome (e.g., for example, interaction for attitude change, understanding of role, or deliberation about political action), offering several delivery methods acknowledging students' diverse preferences would enhance the learning experience and support academic achievement. When designing courses, practitioners of distance education in particular should consider a mix of delivery methods, specific content, desired outcomes, characteristics of learners, and state of the technology. All of these variables, when incorporated, should facilitate optimum program delivery.
The authors thank the NODE Learning Technologies Network for funding this project; Michael Williams of Assessment Strategies and Femmy Mes for their major contributions to this research; Dr. Dolly Goldenberg for her editorial expertise; and Dr, Dawn Yankou for her helpful consultations.
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Mean Scores for Learning Preference Items According to Group Size, Learning Style, and Sensory Channels
Correlations Between Learning Preference Hems
Mean Ratings for Delivery Method Preferences by Selected Content Area
Correlations Between Learning Preference Kerns and Mean Preferences for Distance Modalities