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Clinical Consultation: How Do We Assess the Learning Style of Our Patients?
Situation: Two patients with diabetic foot ulcers are seen in your outpatient clinic on the same day. Mr. Lane is a 50-year-old patient with type II diabetes mellitus. Ms. Day is a 70-year-old patient with type II diabetes. It is your responsibility to educate Mr. Lane and Ms. Day about proper foot care. Armed with your center’s diabetes educational materials, you enter Mr. Lane’s room. Several minutes later you emerge, happy with the outcome of the session and convinced of Mr. Lane’s understanding of the presented materials. Enthusiastic about your upcoming session with Ms. Day, you collect the same educational materials and begin your instruction. Several minutes later, it is apparent that she is still unclear about the content. You attempt to clarify the information, but she still seems confused. How can you alter your educational session to better address Ms. Day’s learning needs?
Consultation: Sharilyn Hamilton, BSN RN, graduate assistant at the University of Cincinnati, Cincinnati, OH, replies:
“To make the most of teaching in a classroom setting or in less formal encounters with adult learners, it is important to assess the learning styles of the learners” (Dobbin, 2001, p. 4). Learning style has been defined as the way in which a person receives, processes, organizes, and understands information (Marcy, 2001). Individual learning-style preferences determine the way in which information is best absorbed and applied (Kessler & Alverson, 2003). Assessment of each patient’s individual learning style and instructional preferences can provide clues for ways to effectively teach your patient. Instructing your patient with their learning style in mind is considered an effective way of enhancing their learning and maximizing their retention of the material (Kessler & Alverson, 2003; Marcy, 2001).
A variety of tools are available to assess learning styles, including the VARK inventory. Developed by Neil D. Fleming in 1987, the visual, aural (auditory), read/write, and kinesthetic (VARK) inventory employs a questionnaire designed to identify individual learning styles and instructional preferences. The instrument is intuitive and therefore possesses face validity. Portney and Watkins (2000) define face validity as “the assumption of validity of a measuring instrument based on its appearance as a reasonable measure of a given variable” (p. 744). The 13-question, multiple-choice questionnaire can be taken and interpreted online quickly, or printed for administration and manual scoring from www.vark-learn.com. Many universities, including Pennsylvania State University, the University of Akron, the University of Hawaii, and Wright State University, recommend this questionnaire to their students and graduates.
The questionnaire’s stated purpose is to answer the question “How do I learn best?” It helps identify an individual’s learning preferences based on visual, aural, read/write, and kinesthetic modalities, as well as formats that combine two or more of these communication modalities. The results can assist the nurse or teacher in choosing the most effective way to present information. Recognition and attention to individual learning styles does not necessitate alteration of the teaching content or evaluation; instead, it can focus the rehabilitation nurse’s delivery of the material to better serve the patient and enhance understanding (Dobbin, 2001).
Here are strategies and suggestions based on learning style that may assist in developing a teaching plan for Ms. Day, Mr. Lane, or any other patient (Fleming, 2002).
Visual Learning Style
Visual learners prefer pictures, posters, videos, diagrams, graphs, and flow charts. They favor information that is well spaced, with plenty of pictures. When teaching visual learners, the educator should try to replace words with symbols or initials. Encourage the learner to create a picture in their mind of what you are presenting. Ask them to draw a diagram or graph of what you have taught them and to highlight or color-code important information. When appropriate, incorporate “gestures, picturesque language, and word pictures” (Fleming, 2002, p. 5).
Aural/Auditory Learning Style
Aural (auditory) learners respond well to information that is presented verbally, therefore, they prefer their educator to explain the information. Aural learners remember interesting stories, examples, verbal analogies, and descriptive language. When teaching aural learners, educators should encourage discussion and sharing of information. Ask the patient to restate what you have told them. Provide opportunities to talk about what they have learned. In the case of Ms. Day, for example, you could ask her to repeat the reasons to phone her physician. If possible, provide a tape recording of the teaching session for the patient to review at home.
Read/Write Learning Style
Individuals with a read/write preference respond well to written words. Provide their information in list or bullet format, with headings and definitions. Handouts, pamphlets, and manuals are especially helpful to read/write learners. Encourage these patients to take notes while you teach. When the session is complete, ask them to write down what was taught in their own words. For patients with Internet access, suggest helpful Web sites. The American Diabetes Association has an excellent Web site, http://www.diabetes.org , for diabetes information. Also, http://www.healthybodyhealthymind.com has a video, Diabetic Foot Infections, that provides an interesting overview on the topic. The video may be viewed online. Remember, read/write learners believe that talk is good, but a handout is better (Fleming, 2001).
Kinesthetic Learning Style
Kinesthetic learners prefer to attach new learning to a base of what they already know or have experienced. They must integrate what they know with what they are learning to fully accept and use the new information. “To reach them, you need to see things from their perspective and start from where they are” (Fleming, 2002, p. 8). Utilize case studies and real-life examples to illustrate material before tackling theory and practice. For example, talk about a patient who notices redness and swelling on the sole of their foot and what they do to intervene before you begin teaching the actual steps of foot assessment. This example provides kinesthetic learners with an opportunity to test their preexisting knowledge and enhance their confidence regarding mastery of the information. Include samples, photographs, and recipes for solving problems in your presentation and encourage your patient to use all of his senses (sight, touch, hearing, smell, taste). When possible, allow a hands-on approach to learning.
In addition to assessing the patient’s preferred learning style, the rehabilitation nurse also must consider the patient’s literacy level. Literacy can be defined as the ability to read and comprehend written material (Doak, Doak, & Root, 1996). The 1992 National Adult Literacy Survey (NALS), the most recent national survey for which statistics are available, found that 23% of U.S. adults can read a little, but not well enough to read a food or medicine label. Twenty-seven percent of adults can perform tasks such as comparing and contrasting and synthesizing information, but are usually unable to perform higher level reading and problem-solving (National Institute for Literacy, n.d.). These patients are not readily identifiable through casual conversation (Doak, Doak, & Root). “They may be poor or affluent, native born or immigrant, and they are found everywhere” (Doak, Doak, & Root, p. 1).
An effective tool for assessment of literacy level is the Rapid Estimate of Adult Literacy in Medicine (REALM). This test is believed to be more acceptable to patients because it uses medical and health-related words and therefore is less likely to be insulting (Doak, Doak, & Root). The test is easy to administer, and scoring is simple. Doak, Doak, and Root’s book, Teaching Patients with Low Literacy Skills, clearly outlines the use of the REALM test.
Readability of Material
Because many patient teaching and instructional materials are written for those at higher literacy levels, it is necessary for the rehabilitation nurse to assess the readability of presented materials (Doak, Doak, & Root, 1996). There are several valid formulas for assessing readability. The SMOG formula, developed by G. Harry McLaughlin, and the Fry Readability Formula, developed by Dr. Edward Fry, are two helpful models. Doak, Doak, and Root (1996) provide a clear explanation of the use of these formulas. They recommend the Fry formula because it is widely accepted and requires a less-extensive test sample. The formula examines the number of sentences and syllables in a passage to test readability of the information. The information obtained from the use of the Fry formula can guide your development and assembly of proper educational materials.
Patients will master new information “more quickly and easily when they are able to capitalize on their preferred learning styles” (Forrest, 2004, p. 74). Ms. Day is a 70-year-old Hispanic female, born in Mexico and raised in the United States. She speaks English fluently. The REALM test places Ms. Day’s range for reading at between seventh and eighth grade. Use of the Fry formula affirms that the center’s information materials are appropriate.
Administration of the VARK questionnaire reveals that she is primarily a visual learner. A reassessment of the available teaching materials is necessary, based on her identified learning style. Because she is a visual learner, the rehabilitation nurse understands that it is helpful to liberally space the words in the written information and to create a flow chart that illustrates the steps of daily foot assessment using words and pictures. It also would be helpful to have illustrated handouts to express actions to avoid, such as pictures of bare feet and open-toed shoes with an “X” through them. Ms. Day should be asked to organize the information in lists with headings, such as “Daily Foot Care,” “What Not to Do,” and “When to Call the Doctor.” She should be provided with highlighting pens of different colors to color-code the information. Ms. Day’s input while organizing the information will not only increase her understanding, but also will aid the rehabilitation nurse in her evaluation of Ms. Day’s learning. By altering the educational session based on the patient’s learning style, the nurse has maximized the patient’s learning potential (Forrest, 2004).
Rehabilitation nurses are committed to providing high-quality, comprehensive care to their patients. Knowing that patients have a clear understanding of how to care correctly for themselves is essential to this commitment. Many factors contribute to effective learning, such as the patient’s level of health, environment, and readiness to learn. The initial time investment necessary to assess your patients’ preferred learning style will pay off as the educational session progresses and your patients learn and retain the information. Ultimately, “teaching has to be about learning, otherwise, there is only talking” (Fleming, 2002, p. ii).
About the Author
Sharilyn Hamilton, BSN RN, is a graduate student in the Adult Nurse Practitioner program at the University of Cincinnati College of Nursing, Cincinnati, OH. She may be reached at firstname.lastname@example.org.
Doak, C., Doak, L., & Root, J. (1996). Teaching patients with low literacy skills. Philadelphia: J. B. Lippincott Company.
Dobbin, K. (2001). Applying learning theories to develop teaching strategies for the critical care nurse. Critical Care Nursing Clinics of North America, 13, 1–11.
Fleming, N. (2002). 55 strategies for better teaching. Christchurch, New Zealand: Author.
Fleming, N. (2001). VARK: A guide to learning styles. Retrieved October 9, 2004, from http://www.vark-learn.com
Forrest, S. (2004). Learning and teaching: The reciprocal link. The Journal of Continuing Education in Nursing, 35, 74–79.
Kessler, T., & Alverson, E. (2003). Health concerns and learning styles of underserved and uninsured clients at a nurse managed center. Journal of Community Health Nursing, 20, 81–92.
Marcy, V. (2001). Adult learning styles: How VARK learning style inventory can be used to improve student learning. Perspectives on Physician Assistant Education, 12, 117–120.
National Institute for Literacy. (n.d.). Frequently asked questions. Retrieved November 9, 2004, from http://www.nifl.gov/nifl/faqs.html#literacy%20rates
Portney, L., & Watkins, M. (2000). Foundations of clinical research: Applications to practice. (2nd ed.). Upper Saddle River, NJ: Prentice-Hall.