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					 THE IMPACT OF MATCHING CLINICAL ORIENTATION PROCESS

TO PREFERRED LEARNING STYLES FOR NEW REGISTERED NURSES


                                 by

                   Kimberly Carol Long Horton




           A Dissertation Presented in Partial Fulfillment

                of the Requirements for the Degree

                 Doctor of Health Administration




                   UNIVERSITY OF PHOENIX

                           October 2008
            3345051

Copyright 2008 by
Horton, Kimberly Carol Long

All rights reserved




             3345051
    2009
COPYRIGHT © 2008 by KIMBERLY CAROL LONG HORTON

             ALL RIGHTS RESERVED
                                   ABSTRACT

The purpose of this quantitative, quasi-experimental, non-equivalent group study

was to analyze the effect of learning style-based clinical orientation on turnover

rates for new RNs. This study documents an analysis of turnover rates of a cohort

of new RNs who participated in a learning style-based clinical orientation

program. The study also contains baseline information obtained from a cohort of

previously graduated new RNs who participated in a non-learning style-based

clinical orientation program. Both cohorts consisted of new RNs who were

members of graduating classes from both university and junior college registered

nursing programs. The study sites consisted of three Bakersfield, California acute

healthcare facilities.
                                   DEDICATION

       I dedicate this dissertation and this degree to my parents, Raymond B.

Long and Parthenia B. Riley, who were the role models for perseverance and

determination. This is also dedicated to my grandmother, Ms. Pairlee Walton,

who at age 94 is still the epitome of grace and spirituality. I also dedicate this

degree to my husband, Steve Horton, my children (Duane, Teasha), my stepson

(Steven) and my precious grandchildren (Brian, Kimbria, Dameon, Jhourdan and

Garrett) who have supported me through this process and have been a tremendous

source of encouragement. Most importantly, I dedicate this to my Lord and

Savior, Jesus Christ, who sent comfort, when needed, during the turbulent times

so that I might finish this degree and use it to encourage others.
                            ACKNOWLEDGMENTS

       Thank you so much to my mentor and committee chair Dr. Louiseann

(Mickey) Richter, who is a tremendous scholar and wonderful friend. Mickey,

you are the guide of all guides and I would not have been able to do this without

your counsel, support and encouragement. I also thank Dr. Jerry Griffin and Dr.

Brent Muirhead who were willing to serve as committee members and have

provided tremendous guidance and support. I also thank my husband, parents,

children, grandchildren and siblings, who gave me encouragement when I felt like

giving up. I also would like to extend a special thank you to my friends at work. I

can only say that I am fortunate to have such wonderful and encouraging

colleagues. They encouraged me and cheered me on with kind words, and

celebrated my successes. For each of these individuals, I am eternally grateful and

am fortunate to have them in my life.
                                                                                                                         v

                                          TABLE OF CONTENTS

LIST OF TABLES.....................................................................................................xi

CHAPTER 1: INTRODUCTION ..............................................................................1

Background of the Problem .......................................................................................4

Statement of the Problem...........................................................................................8

Purpose of the Study ..................................................................................................9

Significance of the Study ...........................................................................................11

Significance to Leadership.........................................................................................12

Nature of the Study ....................................................................................................13

Research Questions....................................................................................................14

Hypotheses.................................................................................................................14

Theoretical Framework..............................................................................................15

         Multiple Intelligence........................................................................................15

         Learning Styles. ..............................................................................................18

         Learning Styles in Nursing Orientation ...........................................................22

Definition of Terms....................................................................................................23

Assumptions...............................................................................................................25

Limitations .................................................................................................................27

Delimitations..............................................................................................................28

Summary ....................................................................................................................28

CHAPTER 2: LITERATURE REVIEW ...................................................................30

Documentation...........................................................................................................31

Historical Overview ...................................................................................................32
                                                                                                                    vi

          The Concept of Turnover ..............................................................................33

          Registered Nurse Turnover ............................................................................35

          Nursing Shortage Factors...............................................................................38

          Student-to-practitioner transition................................................................... 42

          Adult Learning Concepts ...............................................................................44

Current Findings ........................................................................................................46

          The Concept of Turnover………………………………………................... 46

          Registered Nurse Turnover………………………………………………… 48

          Nursing Shortage Factors…………………………………….......................51

          Student-to-practitioner transition…………………………………………... 54

          Adult Learning Concepts…………………………………………………... 62

          Learning Styles…………………………………………………………….. 65

          VARK……………………………………………………………………… 69

Gaps in Knowledge………………………………………………………... ............73

          Significance of Learning Styles in Nursing Education..................................74

Conclusion……………………………………………………………………. ........74

Summary……………………………………………………………………… ........75

CHAPTER 3: METHOD………..…………………………………………………. 77

Research design……………………………………………………………. ............78

Appropriateness of Design……………………………………………….................81

Research Question…………………………………………………………. ............85

Hypotheses…………………………………………………………………….........85

Population…………………………………………………………………….. ........86
                                                                                                                      vii

Sampling Frame……………………………………………………………. ............88

Informed Consent…………………………………………………………...............89

           Confidentiality……………………………………………………………... 90

Geographic Location……………………………………………………………….. 90

Instrumentation.......................................................................................................... 91

           VARK learning style inventory…………………………………………... 91

Clinical Preceptor Training…………………………………………………….….. 92

Data Collection…………………………………………………………………….. 94

Data Analysis………………………………………………………………………. 95

Reliability and Validity…………………………………………………………….. 96

           Reliability…................................................................................................... 96

           Instrument Reliability…………………………............................................ 97

                      Instrument Validity………………………………………............... 98

           Internal Validity……………………………………………………………. 98

           External Validity…………………………………………………………… 101

Summary…………………………………………..……………………………… 103

CHAPTER 4: RESULTS……………………………………..……………………. 105

Hypothesis..................................................................................................................106

Research Question .....................................................................................................107

Data Collection ..........................................................................................................107

Intervention ................................................................................................................109

Sample Size................................................................................................................111

Demographic Statistics ..............................................................................................112
                                                                                                                     viii

Data Analysis .............................................................................................................113

                 Descriptive Statistics...............................................................................115

Results and Finding....................................................................................................119

Acceptance/Rejection of the Hypothesis ...................................................................126

Summary ....................................................................................................................126

CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS.............................129

Responding to the Problem........................................................................................130

Limitations .................................................................................................................131

Interpretation of the Literature Review......................................................................133

Research Question and Hypothesis............................................................................134

Discussion and Answers to the Research Question and Hypothesis Findings ..........135

Implications of the Study ...........................................................................................136

           Broader Application to Leadership................................................................137

           Social Significance………………………………………………………….138

Recommendations......................................................................................................139

Summary ....................................................................................................................140

REFERENCES ..........................................................................................................142

APPENDIX A: INTERVIEW WITH NEIL FLEMING ...........................................162

APPENDIX B: INFORMED CONSENT

(LEARNING STYLES ORIENTATION GROUP) ..................................................209

APPENDIX C: RESEARCH SUBJECT INFORMATION AND

CONSENT FORM.....................................................................................................211

APPENDIX D: VARK QUESTIONNAIRE .............................................................217
                                                                                                    ix

APPENDIX E: DEMOGRAPHIC QUESTIONNAIRE............................................223

APPENDIX F: PRECEPTOR TRAINING PROGRAM...........................................225

APPENDIX G: PERMISSION TO USE AN EXISTING SURVEY........................236

APPENDIX H: LETTER FROM NEIL FLEMING .................................................237

APPENDIX I: INFORMED CONSENT: PERMISSION TO USE PREMISES,

NAME AND/OR SUBJECT .....................................................................................238

APPENDIX J: TEACHING GUIDELINES..............................................................241
                                                                                                                           x



                                                LIST OF TABLES

Table 1 Summary of Sources in the Literature Review..............................................32

Table 2 Descriptive Statistics for Variables Included in the Study (Still With

Organization and Age)...............................................................................................116

Table 2a Descriptive Statistics for Variables Included in the Study (Ethnicity,

Gender, Degree and Orientation Type) .....................................................................117

Table 3 Cross-Tabulation Results For Orientation Groups and Employment

Status..........................................................................................................................119

Table 4 Parameter Estimates for Logistic Regression (Orientation Type and Still

Employed After Six Months) .....................................................................................120

Table 5 Parameter Estimates for Logistic Regression (Orientation Type and Age)

………………………………………………………………………………............122

Table 6 Parameter Estimates For Logistic Regression (Orientation Type and

Gender) ……………………………………………………………………….. .......123

Table 7 Parameter Estimates For Logistic Regression (Orientation Type and

Ethnicity)….…………………………………………………………………… .......124

Table 8 Chi Square Test Results (Turnover Rates) ...................................................125
                                                                                    1



                         CHAPTER 1: INTRODUCTION

       The nursing shortage has caused significant concern on both state and

national levels. In 2001, the U.S. Department of Health and Human Services

(DHHS) conducted a study identifying the current supply and demand for nurses

and projecting the estimated demand through the year 2030. Based on the data

collected, DHHS suggests that a significant deficit in the number of nurses needed

to care for the current and projected population exists. Additional research

conducted by Spetz (2006) analyzed the state-by-state comparison of nurse supply

and demand. Projections for the supply and demand for nurses in California

reflected a need for over 100,000 additional registered nurses (RNs) for California

to remain comparable to the national average of nurses per capita.

       California ranked 49th in the number of nurses per capita with regard to

actual and projected nursing supply over the next 23 years (Spetz, 2006). In

response to the increasing deficit of nursing personnel, California nursing schools

have increased admissions and directed additional resources toward instruction

and examination preparation methods to improve licensing examination pass rates

(Spetz, 2006). These efforts have been successful in increasing the number of

nurses graduating from registered nursing programs but have been less successful

in adequately preparing new nurses for actual clinical practice. This lack of

preparation has resulted in a 25-50% turnover among new RNs during the first six

months of nursing practice (Hom, 2003; DHHS, 2005). New RN turnover rates

have continued to multiply. This increase in turnover rates has led to escalating
                                                                                       2

labor costs for healthcare organizations and has exacerbated the current critical

nursing shortage (Spetz, 2006; Hayhurst, Saylor, & Stuenknel, 2005).

       In the study analyzing the projected supply of RNs between 2012 and

2030, Spetz (2006) suggests that over 30% of RN full-time positions will be

vacant in the Central California Region, the location of this study. The basis for

this projection is the estimated number of RNs retiring and the number of

anticipated nursing school graduates. Spetz further states that the Central

California Region will continue to face nursing shortages in spite of the increasing

number of new nurses expected to graduate from area nursing programs. In

addition, Unruh and Fottler (2005) suggest that contributing factors to the

shortage are (a) the inability of area nursing schools to produce RNs at a rate

commensurate with the population growth in the area, (b) a decline in nurses’

desire to work in acute care settings, (c) and increased opportunities for nurses in

careers outside of nursing. Twenty five to 50% of nurses who are able to complete

training because of increased enrollment are leaving within the first six months of

practice (Hom, 2003). These factors have resulted in a projected overall RN

shortage of 15,000 by the year 2030, and will have a significant impact on the

overall quality of healthcare services in the region. In order to minimize the

impact of the nursing shortage, significant change must occur in order to mitigate

this phenomenon. Focusing on the manner in which RNs are oriented into the

practice setting after graduation may be the vehicle to accomplish this goal.

       One possible method of addressing this issue is to ensure that individuals

who complete nurse training are well prepared academically and clinically, thus
                                                                                   3

increasing the possibility of retaining them in the nursing workforce (Sims, 2006).

According to Sims (2006), a proactive approach toward individualizing the

learning experience may prove beneficial in improving the overall experience of

employees in the work setting and students in the academic setting. Furthermore,

Baltimore (2006) suggests that consideration of employee learning styles when

developing and implementing orientation programs allows the employee to

progress at a more comfortable pace and creates a more effective learning

environment. A learning style-based clinical orientation program provides a

mechanism that uses preferred learning styles to improve the learners’ retention of

information thus increasing the new RNs ability to provide competent nursing

care. These factors may increase RNs desire to maintain current employment.

       McDonough and Osterbrink (2005) suggest that although congruence

between instructional methods and learning styles is not indicative of academic

success, the process of matching the two may reduce learning barriers and

improving experiential learning opportunities. The information presented in the

literature provides the foundation for further evaluation of methods to improve

preparation of new RNs and further supports the need to consider incorporation of

learning style-related concepts in clinical orientation programs. Chapter 1 will

further review the fundamental elements associated with learning style-based

concepts, and review any potential value these concepts possess with respect to

new RN orientation. In addition, Chapter 1 will outline information to lay the

foundation for further evaluation of the concept of matching learning styles and
                                                                                        4

orientation techniques, and evaluate any actual or potential relationship to new

RN turnover.

                                 Background of the Problem

       Nursing education has become a primary topic for research due to the

current shortage of nursing professionals and the severity of the projected deficit

(Myers & Dreachslin, 2007; Spetz, 2006). Several factors contribute to the

projected deficit. One is the number of nurses retiring (Aiken, 2001). The second

is the inability of nursing schools to admit all qualified applicants. A third is the

high turnover rates among new RNs (Spetz, 2006; Unruh & Fottler, 2005).

Although the nursing schools have made progress in increasing the number of

students admitted to nursing programs, the gap continues to widen because of the

ongoing high turnover rates of new RNs once they enter their practice setting

(Aiken, 2001; Hom, 2003), particularly in the area of acute care. This workforce

deficit causes significant concern due to the increased patient acuity and the

incoming number of baby boomers, individuals born between 1946 and 1964,

requiring medical care (Myers & Dreachslin). An adequate supply of nurses is

essential in order to maintain the stability of healthcare (Spetz). Retention of new

RNs, who represent a large number of incoming nurses, requires increased focus

if the supply issues are going to be addressed (Bowles & Candela, 2005).

       According to Spetz (2006), over 450,000 nurses will be required in the

United States by the year 2008 in order to meet the demand for healthcare

services. This projection does not fully reflect the true need due to the inability to

project the number of retiring members of the nursing workforce or those who
                                                                                       5

will transition from acute care nursing to other professions. Nursing not only

requires scientific knowledge regarding human physiology, pharmacology, and

behavioral and social interaction, but it also requires a level of critical thinking

that allows the nurse to recognize potential complications, take action to minimize

the potential for an adverse event, and positively influence the patient’s sense of

well-being (Ballard, 2003). Appropriate preparation is essential in order to

provide a nursing workforce that is sufficient in number and is well equipped to

provide quality nursing care.

       The national nursing shortage has been a topic of conversation and an area

of concern for over 20 years (Spetz, 2006). Although the number of full time RNs

is increasing nationwide (Buerhaus, Auerbach, & Staiger, 2007), the State of

California continues to face challenges with respect to ensuring an adequate

number of nurses and sufficient nurse preparation (Spetz). The nursing workforce

shortage is more significant in the Central Region of California where the nursing

supply per capita is half that of the statewide average (California Healthcare

Foundation, 2001).

       Central California community colleges and universities have attempted to

address the nursing shortage by increasing the number of nursing students

admitted to RN training programs from approximately 170 to over 220 annually.

These numbers represent combined admissions of the Associate’s and Bachelor’s

degree programs. Although the admission numbers have improved, these efforts

have proven futile in reducing the nursing deficit due to the high turnover rate

among new RNs (C. Collier, Director of Nursing, Bakersfield College & P.
                                                                                      6

Leapley, Chair, Nursing Program, California State University, Bakersfield,

personal communication, May 1, 2007).

       Increasing the number of nurses is of vital importance; however, retaining

incoming nurses must also receive attention. Further exacerbation of the current

nursing shortage will also occur if focus on nurse retention remains at its current

level (Cowin & Jacobsen, 2003). Schoessler and Waldo (2006) suggest that 35-

60% of RNs resign from their first nursing positions within the first year of

employment. Turnover rates in acute care facilities in Central California range

from 25-35% during the first year of employment, which equates to turnover of

approximately 40-56 RNs (Association of California Nurse Leaders, Kern County

Chapter, personal communication, May 15, 2007). Although the actual turnover

occurs within the first year of employment, Halfer and Graf (2006) suggest that

the feeling of being overwhelmed and the initiation of activity that leads to

turnover starts three to six months after initial employment. New RNs represent

the largest pool of nurses for recruitment. Approximately 42% of nurses recruited

into healthcare organizations are recent graduates of nursing programs, yet the

ability to retain this labor pool has not shown significant improvement (Keller,

Meekins, & Summers, 2006).

       New RNs consistently report feeling overwhelmed and report a lack of

sufficient and effective hospital-based orientation (Bowles & Candela, 2005;

Carroll, 2005; Schoessler & Waldo, 2006). New nurses also report job

dissatisfaction and job-related stress due to feelings of inadequacy and lack of

support during the initial orientation period (Floyd, Kretschmann, & Young,
                                                                                    7

2005). Although the nursing crisis has resulted in numerous studies aimed at

identifying causes and potential solutions to the nursing shortage, few studies

have delved deep enough to reach the core of the problem and develop solutions

that can significantly reduce new RN turnover rates (Bowles & Candela).

         The concern regarding new RN turnover has resulted in the development

of multiple new programs and revisions to current hospital-based clinical

orientation processes (Bowles & Candela, 2005; Crow, Smith, & Hartman, 2005;

Lindsey & Kleiner, 2005; Schoessler & Waldo, 2006). Nurse internship,

residency and extended orientation programs have shown some promise in

reducing new nurse turnover (Bowles & Candela, 2005; Crow, Smith, &

Hartman, 2005; Lindsey & Kleiner, 2005; Schoessler & Waldo, 2006); however,

the benefits have not demonstrated long- term improvement in new nurse

retention. Genovese’s (2004) examination of learning style preference reliability

concluded that learning style-based education improves the quality of instruction

and the self-knowledge of the learner. In addition, Rayneri, Gerber, and Wiley

(2006) suggest that learning style-based education plays an important role in

determining learners’ performances. Incorporation of individual learning styles

does improve the learning experience, yet primary studies addressing new nurse

orientation fail to reflect the use of learning style-based clinical orientation

modalities (Baltimore, 2006; Boyle, Duffy, & Dunleavy, 2003; Fleming, 2005).

Due to this lack of focus on individualizing new RN orientation, methods to

address new nurse turnover have failed to produce the needed results (Loos,

2004).
                                                                                      8

                             Statement of the Problem

       Efforts to increase the number of incoming nurses have failed to reduce

the gap between nursing supply and demand due to the ongoing turnover of new

RNs (Aiken, 2001). McDonough and Osterbrink (2005) and Kiguwa and Silva

(2007) suggest that the use of learning styles in academic and clinical settings has

shown some promise with respect to improving retention of information and

reducing stress-related to learning new concepts. This method has also assisted in

eliminating the “one size fits all” (McDonough & Osterbrink, p. 93) approach to

nursing education. Hall and Mosley (2005) noted that although learning style

research has received criticism in the past, new focus should be directed toward

synthesizing concepts from learning style and critical thinking research in order to

develop a new concept on thinking and learning. The lack of further research on

the use and effectiveness of learning style in clinical orientation programs leaves

one potential solution to new RN turnover unexplored. Although the literature

discusses different learning styles, none addresses nursing to the extent required

to impact significant change.

       A number of factors contribute to new RN turnover. Insufficient

preparation for practice is one factor that has failed to garner the attention needed

to develop corrective strategies in an effort to reduce related nurse turnover

(Atencio, Cohen, & Gorenberg, 2003; Connelly, 2005; Bowles & Candela, 2005;

Craven, Mengel, & Barham, 2004). The problem is that programs to reduce new

RN turnover have not yielded a reduction significant enough to close the gap
                                                                                       9

between nursing supply and demand. Learning style-based clinical orientation

programs may offer a possible solution to this problem (Drago & Wagner, 2004).

       Reduction in turnover of new RNs may occur by providing a work

environment that allows ease of learning, professional growth and development,

and more enhanced opportunities to individualize the learning experience

(Baltimore, 2006; Cowin & Jacobsen, 2003). Assuring appropriate clinical

orientation methods will optimize learning and knowledge reinforcement

opportunities during orientation and better prepare nurses to provide quality

patient care. Use of appropriate clinical orientation methods also lessens anxiety,

promotes teamwork, and instills organizational values (Ashcraft, 2004).

       A quantitative, quasi-experimental research design was used in this study

to examine the effect of implementation of a learning style-based clinical

orientation program on new RN turnover rates. The study compared the turnover

rates of new RNs who participate in a learning style-based clinical orientation

program to those of new RNs who participated in a non-learning style-based

clinical orientation program in three Bakersfield, California healthcare facilities.

The two groups had similar demographic characteristics and were graduates from

either an Associate’s or a Bachelor’s undergraduate degree nursing program.

                                Purpose of the Study

       The purpose of this quantitative, quasi-experimental, non-equivalent group

study was to analyze the effect of learning style-based clinical orientation on

turnover rates for new RNs. This study documents an analysis of turnover rates of

a cohort of new RNs who participated in a learning style-based clinical orientation
                                                                                  10

program. The study also contains baseline information obtained from a cohort of

previously graduated new RNs who participated in a non-learning style-based

clinical orientation program. Both cohorts consisted of new RNs who were

members of graduating classes from both university and junior college registered

nursing programs. The study sites consisted of three Bakersfield, California acute

healthcare facilities.

        This study focus was to identify what difference existed in turnover rates

of new RNs based on the use of a learning style-based clinical orientation

program as a means to equip new RNs with information required to practice

nursing in an acute care setting. Use of a quasi-experimental research design for

this study was most appropriate due to the implementation of an intervention with

a non-randomized subject pool and the introduction of the independent variable at

different points in time (Polit & Beck, 2004). Although a cause-and-effect

relationship cannot be determined using this type of research design, use of

cohorts with similar characteristics provided foundation for accurate comparison

of the effects of an intervention allowing inferences based on the post-study data

analysis (Polit & Beck). A single dependent variable, turnover rates six months

after graduation was examined in this study in order to identify any effect a

learning style-based orientation program had on turnover rates of new RNs at a

single point in time. According to Halfer and Graf (2006), many new RNs

determine if they desire to continue employment in the acute care setting

approximately three to six months after beginning nursing practice; therefore, the

six-month time period was selected as the most optimal point for data collection.
                                                                                   11

       The study also examined a single independent variable, a learning style-

based method of conducting clinical orientation, to determine the effect of this

variable on turnover rates. Learning style-based clinical orientation describes the

use of visual, auditory, read-write or kinesthetic teaching modalities as a preferred

method of individualizing education for new RNs. Learning style-based clinical

orientation has been minimally explored with respect to education for registered

nurses in academic and professional training environments and is, therefore

worthy of further exploration.

                                 Significance of the Study

       Baltimore (2004) and Fleming (2005) suggest that increasing the number

of practicing nurses requires innovation in nursing education in both academic

and professional settings. Clinical education modalities for the new nurse do not

currently take into consideration the new RNs learning styles and their preferred

methods of instruction (Bowles & Candela, 2005). Understanding the need to

include these two variables provides opportunity to increase the potential for

retention of information and improve the ability to transition the information

learned from theory to application (Bowles & Candela). Individualizing clinical

orientation programs using learning style-based teaching concepts may assist the

new RN in analyzing and applying information to the development of the nursing

care plan and to individualized patient care. Through an evaluation of learning

style innovations to improve retention, Neuhausar (2002) demonstrated that

incorporating learning styles into course curriculum improved course content

retention rates by 84% as compared to traditional curriculum formats.
                                                                                   12

       Information that may be used to assist in improving the experience of new

RNs during the initial period of independent practice was provided throughout the

course of this study. An enhanced experience may lead to increased nurse

retention and increased competency in application of nursing tasks. In a time

when the demand for nurses is escalating and the supply of nurses is decreasing,

strategies for heightened retention and greater nursing competency are of utmost

importance.

                            Significance to Leadership

       Evaluating new and innovative methods to transition the orientation

process for new RNs from a generalized process to a more individualized process

presents an opportunity to better equip nurses for independent practice. This

process may also assist in creating an optimal environment for effective learning.

The body of knowledge on leadership may improve through the study analysis of

methods to develop an environment for transition from theory to application in the

workplace and develop individualized methods of employee orientation. This

process provides a foundation for leaders to improve their ability to meet the

educational needs of employees. Dunn and Griggs (1998) and McDonough and

Osterbrink (2005) suggest that application of these concepts introduces a more

individualized approach to nursing orientation and improves work environment

through education. In addition, “learning styles can be viewed as a distinct and

habitual manner of acquiring knowledge, skills and attitudes through study and

experience” (McDonough & Osterbrink, 2005, p. 89). Understanding and

incorporating this concept provides opportunity for “leaders to invite others to
                                                                                     13

participate in their development and provide feedback and model the way people

need to work” (Kerfoot, 2006, p. 506). In addition, effective leadership requires a

willingness to challenge old paradigms in order to create an environment for

ongoing growth, enhance learning opportunities, and facilitate awareness of

additional opportunities for skills enhancement (Keller, Meekins, & Summers,

2006). Application of this concept in nursing orientation may potentially lend

toward an enhanced learning environment, thus enabling the nurse to better retain

information, increase the level of motivation, and improve the learning

experience. This leadership characteristic creates a comfortable environment

within which employees can take risks, try new things, and ultimately expand

their abilities and levels of competence (Butler & Hardin-Pearce, 2005).

                                Nature of the Study

       This quantitative, quasi-experimental, non-equivalent group study

evaluated what difference existed between the turnover rates of new RNs who

participated in a learning style-based clinical orientation program and the turnover

rates of those who participated in a non-learning style-based clinical orientation

program. The gold standard for research, particularly in the nursing discipline

continues to be quantitative research methods (Polit & Beck). Quantitative

research designs provide an avenue to analyze if implementation of one or more

interventions results in a change in outcomes (Polit & Beck, 2004). Polit and

Beck also suggest that in order to obtain the desired data and determine whether

the intervention leads to a change in outcomes, researchers must apply deductive

reasoning to test predictions that either accept or reject the study hypotheses. A
                                                                                   14

description of the effect of learning style-based clinical orientation on new RN

turnover rates six months post graduation was included in this study through

comparing turnover rates of those who participated in learning style-based clinical

orientation and those who did not.

                                 Research Questions

       Obtaining a better understanding of any effect learning style-based clinical

orientation may have on new RN turnover rates will provide information that may

prove beneficial to healthcare organizations in both clinical and academic

settings. This information may assist in the development and implementation of

more effective educational strategies. The current deficits in the nursing

workforce in Central California and the need to identify methods to improve new

RN retention provide justification for analysis of retention strategies. This

research study explored the following research question: What effect will a

learning style-based clinical orientation program have on turnover rates of new

RNs during the first six months of nursing practice in three Bakersfield,

California, acute healthcare facilities?

                                      Hypotheses

       This study documents findings related to the process used to determine

what affect a learning style-based clinical orientation program had on the turnover

rates of new RNs, six months after graduation. This study presents data in order to

test the following null hypotheses:

       H0: New RNs who participate in a learning style-based clinical orientation

program will not show lower turnover rates than new RNs of similar
                                                                                  15

demographics who participated in a non-learning style-based clinical orientation

program during the first six months of nursing practice in three Bakersfield,

California, acute healthcare facilities.

        HA: New RNs who participate in a learning style-based clinical

orientation program will show lower turnover rates than new RNs of similar

demographics who participated in a non-learning style-based clinical orientation

program during the first six months of nursing practice in three Bakersfield,

California, acute healthcare facilities.

                               Theoretical Framework

        The theoretical framework for this study was derived from two primary

areas, the concepts presented in Gardner’s (1993) theory of multiple intelligence,

and learning style concepts provided through research from Dunn and Dunn

(1979), Kolb (2005), and Fleming (2005), among others. In order to provide a

solid foundation on which to base this study, in-depth review and analysis of both

the theory of multiple intelligence and the concept of learning styles was in order.

The following section contains a summary on these topics.

Multiple Intelligence

        Multiply researchers have incorporated the theory of multiple intelligence

as one of the foundational elements of curriculum development for academic and

vocational training programs (as cited in Denig, 2004). In addition, academicians

have expanded on this concept in order to develop more individualized

educational opportunities for students to assure proper comprehension of study

materials (Denig). In order to improve understanding of the foundational elements
                                                                                       16

of the theory of multiple intelligence, this section will present a brief summary of

the theory and the significance of the concepts contained within the theory.

       The theory of multiple intelligence (TMI) outlines the existence of

different intellectual strengths and weaknesses and summarizes concepts

suggesting varying forms of cognition and modes of information processing

(Gardner, 1993). The central theme of the TMI is based on the notion that

“intelligence is the existence of more basic information processing operations or

mechanisms, which can deal with specific kinds of input” (Gardner, 1993, p. 64).

In addition, Gardner also suggests that human intelligence should be viewed as a

biophysical potential with a pluralistic nature, rather than as a general ability (as

cited in Chen, 2004).

       As suggested in the TMI, Gardner (1993) posits that intelligence is found

in nine different ways: linguistic, logical-mathematical, musical, spatial, bodily

kinesthetic, naturalistic, interpersonal, intrapersonal, and existential. Linguistic

intelligence is the ability to understand and use written and spoken

communication. Logical-mathematical intelligence represents the ability to

understand and use logic and numerical symbols and operations. Musical

intelligence manifests through one’s ability to understand and use concepts of

rhythm, pitch, melody, and harmony. Spatial intelligence represents the ability to

orient and manipulate three-dimensional space. Bodily kinesthetic intelligence

manifests through the ability to coordinate physical movement and is most

frequently evident in individuals with tremendous athletic prowess. Naturalistic

intelligence denotes the ability to categorize natural objects or phenomena.
                                                                                     17

Interpersonal intelligence manifests in one’s ability to understand and interacts

well with others. Intrapersonal intelligence describes one’s ability to understand

and use one’s own feelings, preferences, and interests in order to self regulate and

direct one’s own life. Existential intelligence depicts the ability to contemplate

phenomena or questions beyond existing data such as the infinite or infinitesimal

and manifests in individuals who are interested in astrology, cosmology, or

philosophy (Moran, Kornhaber, & Gardner, 2006). Gardner (1993) suggests that a

transition from a single-view perspective to a multiple-view perspective is

required to recognize the uniqueness of individuals regarding cognitive function,

information processing and optimal learning. Gardner also suggests that the view

of intelligence should not be through a single perspective nor should the

measurement occur through linear evaluation mechanisms.

       Theorists have used the TMI as one of the foundational theories that

provide a platform on which to expand learning style concepts (Kolb, 2005).

Through TMI, Gardner (1993) suggests consideration of individual characteristics

and learning preferences as one determines methods by which information should

be communicated in order to optimize comprehension and increase ability to

operationalize concepts. The TMI is a foundational theory for the conceptual

framework of learning style-based education.

       The TMI and other work conducted by Gardner (1993), Dunn and Dunn

(1979), Kolb (2005), and Fleming (2005) provided information that has assisted

in developing methods by which preferred learning styles are determined. Using

this information to provide a mechanism to individualize educational curriculum,
                                                                                  18

assures that the method of information conveyance is in concert with the manner

with which the receiver processes information. In other words, information is

presented in a manner that is consistent with the learning language or the learning

style of the receiver. Learning style concepts are based on Gardner’s TMI and

have been further enhanced by Fleming (2005), Dunn and Dunn (1979) and Kolb

(2005) among others. Interest in learning styles and implementation of learning

style-based educational concepts has increased because of the work of these

researchers.

Learning Styles

       The term learning style became more prominent after its use in describing

the unique manner that individual’s analyze, comprehend, and apply concepts

(McDonough & Osterbrink, 2005). The approach used for learning style research

primarily focuses on environmental and emotional preferences, variation in

cognitive style, and physiological influences based on sensory or perceptual

preferences (Boyle, Duffy, & Dunleavy, 2003). Learning style work was further

refined through research studies and operational application of Gardner’s TMI

and the learning style concepts developed from it. Using the TMI as the basis for

further learning style research, individuals such as Dunn and Dunn, and Kolb

subcategorized learning styles based on their areas of expertise and specific

application of the theory (Hall & Moseley, 2005). Hall and Moseley posit that

Dunn and Dunn’s learning style theory is based on the understanding that each

person has biological and developmental characteristics that respond to a variety

of environmental, emotional, sociological, physiological or perceptual, cognitive,
                                                                                   19

and instrumental variables. Recognition and response to these variables are strong

determinants of the success or failure of students’ learning experience (Dunn &

Griggs, 1998).

        Hall and Moseley (2005), also submit that Dunn and Dunn, and Kolb have

taken the concepts outlined in Gardner’s (1993) TMI and applied them to overall

learning style concepts. Denig (2004) defines learning styles as “the manner in

which each person begins to concentrate on, process, internalize, and remember

new and difficult academic content” (p. 101). Fleming (2005) and Denig (2004)

suggest that the ability and level of comprehension is dependent upon if the

information is provided in the same learning language used by the receiver. In

order to convey information in an effective manner, the method of conveyance

must be consistent with the manner in which the learner receives and processes

information (Fleming, 2005; Hall & Moseley, 2005). Learning style concepts seek

to “shift to a focus on the learner, rather than on the subject matter and to develop

the necessary attitudes and skills for lifelong learning” (Hall & Moseley, 2005, p.

248).

        The experiential learning model, developed by Kolb (2005), outlines a

four stage learning cycle. According to Kolb, the four stages include concrete

experience, abstract conceptualization, active experimentation, and reflective

observation. Concrete experience summarizes experiential learning. Abstract

conceptualization depicts a preference for conceptual and analytical thinking in

order to achieve understanding. Active experimentation involves active trial and

error learning. Reflective observation consists of extensive consideration to tasks
                                                                                    20

and potential solutions before an attempt toward action occurs (Kolb, 2005). Kolb

further describes learning styles using terms such as convergence, divergence,

assimilation and accommodation. The individual with a convergence of learning

styles “uses abstract conceptualization to drive active experimentation,” (Cassidy,

2004, p. 431) meaning that action is based on an abstract understanding of the

expected task. The individual then uses a strategic approach based on prior

analysis to complete the desired task successfully. The individual with a divergent

learning style preference uses reflective observation combined with experience to

determine process and problem resolution. This individual is able to evaluate

multiple strategies for learning and problem solving and incorporate those

strategies into the overall learning process. Individuals with assimilation learning

styles are conceptual largely, preferring to refine processes rather than develop

solutions to discrete problems. The individual with accommodation learning

tendencies prefers prompt action and possesses a strong ability to adapt to

multiple situations (Cassidy, 2004; Kolb, 2005; Loo, 2004). Each of these

learning characteristics forms the basis for learning style preferences. Kolb

suggests that particular preferences for learning are determined by individual

strengths (as cited in Sadler-Smith & Smith, 2004) and that these learning style

preferences, combined with how information are presented, determine the level at

which the learner perceives and comprehends material.

       Learning style research, although originating from multiple disciplines,

incorporates learning style preferences formed based on sensory or physiological

modality (Fleming, 2005). The sensory preferences are strong determinants of the
                                                                                  21

students’ level of success (Dunn & Griggs, 1998; Dunn & Dunn, 1979). Although

Dunn and Dunn (1979) and Kolb (2005) further expand learning style concepts to

include cognition, the focus of this study will be limited to the sensory or

perceptual learning style preferences as is predominant in Fleming’s (2005)

visual, aural, read-write, kinesthetic (VARK) learning styles conceptual model.

       Enhancement of learning style research occurred through the work of Neil

Fleming. Neil Fleming was an educator who possessed particular interest in

understanding why students who had poor instruction did well while other

students who had excellent instruction did poorly (Neil Fleming, VARK

researcher, personal communication, May 22, 2007) (see Appendix A). Fleming

conducted research using direct observation and interviews to identify factors that

affected students’ academic success, such as study habits, learning style and

instruction matching. Fleming’s research was the foundation for the creation of

the VARK learning style inventory and learning style profiles using the VARK.

According to Fleming (Neil Fleming, VARK researcher, personal

communication, May 22, 2007), over 100,000 individuals used the inventory to

identify particular learning styles and have implemented study and teaching

strategies that have improved academic performance and have increased student

retention in academic programs. Although these researchers approached the

concept of learning style from diverse perspectives, a common premise within

each of the learning style concepts is learning enhancement through identification

of the learners’ individual learning preferences and incorporation of those

preferences in the learning process.
                                                                                   22


Learning styles and nursing orientation.

       Incorporation of learning styles into new nurse orientation may provide an

avenue to assure that presentation of information occur in a manner that is

consistent with the learning style of the new graduate nurse. Learning style-based

clinical orientation processes also, increase the potential of improving

comprehension of information and facilitating the ability to apply the information

received (McDonough & Osterbrink, 2005). Defining the learning style of an

individual assists in constructing a learning experience that is individualized, thus

aligning the learning experience with the learning need (McDonough &

Osterbrink). Further, McDonough and Osterbrink conclude that the use of

learning style-based orientation for new RNs may increase comprehension of

clinical concepts, improve application of those concepts in direct patient care,

increase perceived comfort and confidence in performing nursing-related

activities, and improve the desire to remain in the nursing profession.

       Learning style research provides a foundation on which to enhance the

manner in which academic and clinical instruction occurs (Cassidy, 2004).

Demonstrating the influence and application of individualized learning style-

based clinical orientation for new RNs may reduce new nurse turnover at a time

when the supply of nurses is at an all-time low and projections of improving the

deficit are less than promising. Research in the application of learning style-

related concepts through incorporation of learning style-based clinical orientation

can provide healthcare facilities with information that may be used to improve the

perception of new RNs regarding their clinical orientation experience.
                                                                                   23

Additionally, Fleming (Neil Fleming, VARK researcher, personal

communication, May 22, 2007) suggests that application of learning style

concepts in the academic setting resulted in students demonstrating improved

academic performance after replacing traditional study skill enhancing techniques

with learning style-specific study skills enhancing techniques (see Appendix A).

Application of research and observational findings in this study can potentially

translate into improved clinical performance and provide useful information with

respect to influence on new nurse turnover.

                                Definition of Terms

       Operational definitions of terms, phrases, and concepts used for the

purpose of this study are outlined below:

            Acute care healthcare facility: “A facility providing medical and/or

surgical services to all individuals that seek care and treatment, regardless of the

ability of the individual to pay for such services. Acute care hospitals are capable

of providing care on an immediate and emergent basis through an established

Emergency Department as well as continuous treatment on its premises for more

than twenty-four (24) hours” (State of Hawaii, n.d. ¶ 1)

       Auditory (Aural) learner: “a person who prefers information that is spoken

or heard” (Fleming, 2005, p. 3).

       Clinical orientation: “hospital based programs designed to facilitate the

transition of newly employed nurses from the educational to the clinical practice

setting” (Pickens & Forgotstein, 2006, p. 32).
                                                                                   24

       Clinical preceptor: "An experienced nurse who guides, directs or trains

another nurse or nursing student in giving quality nursing care" (Smith, 2006, p.

1).

       Kinesthetic learner: “a person who learns best by doing” (Drago &

Wagner, 2004, p. 3).

       Learning style: In terms of this study, learning style is “individual

characteristics and preferred ways of gathering, organizing and thinking about

information” (Fleming, 2005, p. 1).

       Learning style-based clinical orientation: Clinical instruction based on

“the learners preference for different types of learning and instructional activities”

(Rasool & Rawaf, 2007, p. 36).

       Non-learning style-based clinical orientation: Clinical instruction based

on instructors “preconception of teaching context and their success within it”

(Kiguwa & Silva, 2007, p. 354).

       New graduate turnover rate: “the ratio of the number of new RNs who

resign to the average of new RNs who were hired” (Shader, Broome, Broome,

West, & Nash, 2001, p.213). In the case of this study, turnover rates address

resignation that occurs within the first six months after beginning post graduation

nursing practice.

       Read-Write learner: “a person who learns by taking notes by hand or on a

computer or by manipulating materials” (Giordano & Rochford, 2005, p. 23).

       RN: “A registered nurse is a person who practices professional nursing

(State of Wisconsin, Department of Regulation and Licensing, 2006).
                                                                                      25

       VARK: “VARK is a questionnaire that provides users with a profile of

their learning preferences. These preferences are about the ways that they want to

take-in and give-out information” (Fleming, 2005). This questionnaire will be

used to identify the preferred learning style of the study participant, and will be

the basis for determination of instruction methodologies.

       Visual learner: “a person who prefers information in pictures, charts,

graphs flow charts, and symbols” (Fleming, 2005, p. 1).

                                    Assumptions

       This study is dependent upon the information provided by the study

organization with respect to current turnover rates of new RNs. In order to

understand the effect of learning style-based clinical orientation programs on new

nurse turnover rates in the study group, several assumptions will be made. A

summary of each assumption is contained in the following paragraphs.

       The first assumption was that the participants would represent an adequate

sample size and a cross section of the graduating class from the local Associates,

and Bachelor’s degree programs. Ensuring appropriate sample size is essential to

credible generalization of the study findings (Polit & Beck, 2004). In the case of

this study, a sample size of 25 new RNs from the graduating class of December

2007 was used for the study. This number represented approximately 42% of the

December 2007 RN program graduates in the area.

       A second assumption was that the study participants would be willing to

complete the VARK Learning Style Inventory and would provide honest

responses to the questions. Lack of willingness to complete the inventory would
                                                                                   26

result in insufficient information on which to base the clinical orientation process.

In addition, if the participants failed to provide honest responses on the inventory,

an incorrect learning style determination would result.

       The third assumption was that the VARK Learning Style Inventory would

accurately reflect the preferred learning style of the study participants. According

to Fleming (2005), the VARK Learning Style Inventory is based on the

respondents’ stated preference of how information is to be received. Therefore,

the inventory results were assumed to reflect learning style preferences.

       The fourth assumption was that the clinical preceptor would adhere to the

learning style-based orientation guidelines during the entire study period. Lack of

adherence by the clinical preceptor could result in blending of non-learning style-

based clinical orientation processes. Blending of learning style based and non-

learning style-based concepts may have resulted in invalidation of the study

findings.

       The fifth assumption was that the turnover rate data obtained from the

study sites would accurately reflect the turnover of the new RNs prior to and after

implementation of the learning style-based clinical orientation program. Since this

study was focused on analyzing the turnover rates specific to new RNs, all data

on turnover rates only included turnover rates of new RNs. Failure to ensure

purity of the data would potentially result in inaccurate research findings.

       The sixth assumption was that measuring the dependent variable at

different points in time did not affect the validity of those measures. External

variables such as change in economy, family dynamics, and relocation contribute
                                                                                      27

to RNs determination of whether to leave or maintain current employment. These

factors were uncontrollable and were considered during the analysis of study

findings.

       The seventh assumption was that non-random assignment of participants

to orientation did not result in biased sampling. Study bias presents a significant

threat to the validity of the study (Polit & Beck, 2004). The potential for bias was

minimized by ensuring an adequate sample size and similar demographic make-

up of the non-learning style-based and learning style-based clinical orientation

groups.

                                     Limitations

          The scope of the study focused solely on the manner in which new RNs

were oriented into the clinical setting. The specific emphasis of the study looks at

adaptation of orientation processes based on the individual learning style

preferences of new RNs and the effect that use of learning style-based orientation

had on turnover rates. The availability of new RNs during the study period placed

some limitation on the study. The study was also limited by availability of data on

the reliability and validity of the learning style inventory, although the tool had

previously been used in similar studies and was considered, anecdotally, as an

accurate tool for assessing the sensory portions of learning style preferences. An

additional limitation to the study was the level of understanding possessed by the

study participants and clinical preceptors regarding learning style concepts.
                                                                                   28

                                   Delimitations

       The study participants were limited to new RNs who were recent

graduates of the local Associate’s degree and Bachelor’s degree nursing programs

and are located in a single geographical area. The selection of participants was

based on a convenience sample. Only participants who volunteered to complete

the VARK Learning Style Inventory and participate in a learning style-based

clinical orientation program were included in the study. Further study including a

broader base of nurses would prove beneficial.

                                     Summary

       The nursing shortage in the United States is of tremendous concern and

deserves focused attention. The nursing shortage in California, particularly the

Central California region is more significant and is the foundation for the focus of

this study. The nursing shortage in California has been the catalyst for heightened

attention. This heightened attention has been directed toward the development and

implementation of methods to increase the number of RNs produced from the

local colleges and universities. Formidable effort has been directed toward

increasing the number of nurse graduates. In spite of these efforts, the high

turnover rate of new RNs prevents those efforts from significantly reducing the

nursing deficit in healthcare organizations.

       The focus of this study was to analyze what effect learning style-based

clinical orientation would have on turnover rates of new RNs. In order to obtain a

increased understanding of the significance of the nursing shortage, the

significance of nurse turnover in both new graduate and experienced nurses, and
                                                                                 29

the application of learning style concepts in nursing education; evaluation of

previous studies focused on these topics must occur. These topics in addition to a

summary of the more significant studies in learning styles based clinical

orientation and its application is provided in Chapter 2.
                                                                                   30

                         CHAPTER 2: LITERATURE REVIEW

       Current research on the nursing shortage focuses on the supply and

demand of registered nurses (RNs). An aging workforce, undesirable work

conditions and the failure to increase the number of incoming RNs were identified

as the most common themes in research studies on this subject (Buerhaus,

Donelan, Ulrich, Norman, Williams, & Dittus, 2005; Chandra & Willis, 2005).

Although the information provided in these studies has proven useful, the focus

on recruitment continues to take center stage while the issue of retaining newly

recruited nurses remains in the background.

       Healthcare facilities and nursing programs have implemented a variety of

strategies to address this issue with marginal results. Increasing the number of

students admitted to nursing programs may prove ineffective in reducing the

current nursing shortage if the new RN turnover rates continue at the current level

(DHHS, 2005; Spetz, 2006). Sims (2006) suggests that instructional programs that

incorporate individual learning preferences are most effective when working with

adult populations in both academic and workplace settings. Further, individual

tailoring of the method of information delivery positively influences effective

learning and students’ level of interest (Kratzig & Arbuthnott, 2006). This

information may prove valuable in assisting new RNs in understanding and

retaining information. It may also prove useful in understanding and resolving

issues related to retention of information and desire to leave employment.

       In order to understand the factors contributing to new RN turnover, an

examination of the concept of turnover from multiple perspectives and associated
                                                                                     31

foundational elements is in order. This literature review will encompass review

and analysis of specific factors contributing to the nursing shortage, the concept

of turnover, registered nurse turnover and contributing factors, and transition from

student-to-practitioner. As a precursor to understanding adult education and the

importance of providing a learning environment that embraces individualized

learning strategies, a discussion of adult learning and the effect of learning styles

in workplace training are included.

                                       Documentation

        One hundred and twenty four articles were used in this proposal (see

Table 1) after an extensive search of foundational, historical, and contemporary

literature. This proposal includes the information obtained from the review of

multiple publications for content and applicability to research on the impact of

matching clinical orientation processes to preferred learning styles for new RNs.

Over 120 professional peer-reviewed journals were reviewed, and 56 were used

for the study. More than 85 periodicals were reviewed, and 44 of those were used

for the study. Additional governmental agency publications and books were

included in the literature review. Information was obtained from websites and

personal interviews.
                                                                                     32

Table 1

Summary of Sources in the Literature Review

Reference Type                          Total            ≥ 5 yrs          ≤ 5 yrs______

Peer-Reviewed Journals                  56              10                   46

Governmental Entities                  10                2                     8

Books                                    6               2                     4

Websites                                 7                2                   5

Periodicals                             44               2                    45

Total                                  124              18                   106

Percent                                                14.6%                 85.4%



        In spite of an extensive literature search, few studies were found that

addressed the use and effectiveness of learning style-based clinical orientation for

new RNs. Current literature from diverse sources represents 85.6% of the

resources contained in this literature review. The current literature is comprised of

articles written or published within the last five years. A summary of the

significant findings from this literature is contained in this chapter.

                                     Historical Overview

        A review of historical data yielded a significant amount of foundational

information on the concept of turnover in general and specifically in the nursing

profession. Information on turnover, the nursing shortage, and student-to-

practitioner transition were summarized in this section to provide a general

overview of contributing factors and possible solutions to turnover of new RNs.
                                                                                   33

To begin the process of examining the practical means of affecting a rapid

intervention to prevent further exacerbation of the nursing shortage, this literature

review will examine the historical perspective on these topics. An introduction to

the concept of adult learning is also included in this section.

The Concept of Turnover

       The concept of turnover has long been of interest in the nursing

profession. The need to explore turnover has become more critical due to the

nursing shortage and the decreasing number of individuals entering the nursing

profession. As cited in Steemsma, Van Brueukelen, and Sturm (2003-2004),

March and Simon analyzed staff turnover in the 1950s in order to identify issues

that resulted in motivation for job transition. Steemsma et al. noted that the most

significant issue was unmet expectations, which addressed the lack of correlation

between the expectations of the employer and those of the employee. Additional

examination of turnover-related factors identified a correlation between turnover

in the labor force and the economic stability of a business or organization

(Atencio, Cohen, & Gorenberg, 2003).

       Recent graduates from five large organizations participated in a study

directed toward identifying factors that influenced the new RNs’ perception of

employers (Sturges & Guest, 2001). Significant factors included whether the

organization met the participants’ pre-employment expectations for career

management assistance and if the organization gave the participants the expected

positions. Additional factors included training and development, culture and

climate of the organization, quality of relationships, balanced work, and home
                                                                                   34

life, recognition for achievement, and career progression. Sturges and Guest

concluded that consistency between pre-employment expectations of the graduate

and the employer, individualized training and development, and career guidance

practices significantly influenced the employee’s decision to leave, and should

become an essential component of recent graduate recruitment.

       Steensma, van Breukelen, and Strum (2003-2004), compared factors that

influence turnover in both former and current employees. The purpose of the

study was to provide data to identify potential similarities in turnover-influencing

factors identified in employees prior to turnover and in employees after turnover

had occurred. Steemsma et al. found no significant difference between factors that

influence turnover of current and former employees. Job satisfaction, job content,

direct management, participation, material expectations, and career opportunities

were identified as factors contributing to turnover in both the current and former

employees.

       The Steensma et al. (2003-2004) and Sturges and Guest (2001) studies

were conducted in an attempt to analyze employer turnover from various

perspectives. Although these data revealed multiple factors that contribute to

turnover, perceived competence, skill autonomy, training, and development

factors were consistent through each study. Both studies provide information that

highlighted the significance of perceived job preparation and skills development

in turnover and other retention issues. In light of the nursing shortage and its

significance to healthcare in the United States, a closer look at the factors

effecting the nursing shortage and RN turnover may prove beneficial in
                                                                                   35

addressing the shortage and in assuring that incoming nurses remain in the

workforce.

Registered Nurse Turnover.

       Turnover rates of registered nurses remain an area of focus due to the

impact of nurse turnover on financial solvency of the healthcare organization,

operational stability and quality of care (Aiken, 2001). Through research

conducted in 2001, the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO), found that nurse’s dissatisfaction with their jobs resulted

in high replacement costs, increased patient care costs, and increased patient

mortality. Factors that contributed to lower job satisfaction included work hours,

compensation, staffing, advancement opportunities, stress, and physical demands

of the job. The JCAHO noted that nursing turnover related directly to the nurses

feeling overworked and overburdened with tasks that were more suited for less-

skilled workers.

       According to Aiken (2001), multiple factors contribute to nursing

workforce deficits. Approximately 40% of nurses surveyed were dissatisfied with

their jobs. Turnover rates mirrored the dissatisfaction levels, demonstrating an

increase from 12% to 15% between 1996 and 1999. In addition, turnover rates

between 1998 and 2000 increased by 14%. Proportions of nurses employed in

hospital settings declined from 68% in 1988 to 59% in 2000, even though the

nursing labor force continued to increase during the same period. Frequent work

redesign, working conditions, lack of sufficient authority, workload, schedules,
                                                                                    36

and stress were identified as additional factors that contributed to nursing turnover

(Aiken).

       In an attempt to explore the perceptions of nurses in Singapore, Fang

(2001) examined two predictors of turnover cognition (considering resignation)

and turnover intention (intent to resign) to identify the significance of each factor

with respect to nursing turnover. The most important factors contributing to

turnover intention included stress, supervisor satisfaction and organizational

commitment. Stress was the most frequently occurring contributing factor as

compared to the other factors identified. Fang concluded that organizational

commitment and supervisor satisfaction were also prominent factors that

contributed to turnover intention, but occurred less frequently than stress.

       Using a cross-sectional survey design, Shader, Broome, Broome, West,

and Nash (2001), examined the relationship between multiple variables and

anticipated turnover of nurses in an academic medical center setting. Self-

reporting questionnaires were used to ascertain nurses' perception of job stress,

work satisfaction, group cohesion, and anticipated turnover. Shader et al. found an

inverse relationship between job stress and anticipated turnover, and job

satisfaction and group cohesion. The inverse relationship between these factors

means that the higher the level of job satisfaction and group cohesion, the lower

the job stress and anticipated turnover rates. Shader et al. also highlighted that job

stress is more significant to anticipated turnover of new RNs than anticipated

turnover of more experienced nurses due to the decreased ability of new RNs to

cope with stressful situations while in a learning mode. Stress can be reduced by
                                                                                       37

individualizing orientation programs and providing adequate support during the

early practice periods (Lindsey & Kleiner, 2005).

       The primary reasons for nurse turnover are staffing levels, management

support, and variation in work schedule. In addition, nurses outlined frustration

with the quality of care they were able to provide due to low staffing and

increased demands (Strachota, Normandin, O’Brien, Clary, & Krukow, 2003).

Strachota et al. suggest that salary contributed to dissatisfaction, and that nurses

who were new to the profession were more likely to leave nursing positions than

nurses who were more experienced.

       Using a non-experimental survey design Larrabee, Janney, Ostrow,

Withrow, Hobbs, and Burant (2003) examined contributing factors to nurse

retention. Intent to leave was strongly associated with perception of control over

their practice, the adequacy of support services for necessary patient care, and

perceptions of the significance of performance on patient outcomes. Larrabee et

al. suggest that job satisfaction was strongly associated with the nurses’

perception of empowerment, support service responsiveness, nurse/physician

collaboration, group cohesiveness and leadership style. Psychological

empowerment and group cohesion were related, and were identified as significant

contributors to nurse retention.

       In 2003, Atencio, Cohen, and Gorenberg examined the relationship

between work environment and nurses’ intent to leave their nursing positions. The

focus of the study was to identify if the perceptions of nurses specific to

autonomy, task orientation, and work pressure were significant contributors to
                                                                                     38

actual turnover or intent to stay. Atencio et al. identified that perceptions of

autonomy and task orientation were significant contributors to nurse turnover.

These factors were more significant to turnover for newer nurses than for nurses

with more experience. Perception of workload and work conditions was more

favorable for nurses working shorter workweeks or fewer hours. There was no

significant difference in perception of autonomy or task orientation with respect

to the number of hours worked.

       These studies addressed issues pertaining to turnover from a conceptual

perspective and from the perspective of specific vocations. While each study

focused on turnover from various viewpoints, a common thread is apparent. A

direct relationship between employee turnover and perceived preparation and skill

level related to performance expectations exists. The conclusions of these studies

point to the need for employers to investigate methods to provide individualized

training for employees and to ensure that employees are provided with the

training required to complete expected job duties. Employers must also recognize

that the factors identified have greater potential for influencing turnover in new

RN populations than for their more experienced counterparts.

Nursing Shortage Factors

       The nursing shortage continues as a topic of concern on both the state and

national levels. In 2001, the United States Department of Health and Human

Services (DHHS) conducted a study identifying current nurse supply and demand

and projecting the estimated demand through the year 2030. DHHS identified a

shortage of approximately 110, 000 (6%) nurses nationally during the study
                                                                                  39

period and projected a four fold increase nationally by 2030. This projection was

based on a comparison of the number of licensed nurses in the nation and the

population growth over the projection period. Nursing schools across the nation

have attempted to respond to the increasing nursing shortage by “adding

customized tracks for accelerated undergraduate, and combined undergraduate

and graduate degree nursing programs” (Hom, 2003, p. 36). These programs have

increased the number of nurses graduating from nursing school, but have not

sufficiently affected the nursing shortage. The accelerated programs decrease time

for gaining clinical skills, leaving many of the nurses uninformed of the true

requirements of providing nursing care. In addition, these RNs do not possess the

skills needed for ease in transition into the nursing workforce (Dracup & Bryan-

Brown, 2004). DHHS provides useful information regarding the inadequate

number of nurses compared to growth in the population, and highlights the need

to increase the number of incoming nurses. In spite of the valuable information

presented in this study, DHHS falls short of truly capturing the shortage specific

to nurse supply, the issue of sufficient preparation for practice, and new RN

turnover. Dracup and Bryan-Brown highlight the need to increase the number of

RNs and consider expanding opportunities for skills development and methods to

prepare RNs for the reality of practicing in nursing in today’s healthcare

environment.

       Another factor is the age of the current nursing workforce. According to

Huston (2003), the mean age of the working nurse is 44 years. The average age of

retirement from nursing is 49 years, indicating that the average nurse will work an
                                                                                        40

additional five years before retiring. The mass exodus of RNs is projected to

occur between 2005 and 2013 due to retirement of a large percentage of the

current workforce. This reduction in working RNs will further exacerbate the

critical nursing shortage. Enrollment in both Associate’s and Bachelor’s degree

nursing programs has increased slightly. The number of nurses retiring exceeds

the number of nurses entering the workforce, leaving a significant deficit in the

nursing workforce (Huston, 2003).

        Nurses across the nation identified workload, staffing levels, overtime,

lack of sufficient support staff, and less than sufficient wages as factors that

contribute to job dissatisfaction and ultimately to staff turnover (DHHS, 2001). In

a similar study, Steinbrook (2002) identified that nurses who begin their careers in

the hospital setting are leaving for other positions more frequently than in prior

years. Steinbrook found that inadequate staffing and excessive workload were

significant contributors to nurse turnover. Additional turnover due to the shorter

lengths of stay for patients, increased severity of patients in the hospital setting,

and increased regulatory requirements further increased the level of job

dissatisfaction.

        In addition to the more objective factors contributing to the nursing

shortage, factors that are more subjective have also become apparent in recent

studies. Peterson (2001) suggests that changes in the United States health system

“have jeopardized nurses’ ability to advocate on their patient’s behalf; has

impacted nurses’ professional integrity; has reduced opportunity for personalized

nursing practice; and has negatively impacted nurses' physical well-being” (¶ 9).
                                                                                     41

These factors have resulted in the transition of nurses out of the acute care setting

and into nursing environments that nurses perceive as less risky and provide more

opportunities for personal fulfillment, increased physical well-being, increased

autonomy, and improved work life balance. Peterson noted that workload, care

environment, and the aging workforce were significant factors contributing to the

nursing shortage. Inadequate training, lack of mentoring and preceptor programs,

and lack of sufficient preparation for independent nursing practice were identified

as having a negative affect on recruitment and retention of new nurses.

       According to the information obtained from these studies, it is reasonable

to conclude that factors such as the aging workforce, patient severity, and shorter

lengths of stay for patients have resulted in changes in consumer demands and

expectations. Other factors such as job dissatisfaction, lack of sufficient

preparation, autonomy, and desire for increased physical well-being have a

greater potential for minimizing nurse turnover, if corrected. Additional focus

needs to be directed toward developing methods to better prepare RNs to care for

sicker patients and to creating an environment that lends toward autonomy and

ongoing skills enhancement.

       Multiple factors have contributed to the nursing shortage, creating a

critical situation, which has significantly affected our current healthcare system

(Bowles & Candela, 2005). DHHS (2001) clearly outlines the significance of the

current and the projected deficit and the efforts put in place to address the

situation. DHHS and Loquist (2002) provide a summary of the conditions that

have led to a decrease in nursing school enrollment and the factors that are
                                                                                     42

causing nurses to transition from the acute care setting or out of the nursing field.

Efforts to increase enrollment in nursing programs may not yield the desired

result unless the factors as outlined in overall turnover and, more specifically,

nursing turnover literature are addressed. Successful preparation of new RNs may

provide greater opportunity to address the nursing shortage by providing a better-

prepared workforce. Evaluation of the student–to-practitioner transition and the

process of preparation are vital in order to identify if incorporation of turnover

prevention activities will effect successful transition and maintenance of new RNs

into the workforce.

Student-to-Practitioner Transition

        Healthcare organizations have the responsibility to assist new employees

in developing skills that promote safe, effective, and competent patient care.

According to the JCAHO (2001), “some elements of orientation need to occur

before staff are competent to provide care, treatment, and services. Ongoing

orientation can occur while staff members are providing care, treatment and

services” (p. 12). Efforts to increase the number of new RNs have proven

ineffective in reducing the current nursing deficit. Hospital-based training

programs have also failed to prepare new RNs for independent practice.

Additional solutions, such as recruitment of international nurses, have fallen short

of their projected benefit (California Healthcare Foundation, 2002). According to

Bieski (2007), nearly 100,000 of the current nursing workforce are foreign-trained

nurses. Due to the variation in nursing practice from country to country, the influx

of foreign-trained nurses has resulted in a need to refine hospital-based orientation
                                                                                   43

programs. In order to ensure that the foreign-trained RNs are functioning in the

same manner as their United States-trained counterparts and in a manner that is

consistent with healthcare practices in the United States, individualized skills

assessment and clinical orientation are required. This requires a very

individualized approach to both didactic and clinical orientation processes

(Dracup & Bryan-Brown, 2004).

       Squires (2002) outlined an eight-week orientation program using a

registered nurse with a graduate degree to function as primary learning facilitator.

The primary learning facilitator provided oversight in development of skills

required for effective function in that particular department. In addition,

implementation of a process called “venting time”, consisting of 60-90 minute

lunches with new RNs, occurred to allow them a safe environment to discuss

concerns and to socialize with other new RNs. Squires suggests that allowing time

for new RNs to express their concerns created an environment of social support.

After one year of employment, seven of the nine participants remained in the

program. Squires considered the program a success due to a post-program

retention rate of 77%.

       JCAHO (2001), Dracup and Bryan-Brown (2004), and Squires (2002)

identify the need to provide transition assistance for new RNs. Each of the

researchers cited information to support the need for an established, research-

based student-to-practitioner transition program. Inclusion of an individualized

process to promote ease of transition and transitional support is also apparent

based on information obtained from these studies. Use of adult learning concepts
                                                                                     44

is important in order to address the needs of the adult learner and ensure

consideration for variation in the educational needs of new RNs. Use of these

concepts may also prove effective in orienting foreign-trained nurses into the

United States nursing workforce. Regardless of if foreign-trained nurses or new

RNs are used, individualized training programs have the potential to reduce nurse

turnover.

Adult Learning Concepts

        Adult learning is a concept that finds its roots in the recognition of the

need for self- directed learning in the adult population. According to Knowles

(1980), adults not only want to be in control of their learning experiences, but

they have a psychological need to direct them. One of the differentiating factors

separating adults from children is their desire to control their life and life

experiences. Knowles suggests that by allowing this differentiation to extend into

the educational realm, adults’ use of self-directed learning will enhance the

learning experience and will increase additional experiential learning

opportunities. Because of information obtained by Knowles with respect to adult

learning, the term andragogy was developed to refer to educational methods using

adult learning concepts.

       During the 1960s, Malcolm Knowles’ work gave the term andragogy a

solid meaning and provided themes on which to make the term operationally

sound. As a result, andragogy became the most persistent, practice-based,

instructional method in adult education because of Malcolm Knowles work

(Knowles III, Swanson, & Holton, 2005). According to Knowles III et al. adult
                                                                                     45

learners bring experience into the learning environment and a need to know

relevant information that is applicable in their workplace. Adult learning concepts

provide a foundation for improved understanding and application of educational

methods to incorporate collaboration between the adult student and the

educational facilitator. This differs from Pedagogy, the concept of child

education, due to the partnership between the adult learner and the facilitator as

compared to the child learner and the instructor (Halfer, 2007). Andragogy-based

instructional methods are appropriate for adults in the workforce and are the best

method to use in preparing the adult learner to function in the work setting. These

concepts are also quite important to the transition of members of the workforce

from one career to another or from one employer to another (Knowles III et al.).

       Use of adult learning concepts in the realm of RN clinical education

provides opportunity for modifications in instructional methods. These

modifications may assist in improving training modalities and easing transition

from student-to-practitioner or from one set of duties to another. Olson et al.

(2001) and Owens, Turjanica, Scanion, Sandhusen, Williamson, Hebert, and

Facteau (2001) agree that systematic orientation programs for new RNs, in the

form of self-directed residency or internship programs, may contribute to more

seamless transition from student-to-practitioner. According to Olson et al. (2001),

nursing students experienced increased ease of transition into the practice setting,

less stress, and increased skills development through participation in self-directed

residency or internship programs that incorporated adult learning concepts. The

students reported improvement in their ability to retain information and apply
                                                                                   46

learned concepts. The students also reported increased comfort with carrying out

nursing tasks and increased feelings of autonomy (Olson et al.).

        Application of adult learning concepts in workplace-based training may

demonstrate utility in nursing education by providing an environment that

facilitates a learning partnership between the new RN and the clinical preceptor.

This partnership assists in empowering the new RN to take control of the learning

experience thus further facilitating the transition from student-to-practitioner. The

current findings portion of this document will outline the most current

information on turnover, nursing shortage factors and student-to-practitioner

transition.

                                      Current Findings

        Contained in this section is the most recent literature on issues

contributing to the nursing shortage with specific focus on RN turnover, current

findings in new RN turnover, application of adult learning theory, and learning

style concepts. Successful preparation of nurses may prove significant in reducing

the nursing shortage. As a result, examination of the student-to-practitioner

transition and the process of preparation are vital in order to identify if enhanced

retention activities will effect successful transition of new RNs into the

workforce. In order to better define these factors, the current findings section will

reflect a summary of current research in these areas.

The Concept of Turnover

        The concept of turnover receives ongoing focus due to the impact that

turnover has on financial, operational and quality initiatives of healthcare
                                                                                    47

organizations. Factors such as job dissatisfaction, work environment, job

mobility, and training continue to surface as primary causes of turnover (Sousa-

Poza & Henneberger, 2004; Mayben, Latter, & Clark, 2006). Mayben et al.

(2006) also suggest that time pressures, role constraints, staff shortages and work

overload significantly contribute to turnover. Recognition of the impact of these

factors in employee turnover provides employers with information that may be

useful in developing and implementing retention strategies.

       In addition to the effect of time pressures, role constraints, labor, and

workload issues on turnover, motivation has also surfaced as a contributing factor

in turnover in recent research studies. Ramlall (2004) analyzed motivation and its

effect on retention within an organization. In this study, Ramlall analyzed

theoretical concepts of need, equity and expectancy. Employee turnover most

often resulted from lack of understanding of expected job performance, inequity

in pay and lack of schedule flexibility (Ramlall). Based on the study findings,

other factors such as insufficient communication of expectations and insufficient

training to prepare for skills requirements were also apparent.

        Using data from the National Employee Survey conducted in 1991 and

1992, Fields, Dingman, Roman, and Blum (2005), examined the predictors of

employees moving to different positions within the same organization, employees

moving to similar positions with different organizations, and employees moving

to different positions with different organizations. Fields et al. focused on the

influence of pay and benefits, job security, job stress, job skill variety and

autonomy, overall job satisfaction, supervision, performance ratings,
                                                                                     48

 unemployment rate, tenure, age, family responsibility, gender, and industry

 decline on employee turnover. Lower pay and benefits, lower job satisfaction and

 higher employee education increased the likelihood of employees changing

 positions within the same organization. Employees voluntarily taking similar

 positions with different organizations were most strongly influenced by perceived

 job security, perceived level of competence and level of supervisory concern, job

 skill/autonomy, overall job satisfaction and levels of tenure and age. Lower job

 security, less tenure, lower age, male gender and fewer family responsibilities

 most significantly influenced the employee’s decision to voluntarily, leave an

 organization for different positions with another organization (Fields et al.). These

 data support the significance of job satisfaction, competence, pay and benefits on

 organizational turnover. Evaluation of factors that affect turnover in general

 provides a solid foundation on which to analyze turnover in designated vocational

 groups. The group most applicable to this study is new RNs. Registered nurse

 turnover is of vital importance to this study as it provides the basis for evaluation

 of new RN turnover. The next section will summarize findings with respect to RN

 turnover.

Registered Nurse Turnover

        Registered nurse turnover is having a significant impact on the ability of

 healthcare facilities to meet the healthcare needs of the public (Biviano, Fritz, &

 Spencer, 2004). This ongoing phenomenon may lead to a healthcare crisis not

 previously experienced in the United States. In order to better understand the

 significance of this problem and identify contributing factors and potential
                                                                                     49

solutions, a review of literature summarizing current findings in the area of

registered nurse turnover, top-level management, and job satisfaction will be

presented.

        Nedd (2006) described the influence of empowerment on employees’

intent to stay in their current positions. Empowerment in this study refers to the

employees’ sense of value and contribution to the overall organizational

outcomes. Empowerment also refers to the perceived ability of the employee to

take initiative and access resources to accomplish a particular task or reach a

particular goal (Nedd). The purpose of this study was to investigate whether

perceived formal power, perceived informal power, and perceived access to work

empowerment structures negatively or positively influenced self-reported intent to

stay on the job. Intent to stay positively correlated with empowerment. Nedd was

unable to identify a correlation between intent to stay and demographic variables

such as age, education, gender, or years in the nursing field. Nedd concluded that

the study findings support the perception that all empowerment variables

positively influenced the intent to stay and absence of one or more of the variables

investigated may contribute to employee turnover.

       Castle (2005) examined the association between caregiver turnover and

top-level management turnover. High turnover of top-level administrators resulted

in less consistency in organizational goals, disruption in the continuity of

organizational operations, and decreased continuity in patient care. These factors

destabilized the work environment, which directly affected caregiver turnover.

The destabilization of the work environment resulted in perceived loss of job
                                                                                  50

security, which led to caregiver instability and caregiver turnover. This

phenomenon was consistent across all nursing disciplines, but was most prevalent

among the unlicensed nursing staff (Castle).

       In addition to the instability in the workplace, Tounsel and Reising (2005)

found that the actual work environment also contributed to caregiver turnover.

Turnover within similar position, increased job dissatisfaction, and stressful

working conditions resulted in increased frequency of burnout and increased

complaints of emotional exhaustion among hospital-based nurses. Feelings of

incompetence led to decreased job performance, absenteeism, tardiness, physical

illness, drug use, and ultimately job turnover (Tounsel & Reising, 2005). These

activities were seen more frequently in younger nurses as compared to their older

counterparts. In addition, younger nurses left nursing practice altogether within a

year because of these factors. Tounsel and Reising concluded that work

environments that support a greater sense of collaboration, mutual support

between coworkers and administration, and sufficient staffing experienced

increased levels of job satisfaction and decreased levels of burnout. Tounsel and

Reising also found that burnout accelerates with decreased sense of personal

accomplishment and that ensuring an environment that promotes a sense of well

being may prove beneficial in addressing employee turnover.

       An additional study conducted by Hayhurst, Saylor, and Stuenkel (2005)

summarized an examination of work factors and their association to nursing

turnover. Using a descriptive, correlational design, Hayhurst et al. analyzed

factors affecting decisions to stay, change departments, or leave the work setting
                                                                                   51

completely. The level of perceived supervisory support and opportunities for

ongoing skills enhancement significantly influenced unit-based and organization-

wide nurse turnover. Nurses provided with growth opportunities, which felt

supported in their efforts for skills development and advanced education, were

more likely to stay, than those who did not.

       Nedd (2006), Castle (2005), Tounsel and Reising (2005) and Hayhurst et

al. (2005) outline the importance of skills development and skills enhancement

activities in ensuring higher levels of job satisfaction for nurses. These individuals

also highlight the correlation between job satisfaction and nurse turnover.

Although supervisory support was noted as an important factor, adequate

preparation and support of skills enhancement was quite significant with respect

nurse turnover, and may demonstrate value if incorporated into strategies that

address the nursing shortage.

Nursing Shortage Factors

       The current nursing shortage has resulted in an increase in research to

identify how to keep practicing nurses from leaving the workforce, and to

recapture those who have previously abandoned the nursing profession. Efforts

are also underway to improve public perception of nurses in order to increase the

number of incoming nurses. Evaluating the factors that contributed to the nursing

shortage may assist in develop strategies to reduce the number of nurses leaving

the profession while also increasing the number of individuals joining the

profession.
                                                                                     52

       The image of nurses is rising to the surface as a significant factor in the

nursing shortage and is certainly worthy of review with respect to the nursing

shortage and new RN turnover. Seago, Spetz, Alvarado, Keane, and Grumbach

(2006) examined the significance of image with respect to the nursing shortage.

During this study, individuals were asked to rank certain factors to indicate their

perception of nurses. The study participants ranked working independently,

prestige and status, and job autonomy quite low as compared to other variables

such as income potential, making a difference, and interesting work. Seago et al.

indicated that although the perception of the nursing profession was quite good as

it pertains to income potential, job security and making a difference, the

perception of nursing with respect to prestige, status and independent practice was

very low compared to that of other professions. Seago et al. concluded that lack of

prestige and recognition significantly affected the participants’ desire to select

nursing as a career. These researchers also found that these factors might

contribute to nurses seeking employment outside of the nursing profession.

       Rising demands on nurses, minimal growth in wages, demographic

changes, and stressful work environments have come to the surface as factors that

contribute to the nursing shortage (Buerhaus, Donelan, Ulrich, Norman,

DesRoches, & Dittus, 2007). In addition, Buerhaus et al. identified ineffective

communication, lack of teamwork, and negative perception of the nursing

profession as factors influencing nurse retention. These factors also inhibit the

ability to increase the number of individuals entering into the nursing profession.
                                                                                     53

       Fewer individuals desiring to enter into the nursing profession is also

influenced by the cycle of change that is present in nursing (West, Griffith, &

Iphofen, 2007). The frequency of revisions to care regulations and guidelines

results in a constant state of change with respect to how nursing care is

implemented. Another factor affecting ones desire to enter the nursing field is the

need for ongoing improvement in mastery of skills, with little resource allocation

to assist with skills development. Healthcare organizations and academic

institutions must maintain operations using limited resources. Resource allocation

requires careful consideration and prioritization, often leading to education

receiving a lower priority status, thus limiting the resources that are directed

toward nursing education in both settings (Fagin, Maraldo, & Mason, 2007).

Other factors included long work hours, increased work responsibilities, and an

ongoing imbalance of work and home life. In addition, nurses continue to

transition from acute care facilities to outpatient and other venues due to the

higher likelihood of having less responsibility and the existence of more

traditional work schedules (West et al.).

       An additional factor that has received little attention is the inability of

nursing schools to accommodate admission of qualified applicants. The American

Association of Colleges of Nursing (AACN) (as cited in Oncology Nurse Society

Connect (ONS), 2007), found that over 32,000 qualified applicants were turned

away from nursing programs between 2005 and 2006. AACN also states that in

order to address the nursing shortage, nursing schools will have to increase the

number of graduates by 90%. Although nursing school graduate numbers
                                                                                     54

increased by 18% over the study period, the number of graduating nurses

continues to fall short of the projected need due to lack of funding and a rapidly

declining pool of qualified nursing faculty (ONS, 2007).

       Lin, Juraschek, Xu, Jones, and Turek (2008) examined the current nursing

supply in California in order to identify the magnitude of the nursing shortage.

According to Lin et al., the RN supply per capita in the majority of California

counties scored very low with respect to nursing supply. The Central California

region received an “F” grade, indicating standard deviation of at least two below

the national standard for RNs per capita. Lin et al. (2006) concluded that the

nursing shortage in California, particularly in the Central California region, the

location of this study is of a critical nature and rapid resolution must occur in

order to prevent a negative impact on care quality in the area.

       The literature clearly outlines multiple reasons for the nursing shortage.

Lack of prestige and recognition, insufficient wage scale, lack of resources for

skills enhancement and education, and lack of qualified faculty present a

collective challenge that has further exacerbated an already critical nursing

shortage. A multifaceted approach to resolving this problem must be considered.

Increased focus, allocation of resources, higher prioritization, and rapid

intervention are necessary to address this issue on a permanent basis.

Student-to-practitioner Transition

       Student-to-practitioner transition for individuals entering the nursing

workforce has received far less attention than other factors contributing to nurse

retention. This is true particularly as it pertains to ongoing training and
                                                                                     55

development (Bowles & Candela, 2005). In spite of the knowledge that

hospitalized patients are sicker and have shorter inpatient lengths of stay, new RN

clinical orientation and skills validation has remained unchanged. This lack of

modification in training and skills development has left the incoming registered

nurses ill prepared to care for the patients entrusted to them (Craven, Mengel, &

Barham 2004; del Buenos, 2005; Harrison, 2007).

        Bowles and Candela (2005) and Naude and McCabe (2005), examined the

perceptions of new RNs with regard to their first registered nurse positions. The

inquiry in both studies focused on if the new RNs left their first nursing positions

and the reason they left. Bowles and Candela used 352 new RNs who volunteered

to participate in the study. The participants were asked if they left their first

nursing position and if so, why they left the position. In this study, 30% of the

participants left their first nursing position within the first year of employment

and 57% left within the second year. Study participants cited patient care issues

such as stressful work, staffing levels, not enough time with patients, and work

conditions as the most negative aspects of the job. Other factors that contributed

to new RN turnover included negative work atmosphere, no opportunities for

advancement, lack of sufficient patient care supplies, and floating to areas where

they did not feel qualified.

        Naude and McCabe (2005) noted four factors as primary determinants of

nurse retention. Those factors included friendly and supportive staff, supportive

and effective management, job satisfaction and effective staff development
                                                                                    56

programs. The presence of an environment that provided ongoing learning

opportunities, and specialized training were significant factors in nurse retention.

       Although some focus has been directed toward improving the preparation

of new RNs through educational support and transition programs, new RN

transition programs remained the same in spite of the changing patient population

(Levett-Jones, 2005). The lack of sufficient research to evaluate the ongoing

effectiveness of such programs created a knowledge deficit and resulted in

inadequate preparation of new RNs for clinical practice. The lack of additional

focus in these areas has also limited the availability of such programs, thus failing

to meet the needs of new RNs. Both Levett-Jones (2005) and Naude and McCabe

(2005) provide excellent information with respect to new RN transition, but failed

to identify the relationship between transition programs and new RN retention.

They also fail to explore if use of individualized orientation programs would

provide better preparation for practice or increase new RN retention.

       After an extensive study on new RN turnover, Connelly (2005) identified

that rapid turnover of new RNs may be indicative of perceived suboptimal

socialization and acceptance into the new work setting. Making the new RN feel

comfortable and supported during the transition period and beyond may prove

beneficial in reducing turnover. Connelly also posits that the possibility of new

RNs feeling overwhelmed is quite likely. Therefore, providing sufficient bedside

training and educational support may contribute to new RN retention and

increasing job satisfaction.
                                                                                    57

        In addition to socialization and promotion of sufficient bedside training

and educational support, Guhde (2005) identified a huge deficit in support of new

RNs during the early periods of independent practice. The frustration level of new

RNs has intensified over the years due to high patient acuities, increased

workload demands, and decreased support from peers and colleagues. Gudhe

identified the need for formal post-orientation programs that last a minimum of

four months. These programs should be patient-centered and provide new RNs

with nursing concepts that may be incorporated in independent practice and

provide a sense of confidence in skills level and task completion. Such programs

should provide a designated individual to shepherd the new RN through the first

year of independent practice. Although these types of programs are time-intensive

and can increase labor expense, the reduction in turnover and the improvement in

job satisfaction may offset any additional labor costs. Any program that assists

new RNs in learning the trade and increases their level of job satisfaction can only

prove mutually beneficial to the nurse and the healthcare organization (Gudhe).

       Casey, Fink, Krugman, and Propst (2004) investigated the stressors and

challenges experienced by new RNs. The study participants consisted of 270

nurses from six Denver hospitals who were in their first year of practice. Using a

descriptive, comparative design with survey style questionnaire, Casey et al.

examined the perceptions of new RNs regarding their skills and procedure

performance, comfort and confidence, job satisfaction, and role transition. Of the

209 respondents, only 4% were comfortable performing all skills and procedures.

The majority of the participants stated decreasing job satisfaction as they gained
                                                                                     58

experience. Stressors related to role transition were significant, specifically in the

areas of confidence with skill performance, deficits in critical thinking, and

clinical knowledge; relationships with peers; struggles with dependence on others

(while desiring independence); frustration with work environment; organization

and priority setting skills; and communication with physicians. In addition, many

of the participants expressed concerns about peer and preceptor relationships,

stating that they felt a lack of acceptance and they disliked the labels placed on

them during their first year of nursing practice, such as new graduate, green, etc.

The participants believed that the precepting process lacked personalization, that

preceptors were out of touch with the new RN experiences, and that the

preceptors lacked sensitivity. Casey et al. concluded that in addition to anticipated

stressors during the first year of practice, new RNs experienced additional

stressors related to personalization of orientation processes and relationships with

preceptors. The individualized concept of learning style-based orientation for

might assist in improving the level of personalization, and may improve new RNs

perception of the preceptors understanding of what the new RNs experience. Such

a process may lend toward retention of new RNs.

       In an effort to resolve issues mentioned in previous sections, academic and

healthcare organizations have designed programs with the goal of ensuring

effective transition from student-to-practitioner for new RNs. These programs

combined didactic and supervised clinical practice to provide an educational

foundation to assist transition of new RNs into practice (Truman, 2004). The

program, as described by Truman, resulted in improved clinical competence and
                                                                                    59

confidence in skills required to carry out nursing care functions and demonstrated

increased professionalism for program participants. The participants also reported

greater job satisfaction, and they remained invested in the hospital as an

organization while seeking a deeper commitment to the organization (Truman).

       Cavanaugh and Huse (2004) used an interactive program to assist with

new RN transition. The program components included a set of tasks and decision

points that allowed new RNs opportunities to improve concept application. The

pilot program participants consisted of 27 newly- employed nurses who were

oriented over a two-year period. Similar to Truman’s, this program consisted of a

combination of didactic and clinical instruction. Each week, the educational

program built upon subject matter presented in the prior week. The program was

considered successful due to the post- program RN retention rate of 93% and a

positive subjective evaluation of skills and competency of the participants.

Cavanaugh and Huse presented convincing anecdotal evidence of success;

however, due to the lack of scientific analysis, these data do not provide sufficient

information to ascertain the true success of the program.

       Floyd, Kretschmann, and Young (2005), describe a structured program for

orientation of new RNs. The program provided clinical and transitional support

for 37 incoming new RNs. The orientation program structure was consistent with

that used by Truman (2004) and Cavanaugh and Huse (2004) which consisted of a

combination of didactic and supervised clinical instruction. According to Floyd et

al., the students used the term enthusiastic to describe themselves, yet the post

program evaluation demonstrated an ongoing lack of confidence and difficulty in
                                                                                    60

acclimating to the new work environment. Approximately one-half of the

participants’ desired ongoing support from preceptors after the program

concluded. As reflected in the preceptors’ post-program evaluation, preceptors

believed that the training was insufficient for the tasks required, and that

expectations were unclear. The preceptors were also concerned about the

workload burden placed on new RNs and that the new RNs were not sufficiently

prepared for the reality of independent practice.

       A pilot study conducted by Schoessler and Waldo (2006) used an 18-

month developmental transition model for training new RNs. The model

integrated multiple concepts, including adult learning and transition theories to

assist the new RN in transitioning from student-to-practitioner. The program

consisted of three themes and marker events. The first theme, the ending,

represented the learning of tasks, struggling with organizational skills, developing

processes for patient and family member relations and communication, and

relating to peers and physicians. The marker for the ending theme was the first

patient death, the first error, and the need for ongoing skills development with

related to the first patient death or first error. The second theme, the neutral zone,

represented the nurses’ fear of patient inquiry, the lack of sufficient knowledge to

address the patients’ educational needs, ability to integrate with the team and

peers, and physician communication. The marker for the neutral phase was that

other staff members began to seek advice from the new RNs. The final period, the

new beginnings period represented the new RNs comfort with procedures, and

other job related expectations, improvement in organizational skills, and ongoing
                                                                                    61

improvement in physician relations. The marker for this phase was that the new

RNs would begin precepting or training other nurses. Schoessler and Waldo

concluded that integration of the novice-to-expert process, transition-management

and use of an experiential learning cycle provided a comprehensive approach to

assisting new RNs during their transition to professional practice. The combined

instructional modalities also assisted in expanding teaching techniques for

preceptors and in improving their ability to provide a more comprehensive

transition process for new RNs (Waldo & Schoessler, 2006).

       Other authors such as Butler and Hardin-Pierce (2005) discuss the need

for increased focus on new RN transition from student-to-practitioner and the

need for leadership to play a more substantial role in providing resources that

promote a seamless transition, optimize learning opportunities, and facilitate a

welcoming environment. Although beneficial, these transition programs have not

significantly influenced turnover rates for new RNs since the new RN turnover

rate continues to exceed that of their more experienced counterparts (Pickens &

Fargotstein, 2006).

       Modifications to new RN orientation, such as individualized instruction

and use of flexible teaching modalities, have shown some promise. These

interventions improved job satisfaction and retention (Block, Claffey, Korow, &

McCaffrey, 2005). Individuals who participated in preceptor programs also

reported improvement in the work environment. According to Beecroft,

Kunzman, Taylor, Devenis, and Guzek (2004), the comprehensive nature of the

training during the transition period clearly affects the success of new RNs with
                                                                                    62

respect to workplace transition. Such training has also proven beneficial in

reducing turnover of new RNs. Sufficient preparation for independent practice,

the work environment, and ongoing support in the transition period were

important factors in each of the studies reviewed. New RNs who participated in

programs designed to provide transition support and ongoing learning

opportunities have demonstrated increased commitment to their first employer,

increased confidence in their ability to provide quality nursing care, and lower

turnover rates (Beecroft et al., 2004).

Adult Learning Concepts

       Incorporating adult learning theory through use of multiple instructional

strategies has proven beneficial in addressing the individual needs of adult

learners (Sims, 2006). In addition, instructional designs that include strategies and

resources that address the particular way people learn increase the potential for

concept retention and better grasp of the subject matter. Sims suggests that in

order to improve the learners ability to apply concepts and increase retention of

learners in educational settings, heavier emphasis must be place on developing

instructional models that “emphasize and acknowledge the role of the learner and

embrace the shift toward a learner-centered focus” (p. 6).

       Adult learning concepts are based on the understanding that life

experiences serve as an instructional resource for adults to incorporate concepts

and themes into their daily lives. Adult learners provide significant contribution to

determining what is learned, and the presentation and application methods used to

determine how information manifests in their daily existence (Wickett, 2005).
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Adult learners are active participants in their learning experience as they

collaborate with others to optimize the learning opportunity (Gaibraith & Fouch,

2007). According to Norrie and Dalby (2007), the foundation of andragogy

consists of the learner’s need to know, the learner’s self-concept, the role of the

learner’s experience, readiness to learn, and orientation to learning. Each of these

foundational elements is unique to adult learners due to the adult learners’ ability

to apply life experiences, and to vacillate between learning from others and

teaching themselves. Due to the complexity and subjectivity of adult learning

concepts, the principles of adult learning are not evidence-based, but are used as

models based on learning assumptions derived from various research studies

focused on adult learners and adult learning concepts (Norrie & Dalby). The

success of application of adult learning concepts is dependent upon personal

motivation of the learner, meaningful topics, experience-centered focus, and

appropriate levels of knowledge, individualized presentation, clear goals, active

involvement, and regular feedback. Success of application of these concepts is

also dependent upon the ability of the instructor to allow time for reflection

(Halfer, 2007; Lake & Ryan, 2004). Personal motivation and experiential learning

are major themes in the application of adult learning concepts in academic and

workplace settings. Illeris (2003) suggests that:

       The competence that is needed cannot be established and acquired through

       education in the more traditional sense because of a constant need for

       change and renewal, and because usability depends on it being linked to a

       number of personal characteristics such as flexibility, creativity and
                                                                                    64

       independence, the ability to cooperate, responsibility and self orientation

       (¶ 2).

       Illeris (2003) concludes that adult learning in the workplace should be

conducted in a manner that is suitable to the learner. Further, adult learning

strategies should also be flexible in context to ensure a firm grasp of concepts and

to increase the ability for concept application. Diversity in adult education

facilitation modalities is important in order to optimize learning opportunities

(Zepke, 2005). The learning opportunities must include incorporation of

individual learning styles and use of experiential learning concepts to assist in

solidifying the understanding of concepts through real life application (Zepke).

With respect to new RN training, Orsini (2005) suggests that the use of adult

learning concepts and dedicated nurse preceptors resulted in 100% retention of

new RNs. Increased quality of care, increased patient satisfaction, and increased

employee satisfaction were unexpected, but were welcomed benefits of this form

of new RN educational preparation.

       Adult education is highly dependent upon real life application of concepts,

adult participation in objectives, enjoyment of the learning experiences, and

diversity of methods of information dissemination. These themes are consistent

with the foundational elements of learning style-based education. Adult education

concepts also provide foundational elements on which to expand and build more

comprehensive, individualized educational programs.
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Learning Styles

The purpose for determining and using learning styles in adult education, in

general, and in new RN education, specifically, is to assist in developing learning

experiences that are meaningful and are closely aligned with the particular needs

of that individual (McDonough & Osterbrink, 2005). When creating learning

opportunities and developing of educational materials, focus should be placed on

incorporating multiple intelligence concepts (Gardner, 2003). Gardner outlines

nine intelligence modalities. The linguistic intelligence addresses language as it

pertains to reading, writing, thinking of words, and verbal communication. The

logical-mathematical intelligence represents the ability to understand cause and

effect, and to work with numbers, operations, and logical reasoning. Spatial

intelligence addresses the internal world such as one’s mind. This intelligence

supports actions such as reading maps, charts, and puzzles and is the foundation

of imaginative thought. The kinesthetic intelligence uses the body to dance, carry

out athletic activities, act, and initiate other motion-related activities. The musical

intelligence supports hearing music, recognizing patterns, identifying sound, and

other activities related to melody and rhythms. The interpersonal intelligence

supports actions required to work with other people, collaborate on projects and

communicate. The intrapersonal intelligence supports self-understanding,

recognition of strengths and weaknesses, and personal goal setting. The

naturalistic intelligence provides the means required to differentiate between

plants, animals, and other natural entities surrounding us (Barrington, 2004;

Denig, 2004). Each of these intelligences is present in all individuals, however,
                                                                                   66

certain intelligences are more dominant and more significant to an individuals’

ability to receive and process concepts. According to Gardner (2003), “the

culturally-constructed sphere of knowledge must bear some kind of relation to the

kinds of brain and minds that human beings have, and the way that those brains

and minds grow and develop in different cultural settings” (p. 11). The culturally

constructed sphere of knowledge, to which Gardner refers, not only represents

ethnic culture. It also includes community, environmental, educational, religious,

and professional culture; and cultures particular to how individuals receive and

process information. Gardner, through the theory of multiple intelligence, gave

rise to various constructs of learning styles and the manner in which these

learning styles are incorporated into the education of both children and adults.

       In contrast, Gardner’s theory has also given rise to concerns regarding the

lack of field staff evaluation of the theory application and lack of analysis of

methods of implementation (Kornhaber, 2004). Additionally, lack of substantive

evidence that implementation of TMI resulted in change in educational practice or

follow up studies casts doubt on the verifiability of Gardner’s claims (Kornhaber).

Kornhaber sought to examine these concerns and conducted a study evaluating

the following questions; (1) why educators adopt TMI, (2) once TMI is adopted,

does anything really change in practice, and (3) when educators claim TMI is

working, what is actually happening in practice?

       According to Kornhaber (2004), TMI complemented the currently

philosophies of the educators. TMI provided a foundation for development and

organization of educational methodologies, and TMI assisted educators in
                                                                                    67

extending their current teaching practices. Kornhaber also found that change did

occur at the locations where TMI was adopted, however the change was

dependent upon the practices at that location, prior to implementation of TMI

based educational practices. Educational institutions that incorporated TMI

reported improvement in standardized test scores, improvement in student

behaviors, increased parental participation, and improvement in performance of

students with learning disabilities (Kornhaber)

       Rita and Kenneth Dunn (as cited in Denig, 2004), suggest that learning

style is the way individuals begin to process, internalize, and remember new

information. In addition, Dunn and Dunn (1979) also suggest that intelligence is

not dependent upon potential, talent or innate ability, but is demonstrated based

on the manner in which people perceive situation, comprehend and adapt to new

situations, how they learn from experience, comprehend and effectively simplify

complex matters, solve problems, analyze information and arrive at

comprehensive, well-develop decisions. Learning style concepts suggest that

environmental, sociological, physiological, emotional, and psychological

variables influence the proper learning environment, based on the preference of

each individual (Dunn & Dunn). The environmental variable considers the

amount of light, sound, temperature, design, and the learning environment

configuration. The sociological variable is inclusive of self, pair, peers, team,

adult, and various combinations of each. The physiological variable includes

perceptual aspects of learning such as hearing, visual, tactile, and kinesthetic. The

emotional variable includes consideration of motivation, level of persistence,
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responsibility, and type of educational structure. The psychological variable

considers the manner in which the individual analyzes information, such as global

(requires the big picture before detailed exploration), hemisphericity (prominent

use of right or left side of brain), and impulsive-reflective (type of process uses to

draw conclusions). In addition, each learner’s primary learning style is an

essential consideration in the development of learning opportunities and in

ensuring a proper learning environment that will optimize the learning experience

(Denig, 2004).

       Kolb (2005) developed a learning style model that arose from the

categorization of personal characteristics. The personal characteristics were then

used to determine the optimal educational approach. This learning styles model

consists of four types of learning styles, convergers, divergers, assimilators and

accommodators. Convergers approach learning from a more abstract perspective

using active experimentation to apply learned concepts. Individuals with

converging learning styles tend to excel in situation where a single correct answer

is required. The diverger is more reflective and uses observation and concrete

experience to comprehend theories and concepts. The diverger is more interested

in people and tends to be more emotional and imaginative. Assimilators learn best

through use of observation to integrate information. The accommodator prefers

learning opportunities that are more experiential and uses concrete versus abstract

methodologies to draw conclusions or make decisions (Kolb).

       Multiple learning style concepts were developed because of the research

conducted by Malcolm Knowles (1980), among others, with respect to learning
                                                                                   69

styles and the significance of individualized learning environments. Application

of these is apparent in the work of Neil Fleming, a researcher and educator in

New Zealand. Neil Fleming, through nine years of observation and quasi-

experimental research, identified specific perceptually-based learning style

classifications that have proven successful in high school and university settings

(Personal communication, Neil Fleming, VARK researcher, May 22, 2007).

Fleming (2005) developed the VARK learning style inventory using the concepts

from the VAK learning styles assessment, which encompassed considerations for

visual, auditory and kinesthetic learning styles. Although applicability of the

VAK learning style was easily identified, Fleming recognized that the visual

component of this learning style assessment needed further revision. This

component needed to be further divided into visual with respect to text and visual

with respect to symbols and graphs. Subsequently, Fleming expanded the VAK

learning style assessment to include a separate learning style designation of read-

write (Personal communication, Neil Fleming, VARK researcher, May 22, 2007).

VARK

       The VARK learning style inventory (see Appendix C) is a tool that can be

used to evaluate the learning preferences of individuals based on sensory input

(Fleming, 2005). These learning styles focus on four perceptual learning

dimensions, visual, auditory, read/write, and kinesthetic. Using scenario-based

questions to assess the learners’ preference, educators may use the VARK

Learning Styles Inventory to identify the preferred learning styles of students.
                                                                                  70

This information may be used to incorporate learner preferences into information-

delivery processes (Tanner & Allen, 2004).

       Fleming (2005) suggests that the visual learner prefers to receive

information through demonstration and learns best through description. This type

of learner may use task lists to create an organized approach to tasks and to

organize thoughts. The auditory learner learns through listening. This learner

enjoys discussion and prefers to resolve issues through talking. Read-write

learners are perpetual note takers. These learners learn through written word, and

translate information through note taking. Rewriting information is also used as a

means to comprehend difficult material. The kinesthetic learner comprehends

information by doing the tasks and prefers hands-on experience (Fleming).

       Learning style preference is dynamic and may be manifested in single, bi-

modal, or multi-modal form (Fleming, 2005). The more predominant learning

style may change depending on the passage of time or the topic under review. For

this reason, learning style assessment must be an ongoing process. Learning style-

based education must be flexible, using diverse educational methods to ensure

that the methods are consistent with the learner's educational needs (Denig, 2004;

Fleming, 2005).

       Learning style concepts highlight the importance of individualized

instruction and learning style-based orientation. By individualizing learning

experiences through learning style-based orientation, “learners are allowed to use

their strengths and not be marginalized by having to focus on traditional ways of

learning which is even more important as we consider the increased diversity of
                                                                                   71

students in today’s society” (Barrington, 2004, p. 423). By analyzing workplace

instruction specific to flexible delivery of workplace educational programs, Smith

(2003) found that even though the five stages of skill development (novice,

advanced beginner, competent, proficient, and expert) were understood by

employers, modification in learning environments based on level of skill

development did not occur. Use of cognition and expert learning models were

insufficient in workplace settings, essentially indicating that learning style-based

education had not been thoroughly incorporated into workplace orientation

modalities (Smith). With respect to new RN orientation, employers continue to

develop programs to address the high turnover rates of new RNs. Multiple

programs such as preceptor and mentor programs and residency programs

continue to provide marginal benefits. Significant reduction in new RN turnover

has not been evident because of these programs. Studies on modalities for new

RN orientation continue to reflect research focused on ensuring the ability of new

RNs to carry out patient-care-related tasks. Minimal consideration is given to

level of comprehension. New RNs are finding that they are unable to comprehend

the complexity of the tasks performed. New RNs also state that they are unable to

process the information in order to understand the task, the reason for carrying out

the task, and the expected outcome (Butler & Hardin-Pierce, 2005). Many new

RNs experience “negative emotions including fear of making mistakes, stress of

inability to manage all aspects of care for complete patient assignments, which

results in a clash between school values and the reality of clinical practice”

(Squires, 2002, p. 203). As a result, new RNs experience a sense of being
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overwhelmed and subsequently transition their practice to less intense

environments or to an environment in which they feel better able to meet

performance expectations (Squires).

       Learning style-based orientation is supported by research as an effective

method of optimizing comprehension in adult learners in vocational training

(Boyle, Duffy, & Dunleavy, 2003; Drago & Wagner, 2004; Fleming, 2005; Loo,

2004). Use of learning styles was found beneficial in creating improved

workplace experiences for new apprentices. Use of learning style-based

orientation in apprentice training proved valuable in improving the workplace

learning experience for this group. These concepts have the potential of positively

affecting the orientation process of new RNs. The improvement in orientation

may be realized by individualizing teaching and learning processes through

presenting information in a manner that optimizes comprehension and increases

the ability to apply learned concepts (Harris, Simon, & Bone, 2006).

       New RNs have expressed a significant level of stress related to

transitioning to independent practice particularly in the areas of level of support

during transition period, fear of failure due to perceived lack of sufficient

preparation, and discomfort during initial practice periods (Squires, 2002). This

stress is the result of several factors. Improvement in support, adjustment in

methods of orientation, and stress reduction activities may significantly improve

the level of comfort during the early practice periods and may subsequently

improve retention rates. This information further supports the need for more
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detailed examinations of specific factors that may affect retention rates for new

RNs and provides foundational data for this study.

       Fleming (2005), Denig (2004), and Harris et al. (2006), among others,

clearly suggest that the type of training provided and the processes used to

prepare individuals to carry out activities are significant factors in determination

of employee turnover. This information, if applied to new RN orientation, may

prove beneficial in developing effective methods to transition new RNs from

student-to-practitioner, thus potentially reducing turnover related to stress and

feelings of being ill prepared. Although these studies provide vital information on

instruction and orientation to new tasks, a knowledge deficit regarding methods

that might be used to enhance clinical education programs remains (Etheridge,

2007). An exploration of this concept is presented in the Gaps in Knowledge

section. This section also includes further justification for additional research in

the area of learning styles use in new RN workplace orientation.

                                    Gaps in Knowledge

       Each of the authors presented in the previous section summarized

identifying factors affecting turnover in general and, more specifically, turnover

of new RNs. Information on turnover rates of new RNs suggests that appropriate

support, opportunity for skills development, and stress reduction activities are

significant areas of consideration. Focus on and subsequent development of

strategies in these areas may ensure seamless transition from student-to-

practitioner and perhaps prevent turnover (California Institute for Nursing and

Healthcare, 2006). Although learning style concepts have been applied
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successfully in other vocational areas, application in nursing has not received the

needed attention (Fleming, VARK researcher, Personal communication, May 22,

2007). A significant gap in knowledge exists, particularly with respect to

understanding the utility and application of adult learning concepts in nursing

orientation and use of learning style concepts during the hospital-based

orientation period.

Significance of Learning Styles in Nursing Education

       A need to identify and develop methods to meet individual learning needs

clearly exists. Whether in the realm of education, skills development, or concept

application, individualized educational methods may prove beneficial in assisting

individuals in improving competence and increasing comfort in performing

assigned duties. Application of these concepts may lead to stress reduction,

improved comprehension and implementation of learned concepts. Incorporation

of information obtained through the research studies presented may improve

workplace-based nursing education. Use of adult learning concepts and learning

style-based orientation programs may lead to reduced stress, improved concept

comprehension, and reduced turnover among new RNs.

                                        Conclusion

       New RN turnover rates remain high, and the gap between nursing supply

and demand continues to increase. In spite of information establishing benefits of

learning style use in the educational realm and the confirmation of the utility of

learning style-based orientation in the workplace, the use of learning style-based

orientation for new RNs remains an area of minimal exploration. A clear
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relationship exists between new RN turnover and the comprehensiveness of

preparation activities directed toward ensuring adequate preparation of new RNs

for independent practice (Beecroft et al. 2004; Floyd et al. 2005). Adult learning

models may provide a solid foundation on which to modify current nursing

orientation practices. The adult learning model, in combination with the multiple

intelligence-based learning style concepts, supports the potential for positive

outcomes associated with incorporation of learning style-based orientation in the

workplace. Learning style-based clinical orientation for new RNs failed to garner

the deserved attention and is worthy of more in-depth investigation and analysis.

                                         Summary

       A review of nursing shortage data indicates a need for intense evaluation

of all aspects of nursing orientation and training. The average mean age of

practicing nurses and the anticipated exodus of nurses from the workforce within

the next 10 years supports the need for increased focus on adequate preparation of

new RNs and on strategies to retain new nurses in the workforce. Evaluation of

research data of turnover in both nursing and non-nursing professions indicates

consistent findings related to job satisfaction, lack of advancement opportunities,

and other work-related issues. Research data on new RN turnover confirms the

existence of a major deficit in preparation for practice, appropriate work

environments, and transition management (Bowles & Candela, 2005; Casey, Fink,

Krugman, & Propst, 2004). In order to find a more effective solution to address

new RN turnover, healthcare organizations may benefit from the exploration of

other educational modalities and begin to evaluate instructional methods that have
                                                                                    76

proven successful in other venues. The focus of this study will be to explore the

effect of incorporation of learning styles into new RN clinical orientation during

the first six months of independent practice. Chapter 3 will outline the

methodology that will be used for this study.
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                                 CHAPTER 3: METHOD

       The purpose of this quantitative, quasi-experimental, non-equivalent group

study was to analyze the effect of learning style-based clinical orientation on

turnover rates for new RNs. The conclusions of this study were obtained by

analyzing the turnover rates of a cohort of RNs who participated in a learning

style-based orientation program. The turnover rates of this cohort were compared

to an existing cohort of previously graduated new RNs who participated in a non-

learning style-based clinical orientation program. Both cohorts had similar

demographic characteristics. The study data was obtained from clinical

orientation groups from three Bakersfield, California, acute healthcare facilities.

       In order to minimize the effect of the nursing shortage, significant change

must be implemented to mitigate this phenomenon (Aiken, 2001). Focusing on

the manner in which RNs are oriented into practice settings after graduation may

be the venue to accomplish this goal. A learning style-based clinical orientation

program provides a mechanism that uses preferred learning styles to improve the

learners’ retention of information, thus increasing the new RNs’ ability to provide

competent nursing care. Improving the RNs preparation for independent nursing

practice may perhaps increase the RNs desire to maintain current employment.

       This study was conducted to analyze the effect of learning style-based

clinical orientation on the turnover rate of new RNs. Included in chapter 3 is a

description of the research methodology, summary of the population, and

identification of data collection procedures. Chapter 3 also includes a review of
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the reliability and validity of the data collection tools and a summary of the

method of data analysis.

                                  Research Design

       This quantitative, quasi-experimental, non-equivalent group study

included the use of a demographic questionnaire to gather data to compare

demographic characteristics of the cohort who participated in the learning style-

based clinical orientation program and the previously, graduated cohort who

participated in a non-learning style-based clinical orientation program. This data

was used to identify similarities or significant differences that may have affected

the study findings. The turnover rate data from the previously, graduated new RN

cohort was obtained from the human resource departments of each study site. The

data was reported in aggregate form and was used as baseline data with respect to

turnover rates of new RNs who participated in a non-learning style clinical

orientation program. The baseline data was compared to the new RN turnover

data for the cohort who participated in a learning style-based clinical orientation

program. The comparison of turnover rates was used to determine the effect of the

learning style-based clinical orientation program on turnover rates of new RNs

during the first six months of nursing practice. This study also used the VARK

learning style inventory to allow the study participants to identify their preferred

learning style. The learning style determination was used to incorporate those

learning style preferences into the clinical orientation process of the study

participants.
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       Quantitative research is used to refine knowledge using objective and

systematic strategies to identify relationships between variables. This information

may be used to adapt knowledge application processes (Sousa, Driessnack, &

Mendes, 2007). Several quantitative research designs were considered for this

study. Quantitative research focuses primarily on four types of studies:

experimental, quasi-experimental, pre-experimental, and non-experimental. These

types of studies are most useful when attempting to analyze the presence or

absence of relationships between one or more variables (Duffy, 2005).

Experimental research is considered the strictest form of research. Experimental

research is only considered valid when a comparable intervention is implemented

between the non-learning style clinical orientation group and the learning style

clinical orientation group under controlled conditions. This type of quantitative

research is considered the most powerful method of testing hypotheses with

respect to cause and effect relationships (Polit & Beck, 2004). A true

experimental design was not used for this study due to the inability to fully

control or regulate internal or external variables and the inability to randomize the

study participants.

       Quasi-experimental research designs are similar to experimental research

designs because both design types examine cause and effect relationships between

or among dependent and independent variables (Polit & Beck, 2004). Quasi-

experimental research is most useful when attempting to analyze the effectiveness

of one or more interventions during the course of natural occurrences and in the

most common settings (Sousa, Driessnack, & Mendes, 2007). Due to the
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increased threat to internal and external validity, the ability to generalize findings

in both experimental and quasi-experimental studies may be decreased. Quasi-

experimental research lacks randomization and is most often used when the

differences between the groups were previously identified. In spite of the pre-

existing group differences, the ability to test the effect of introduction of a

particular variable or variables still does exist (Salkind, 2003).

       Pre-experimental research designs do not include a mechanism to

compensate for the lack of randomization of subjects. These types of studies also

have insufficient safeguards to protect against internal and external validity

threats (Polit & Beck, 2004). Due to the nature of this study and the lack of

sufficient compensation for lack of randomization or safeguards against validity

threats, the pre-experimental research design was not selected for this study.

        Non-experimental studies are used to “describe, differentiate, or examine

associations, as opposed to direct relationships, between or among variables,

groups or situations” (Sousa, Driessnack, & Mendes, 2007, ¶ 5). Non-

experimental cohort studies are used in research when observation of the activities

of participants during their natural state, or under natural conditions is desired

(Polit & Beck, 2004). Investigators use non-experimental studies when

manipulation of conditions is not possible, or when the investigator wishes to

observe a phenomenon as it naturally occurs (Polit & Beck).

        Non-equivalent group studies are structured similar to pretest-post test

studies. This type of study design is often used when random assignment of study

subjects is not possible and equity of group characteristics cannot be guaranteed
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(Trochim, 2006). Non-equivalent group studies, although valid, are susceptible to

the internal validity threat of selection. The threat to internal validity must be

considered when analyzing study findings (Trochim, 2006). In this study, the non-

learning style-based clinical orientation group and the learning style-based

clinical orientation group participated in their respective clinical orientation

during different periods. Randomization of study participants was possible due to

the limited number of available participants and the specific criteria outlined for

the study. The criteria for inclusion in the study lends toward self-selection,

further supporting the inability to randomize study participants and eliminating

the ability to use research designs that require subject randomization.

       The intent of this quasi-experimental research study was to determine the

effect that introduction of a learning style-based clinical orientation for new RNs

had on turnover rates after six months of clinical practice. The study examined a

single independent variable: a learning style-based method of conducting clinical

orientation. The introduction of this variable occurred during the initial phase of

post graduation clinical education in the hospital-based clinical education

program.

                             Appropriateness of Design

       A quantitative, quasi-experimental, non-equivalent group design was

appropriate for this study because it uses existing theory to identify the presence

or absence of a relationship when theoretic principles are applied in real life

situations (Polit & Beck, 2004). This type of research is fairly structured, yet

allows variability in timing and frequency of data collection (Polit & Beck).
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Quantitative research designs allow multiple types of comparisons, the most

common of which are comparisons between two or more groups, comparison of

one group at different times, comparison of one group under different conditions,

comparisons based on relative rankings, and comparisons with other studies (Polit

& Beck).

       Quantitative studies involve comparisons between variables. This research

design was essential to determining the effect learning style-based orientation has

on the study group, and if a difference in turnover rates is noted between the

learning style based orientation group and the previously graduated non-learning

style-based orientation group. This form of research provides an avenue to test the

designated hypotheses while simultaneously providing insight as it pertains to the

phenomenon under investigation (Borkan, 2004). Polit and Beck (2004) suggest

that quantitative research methods are specific to the nature of any intervention,

the comparisons to be made, the methods to be used to control extraneous

variables, the timing of data collection, the study sites and settings, and

information provided to study participants. This form of study is structured and

specific with respect to the matter being evaluated and the methods of evaluation

that will be used.

       During the course of this study, an analysis of the turnover rates of a

learning style-based orientation group were compared to those of a previously,

graduated group of new RNs who participated in a non-learning style-based

orientation group. This comparison was to ascertaining the effect that learning
                                                                                    83

style-based orientation may have had on turnover rates of the study group.

Quantitative research provides the best design to execute this type of analysis.

       The quasi-experimental research design is a form of quantitative research

that is similar to the experimental research design due to independent variable

manipulation (Polit & Beck, 2004). However, quasi-experimental studies do not

include randomization of the study groups, thus making the quasi-experimental

research design inferior to true experimental designs (Trochim, 2006). The study

participants, new RNs, was a pre-determined group as evidenced by their status as

newly graduated RNs who have been granted, temporary permission to practice as

RNs pending successful completion of the licensing examination. This

determination was outside of the control of the investigator. Due to the lack of

pre-existing categorization of participants in this study, the quasi-experimental

design was most appropriate (Salkind, 2003). Quasi-experimental research

provides a high degree of control, but not the highest, which is only possible with

true experimental research (Salkind). Although the experimental research design

yields evidence of a stronger causal relationship, the quasi-experimental design

provides information that can result in reasonable inference on the existence and

magnitude of any effect the independent variable may have on the dependent

variable (Trochim). The relationship or lack thereof, was inferred in this study,

based on differences in turnover rates between new RNs who participated in

learning style-based orientation and those who participated in non-learning style-

based clinical orientation.
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       The non-equivalent group design is the most commonly used in quasi-

experimental research. This type of design is structured like a pre-test, post-test

study but it lacks the customary randomization (Salkind, 2003, Sousa, Driessnack,

& Mendes, 2007). Non-equivalent group designs use pre-existing groups that

appear to be similar or comparable in order to compare the effect of the

intervention introduced during the research period. The use of pre-existing or

intact groups minimizes the probability of equal distribution and equal

characteristics of each study group or individuals within groups. The participants

for this study consisted of a convenience sample that could not be randomized due

to the limitations of the availability of participants and the pre-existing condition

of the RN designation.

       Other study designs, such as true experimental and qualitative, were

considered for this study. The true experimental research design requires

participants to be assigned to groups based on specific criteria (Salkind, 2003).

The pre-assignment of study participants to the designation of new RNs based on

the recent completion of RN training eliminated the probability of group

assignment; therefore, a true experimental design was ruled-out as a research

design option. Qualitative research examines social or behavioral aspects of

research. This type of research occurs primarily through direct observation, focus

groups or individual interviews. Qualitative research is based on open-ended

inquiry and is used to identify common themes associated with the research topic

(Salkind). The focus of this study was to determine the effect of learning style-

based orientation on new RN turnover. Although some information on this topic
                                                                                     85

could have been obtained through a qualitative approach, this approach would be

problematic with respect to the generalizability of the study results. The

previously, graduated non-learning style-based clinical orientation group and the

new RN learning style clinical orientation group, although located in the same

geographical area and graduated from the same academic institutions, did not

possess exact characteristics. The data from the two groups were measured at

different times; therefore, the non-equivalent group design was the most

appropriate research design for this study (Trochim, 2006).

                                 Research Questions

        Understanding the effect that learning style-based clinical orientation will

have on new RN turnover rates will provide information that may be used by

healthcare organizations and academic settings to develop and implement more

effective educational strategies. In light of the current deficit in the nursing

workforce in Central California, and the subsequent need to identify methods to

reduce new RN turnover, this research study explored the following research

question:

        RQ: What effect will a learning style-based clinical orientation program

have on turnover rates of new RNs during the first six months of nursing practice

in three Bakersfield, California, acute healthcare facilities?

                                     Hypotheses

The independent variable under study was the use of a learning style-based

clinical orientation program for training of new RNs in the clinical setting. This

study provides data to determine the effect that a learning style-based clinical
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orientation program will have on the turnover rates of new RNs six months after

graduation. The study also documents data in order to test the following null

hypotheses:

        H0: New RNs who participate in a learning style-based clinical orientation

program will not show lower turnover rates than new RNs of similar

demographics who participated in a non-learning style-based clinical orientation

program during the first six months of nursing practice in three Bakersfield,

California, acute healthcare facilities.

        HA: New RNs who participate in a learning style-based clinical

orientation program will show lower turnover rates than new RNs of similar

demographics who participated in a non-learning style-based clinical orientation

program during the first six months of nursing practice in three Bakersfield,

California, acute healthcare facilities.

                                      Population

        In quantitative research, the term population refers to “the aggregate or

totality of those conforming to a set of specifications” (Polit & Beck, 2004, p. 50).

In concert with this definition, the target population for this study consisted of

RNs in Bakersfield, California. The sample of participants for this study consisted

of a subgroup of the target population, specifically new RNs who reside in the

geographic area and work in the study sites located in Bakersfield, California. In

order to be included in the study, the subgroup had to meet the following

conditions: (a) recent completion of registered nurse training; (b) less than six

months since completion of registered nurse training; (c) employment as a new
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RN; and (d) participation in a learning style-based clinical orientation program.

The sample group also possessed similar demographic characteristics. In light of

the nursing shortage in this region of California, the study participants were

limited to a convenience sample of new RNs residing and working in the focus

area. The study locations represented the three prominent healthcare facilities in

the immediate geographic area. The study participants consisted of 25 individuals

who graduated from an accredited registered nurse program between December

2007 and January 2008 and who volunteer to participate in the study. These

individuals participated in a learning style-based clinical orientation process. This

turnover rate for this group was examined six months after graduation.

       The non-learning style-based clinical orientation turnover rates were

obtained from individuals who graduated from an accredited registered nurse

program between December 2006 and January 2007, and who possessed similar

demographic characteristics, as represented by data collected from the human

resource departments of each study site. These individuals were employees at one

or more of the respective study sites. These study participants captured

approximately 90% of the new RNs hired by the study facilities. Study

participants were between the ages of 21 and 65 years. Both male and female

subjects were included in the study. There was no exclusion of subjects based on

ethnic, religious, political, or social characteristics. Only new RNs were included

due to the study focus on new RN turnover. Based on this criterion, non-RN

health providers and RNs with greater than six months elapsed time since nursing

school completion was excluded from the study.
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                                      Sampling Frame

       Twenty-five new RNs employed by the study sites were targeted for this

study. Convenience sampling was used to select study subjects from the target

population of RNs residing and practicing in Bakersfield, California. Although

convenience sampling is considered the weakest form of sampling, Polit and Beck

(2004) suggest that it remains the most common form of sampling used in various

types of research studies. The requirement for volunteerism in this study lends

toward self-selection of study subjects, which contributes to the potential for

sampling bias (Polit & Beck). In addition, the data collected was focused on

turnover rates within a specified group, new RNs, thus limiting the number of

available participants. Randomization was not applied in this study due to the

limited number of available participants and the context in which the study was

framed. One hundred percent of eligible participants were asked to participate in

the study. Individuals who consented after information was provided were

included in the study.

       The sample of possible study participants was derived from the list of new

RNs hired by each study site. This list was obtained from the human resource

departments at each respective site. Individuals who met the following criteria: (a)

graduated from an accredited registered nurse training program; (b) began

employment as a new RN at one of the study sites, between December 2007 and

January 2008; and (c) volunteered to participate in the study were included in the

study subject pool. Demographic questionnaires and the VARK Learning Style
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Inventory were provided to each study participant in order to assist in identifying

demographic characteristics and determine their preferred learning style.

                                 Informed Consent

       The study population consisted of new RNs who were employed by the

study sites. These subjects were in the very first stages of hospital-based clinical

orientation. Each study participant volunteered to participate in the study. All

individuals who graduated from Associate’s and Bachelor’s degree-nursing

programs employed by the study facilities were included in the potential

participant pool. Each potential research participant received a consent form

explaining the study for the learning style-based orientation group (see Appendix

B). Due to the requirements as outlined in the Certificate of Approval issued by

the Western Institutional Review Board, the research oversight organization for

the study locations, a second consent form was reviewed and signed by the study

participants (see Appendix C). This consent form consisted of information

specific to human subjects, which included an explanation of risks, benefits, costs,

alternatives, voluntary participation and withdrawal, funding and participants

rights. Once a complete explanation was provided and all appropriate questions

addressed, each potential participant was asked if they were willing to participate

in the study. Those who were willing to participate in the study were asked to sign

and return the consent forms. The participants had the option of returning the

consent forms in person or via U.S. mail. A stamped envelope was provided.

Upon submission of a signed consent form, the subjects were given the 16-

question VARK learning style inventory (see Appendix D) and a demographic
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survey to complete. The demographic data was only used to ensure similar

characteristics between the learning style-based clinical orientation group and the

previously graduated RN group whom participated in a non-learning style-based

clinical orientation process.

Confidentiality

        In order to protect the privacy of each study participant, confidentiality of

all information not authorized for release by the participants was strictly

maintained. Documents obtained during the course of this study were maintained

in a locked cabinet and will be accessed only by the investigator for a period not

to exceed 36 months. At the conclusion of the 36-month period, the investigator

will destroy all study-related documents. Demographic information was disclosed

in aggregate form without reference to individual study participants and was

limited to the information that was essential to the study. Participants' names,

addresses, dates of birth, or other personal identifying information was not

included in any published documents. All activities to maintain the confidentiality

of each study participant was explained to the participant both verbally and by

way of the informed consent document, which describes the purpose of the study,

any potential risk of harm, and the option of withdrawing from the study at any

time.

Geographic Location

        The study participants were employees of three healthcare facilities

located in Bakersfield, California. The first facility is a 367-bed facility. The

second facility is a 144-bed facility. The third facility is a 75-bed facility.
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Bakersfield is located in the central region of California and lists a population of

276, 201. This community consists of approximately 48.8% male and 51.2%

female. The ethnic breakdown includes Caucasian 58.8%, African American 9%,

American Indian 1%, Asian 4% (one race), Hispanic/Latino 40.9%, which

represents two or more races (U.S Census Bureau, 2005). California State

University, Bakersfield, and Bakersfield College Nursing Programs enroll

approximately 180 new nursing students annually and have reported a program

attrition rate of 40% and a licensure pass rate of 90% (Cindy Collier, Director,

Bakersfield College Associate Nursing Degree Program and Peggy Leapley,

Chair, California State University, Bakersfield Nursing Program, personal

communication, November 12, 2006).

                                  Instrumentation

       Data collection materials include the VARK Learning Style Inventory,

Version 7 (see Appendix C), and a data collection tool that was used to identify

the learning styles of each study participant. The learning styles included for

categorization in this study were visual, auditory, read-write, and kinesthetic

(Fleming, 2005). The human resources department of each study site provided the

turnover rate data. The turnover data was collected by analyzing the number of

new RNs who began work during the study period and the number of new RNs

that were still employed at the conclusion of the study.

VARK Learning Style Inventory

       The VARK Learning Style Inventory, Version 7, is a 16-question,

multiple-choice instrument, created in 1997 by Neil Fleming, educator and
                                                                                    92

researcher. Neil Fleming, through the VARK Learning Style Inventory, uses short

scenario-based questions to determine the students’ preferred learning style.

Once identified, application of learning style preferences creates an opportunities

for increased accuracy in comprehension of instructional materials and increased

ability of the learner to apply concepts (Dunn & Griggs, 1998). The VARK

Learning Style Inventory was selected due to the specificity of the instrument in

identification of sensory learning styles and the ease of understanding and

application of the concepts in the study setting.

        Participants completed the VARK Learning Style Inventory in order to

identify their preferred learning style. Each participant also completed the

demographic data form (see Appendix D). This information was used to compare

the demographic characteristics of the learning style-based clinical orientation

participants and those of the non-learning style clinical orientation group. This

information was used to identify similar and dissimilar characteristics between the

learning styles-based orientation group and the non-learning style-based

orientation group. The information provided on the demographic data form was

compiled and reported in aggregate form. The specific information on each

participant was not disclosed.

                            Clinical Preceptor Training Process

       All clinical preceptors and clinical educators, who worked with the new

RNs, were required to attend a two-hour education course (see Appendix E). The

content of the course included the overall theory behind learning styles, a

summary of the four primary perceptual learning styles, and an overview of
                                                                                       93

methods to incorporate learning style-based instructional methods into the clinical

orientation process. All preceptors were required to complete the VARK Learning

Styles inventory in order to assist them in understanding the process and in

identifying their own learning styles. A portion of the course was dedicated to

adapting their precepting process to incorporate the new RNs learning styles.

Each preceptor was provided with teaching guidelines specific to each learning

style and study tools that may be used to assist the new RN in collaborating with

the preceptor in developing an effective orientation process. Each study site

adapted their current orientation processes to reflect activities appropriate to the

various individual or combined learning styles. Scenarios were used to provide

practice opportunities for the preceptors to apply the concepts learned in the

course. Monthly meetings were held with each preceptor to evaluate the need for

further reinforcement of instructional methodologies and to facilitate adherence to

the learning style-based clinical orientation process. During the monthly

meetings, each preceptor was asked to provide a summary of the past month’s

experiences with the learning style-based clinical orientation process. Evaluation

of adherence to the learning style-based clinical orientation process and a

subjective assessment of the new RNs receptivity to the orientation process

occurred during each meeting. The investigator provided each preceptor the

opportunity to clarify any areas of uncertainty or concern. All questions were

addressed until the preceptor confirms that no additional information is required.
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                                    Data Collection

       The data collection process consisted of six steps: (a) identifying the new

RNs who were hired by each of the study sites, (b) conducting an information

session with potential study participants and site preceptors, (c) obtaining consent

to participate from study participants and site preceptors, (d) obtaining

demographic information from study participants, (e), obtaining learning style

preference information from study participants, and (f) collecting the data of both

the non-learning style clinical orientation group and the learning style clinical

orientation group on turnover rates from each study site. The human resource

departments of each study site provided the turnover data. These data included

raw numbers representing the number of new RNs who began employment during

the study period who participate in the learning style-based clinical orientation

program, and the number of the same group of RNs who were still employed at

the end of the study period. The demographic data was used to compare groups to

identify similarities in demographic characteristics between the previously

graduated non-learning style-based clinical orientation group and the learning

style-based clinical orientation group. The demographic information from the

previously graduated non-learning style group was obtained from archived

information provided by the human resource department of the study sites. These

data were presented in aggregate form and did not include information that can be

used to identify the individuals.
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                                         Data Analysis

       The data analysis consisted of a comparison of turnover rates of new RNs

who participated in the learning style-based clinical orientation process and the

turnover rates of a previously graduated RN group that participated in a non-

learning style-based clinical orientation process. The turnover rates for the non-

learning style clinical orientation group were obtained from June 2007 turnover

data. The turnover rates for the learning style-based clinical orientation group

were obtained from June 2008 turnover data. The turnover rates were calculated

using standard turnover rate calculations as used by the study facilities.

Demographic data was coded to categorize participants based on level of

education, age, gender, and ethnicity.

        A logistic regression analysis and a Pearson’s Chi Square Test were

conducted to analyze the data for this study. The logistic regression analysis was

used to analyze the impact of multiple variants on the turnover of new RNs

(Worster, Fan, & Ismaila, 2007). The Pearson’s Chi Square Test was used to test

the null hypothesis. The outcomes of these statistically analyses were used to

determine the difference in turnover rates between the learning style-based

clinical orientation group and the previously graduated, non-learning style-based

clinical orientation group and to identify the impact that each of the variables had

on the turnover rates for the study population. These analyses were based on a

comparison of turnover rates between the two groups during the first six months

of independent practice in each facility. The dependent variable in this analysis

was the turnover rate for each individual. The independent variables were: (a) a
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dummy variable representing whether the subject belonged to the learning style

group or the non-learning style group; (b) age; (c) gender; (d) ethnicity; and (e)

level of education. The purpose of the logistic regression analyses were to

determine the degree of association between group membership (learning style or

non-learning style) and turnover rates after controlling for the demographic

characteristics outlined. In addition, the magnitude of this regression coefficient

allows estimation of the net change in turnover rate associated with different

groups after accounting for demographic characteristics.

                              Reliability and Validity

       Reliability and validity evaluations serve to assess the quality of the study.

These two study assessment measures are two of the most important criteria to

determine the value of study findings (Polit & Beck, 2004). The term reliability

reflects the accuracy and consistency of any information obtained through a

research study and is representative of the generalizability of the study findings

(Polit & Beck). The term validity reflects that the study being implemented does

what is it supposed to do or that the study’s evidence is sound (Polit & Beck).

Reliability

       The purpose of this study was to evaluate the degree to which the use of

learning style-based clinical orientation programs affect turnover rates of new

RNs. In the case of this study, reliability of the study was dependent upon the

level of adherence to the learning style concepts with respect to the orientation

process, and the new RNs response to the modified orientation process.

According to Fleming (2005), human preferences are dynamic and vary
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depending on the environment and the circumstance under which the preference is

determined. Human preferences also change over time, based on level of maturity.

Consequently, human preference in this case may affect the reliability of the study

findings.

Instrument Reliability

       The VARK Learning Style Inventory derives its results from the concept

of human preference. According to Fleming (2005), human preferences are

dynamic and vary, depending on the environment and the circumstance under

which the preference is determined. Human preferences also change over time,

based on level of maturity. An independent evaluation of the VARK Learning

Style Inventory resulted in the following statement regarding the reliability of the

instrument:

              The questionnaire was not designed to be reliable in terms of

              consistency in scores over a long period. Instead, the questionnaire

              was designed to provide students with effective learning strategies to

              use on their learning preferences. Over the course of the student’s

              career it is likely that some modes will strengthen, some will

              dominate and others may be underutilized, therefore, it is difficult to

              say that a student taking this test each year for 12 consecutive years

              will obtain similar scores each year. On the other hand, if a test/retest

              occurs within a few weeks it is likely that the scores would be similar

              (Fleming, 2005, p. 53).
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Longitudinal studies on this instrument are in progress; however, because the

VARK Learning Style Inventory provides a profile as compared to other

inventories that provide single score results, the use of longitudinal studies for

traditional determination of reliability is unlikely to yield traditional reliability

data on this instrument (Fleming, 2005). In addition, Fleming also suggests that

exposure to external variables influence the dominance of learning style

preferences, therefore longitudinal study results may vary (Neil Fleming, personal

communication, October 7, 2006).

Instrument Validity

        The concept of validity addresses whether there is evidence to support that

the desired concepts to be measured are actually being measured (Polit & Beck,

2004). According to Fleming (2005), the content validity of the instrument is

strong. The use of this instrument in multiple studies demonstrates consistency of

results with the perceptions of individuals regarding their preferred learning style.

Fleming also suggests that students chose study strategies that were consistent

with their VARK results (Fleming, 2005). The VARK Learning Styles Inventory

was designed as an advisory tool, not as a diagnostic or predictive tool; however,

research will continue in an effort to increase both reliability and validity

measures of the instrument (Neil Fleming, personal communication November

11, 2006) (see Appendix H).

Internal Validity

        Internal validity represents the extent to which the study confirms that

causal or influential relationships exist between the independent and dependent
                                                                                       99

variables (Polit & Beck, 2004). Internal validity also represents the verification

that the results obtained can be attributed to the introduction or manipulation of

the independent variable (Salkind, 2003). Salkind refers to circumstances that

may affect the reliability or validity of study findings as threats. These threats are

categorized based on their perceived points of origin and are considered either

internal or external (Polit & Beck, 2004). Common threats to internal validity

include history, maturation, selection, testing, instrumentation, regression, and

mortality (Salkind).

       The internal threat of history is present when a study takes place over time

and external events occur that may affect the outcome of the study (Salkind,

2003). In the case of this study, the internal threat of history was present, but to a

minimal extent. This study examined turnover rates at one given point in time, six

months after graduation, for both the non-learning style clinical orientation group

and the learning style clinical orientation group. Although external factors

contributed to turnover that is not related to the type of clinical orientation

experience, this external factor was of equal threat to both groups.

       The threat of maturation represents the normal growth of groups between

the pretest and the posttest (Trochim, 2006). This condition may also be present if

changes occur because of biological or psychological forces (Salkind, 2003). In

the case of this study, the threat of maturation did not exist as the turnover rates

were being measured at a single point in time. In addition, the study did not have

a component that was dependent upon biological or psychological forces, thereby

minimizing any potential of the threat of maturation.
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       The threat of selection represents when a selection process is not random

thus providing opportunity for systematic bias that may result in significant

differences between the non-learning style clinical orientation group and the

learning style clinical orientation group (Salkind, 2003). The study participants

possessed the common characteristics of being new RNs, being employed at

common locations, functioning as RNs within six months of graduation. The

participants differed in the area of time during which the clinical orientation

occurred, the participation in the learning style-based clinical orientation program,

the individuals from whom they received their clinical training, and various

demographic characteristics.

       The internal threat of testing represents the possibility that performance on

a pretest may affect the performance on a posttest. This threat of testing was not

applicable to this study due to the absence of a pretest. The threat of

instrumentation represents the possibility of changes in scores of the measurement

being changed by the scores themselves (Salkind, 2003). Data used for this study

consisted of turnover rate data that were based on standardized calculations.

These data were not based on instrumentation scoring; therefore, neither the threat

of instrumentation nor the threat of testing was of concern.

       The threat of regression represents that probability that scores that are very

high or very low may regress toward the mean during subsequent testing (Salkind,

2003). In the case of this study, instrumentation was only used to ascertain the

preferred learning style and demographic composition of the study participants.

The scores from the learning styles inventory were inconsequential with respect to
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the turnover rates since the instrument was only being used to assist in guiding the

study participants to the proper learning style-based clinical orientation modality.

       The internal threat of mortality occurs when attrition for the study results

in an inability to locate participants for retest or follow-up purposes, resulting in a

change in the composition of study subjects (Salkind, 2003). In this study, the

threat of mortality was minimal due to the focus on turnover rates among the

study participants. The mortality component was essential to the study because

the participants who dropped off were the focus of the study. Therefore, the threat

of mortality was not an actual threat to the validity of the study.

External Validity

       External validity refers to the existence of the ability to generalize the

findings of the study to other study settings or other research topics (Polit & Beck,

2004). External validity is not focused on the effect that the independent variable

had on the dependent variable, but whether the results of the study can be

generalized to another setting or applied to a different group of participants

(Salkind, 2003; Trochim, 2006). Salkind refers to circumstances that may affect

the validity of study findings as threats. Common threats to external validity

include expectancy, novelty, interaction with history and treatment, experimenter

and measurement.

       The expectancy threat is present when research participants behave in a

particular manner because of knowledge of the study (Polit & Beck, 2004). If the

research participants change behavior because of the knowledge that their

behavior is under observation, the generalizability of the study findings may be in
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question. In the case of this study, the study participants were participating in a

particular orientation process. This orientation process was adjusted based on

their individual learning preferences. The dependent variable for this study was

turnover rates, which was an objective measure of an outcome rather than of the

behaviors of the study participants. The threat of expectancy may be present, but

is of minimal impact.

        The threat of novelty denotes an alteration in the behavior of research

participants because of the introduction of a new concept (Polit & Beck, 2004). In

this study, each of the study participants was made aware of the introduction of a

learning style-based clinical orientation process. The threat of novelty was present

in this case.

        The threat of interaction of history and treatment was an additional threat

to external validity that needed to be considered. This condition occurs when the

results obtained reflect the effects of the treatment or external events. The

potential for this condition was present due to the multiple conditions that may

lead to turnover. In order to control for this threat, turnover associated with life

occurrence such as death, relocation and conditions leading to inability to work

were excluded from the study results.

        Experimenter effect occurs when the behavior of the research participant

may be affected by the characteristics of the experimenter (Polit & Beck, 2004).

This condition may lead to replication challenges due to the differences in

experimenter characteristics. This study was carried out with minimal interaction

between the experimenter and the study participants. The study participants and
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the experimenter were in contact for a maximum of two hours throughout the

course of the six-month orientation period, during which time the experimenter

explained the study, obtained consent, and administered the learning style

inventory. The independent variable, turnover rates were obtained from of the

human resource departments of each facility and did not require further contact

with the study participants.

       The measurement effect occurs when the results of a study cannot be

applied to another group due to differences in the data collection procedure (Polit

& Beck, 2004). The measurement effect may have been present in this case if the

knowledge that the learning style-based clinical orientation group received a

different form of orientation than other similar groups in the same location was

noted. In this case, all new RNs at each facility participated in the study.

Therefore, the measurement effect was not an issue.

                                          Summary

       The purpose of this quantitative, quasi-experimental, non-equivalent group

study was to analyze the effect of learning style-based clinical orientation on

turnover rates for new RNs. The study derived its conclusions by analyzing the

turnover rates of a cohort of new RNs who participated in a learning style-based

orientation program. The turnover rates of this cohort were compared to an

existing cohort of previously graduated new RNs who participated in a non-

learning style-based clinical orientation program. The study consisted of a three-

step process: (a) completion and compilation of the demographic information; (b)

completion and compilation of the learning style preference information; (c)
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collection of data of both the non-learning style clinical orientation group and the

learning style clinical orientation group on turnover rates from each study site.

These data consisted of turnover rates of previously-graduated RNs (non-learning

style-based clinical orientation group) who began employment as RNs at the

study sites between December 2006 and January 2007, and that of new RNs

(learning style-based clinical orientation group) who graduated and began

employment at the study sites between December 2007 and January 2008. The

study participants were selected based on their position as new RNs employed at

the study sites. The participants only consisted of individuals who volunteered to

participate in the study. Although some limitations to the study were present, the

application of a quantitative, quasi-experimental, non-equivalent group design and

the resulting data may provide the foundation for a more in-depth evaluation of

additional factors that affect turnover rates within this sub-group.
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                                  CHAPTER 4: RESULTS

       The purpose of this quantitative, quasi-experimental, non-equivalent group

study was to analyze the effect of learning style-based clinical orientation on

turnover rates for new RNs. The study reflects documentation of an analysis of

turnover rates of a cohort of new RNs who participated in a learning style-based

clinical orientation program. The study also contains baseline information

obtained from a cohort of previously-graduated new RNs who participated in a

non-learning style-based clinical orientation program. Both cohorts consisted of

new RNs who are members of graduating classes from both the university and

junior college registered nursing programs. The study sites consisted of three

Bakersfield, California, acute healthcare facilities.

       This study sought to identify what differences if any, existed in turnover

rates of new RNs based on the use of a learning style-based clinical orientation

program as a means to equip new RNs with information to practice nursing in an

acute care setting. A quasi-experimental research design was chosen for this study

due to the implementation of an intervention with a non-randomized subject pool

and the introduction of the independent variable at different points in time (Polit

& Beck, 2004). Although cause-and-effect relationships cannot be determined

using this type of research design, use of cohorts with similar characteristics

provided a foundation for an accurate comparison of the effects of an

intervention, which allowed for inferences based on the post-study data analysis

(Polit & Beck). A single dependent variable, turnover rates six months after

initiation of nursing practice, was examined in this study in order to identify any
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effect a learning style-based orientation program had on turnover rates of new

RNs at a single point in time.

       The study also examined a single independent variable, a learning style-

based method of conducting clinical orientation, to determine the effect of this

variable on turnover rates. Learning style-based clinical orientation describes the

use of visual, auditory, read-write or kinesthetic teaching modalities as a preferred

method of individualizing education for new RNs. Chapter 4 presents a

summation of the data analysis. Three primary topics are emphasized in this

chapter: (a) the introduction, (b) the data collection and analysis, and (c) a

summary. Demographic data on the study participants are also presented and

analyzed for consideration of related demographic variables with respect to the

study findings.

                                      Hypotheses

       Chapter 4 contains a summary of an analysis of study findings in order to

provide information required to accept or reject the following hypothesis. This

hypothesis is related to the determination of any effect that a learning style-based

clinical orientation program will have on the turnover rates of new RNs, six

months after graduation. Based on this objective, the following hypothesis was

addressed:

                  H0: New RNs who participate in a learning style-based clinical

       orientation program will not show lower turnover rates than new RNs of

       similar demographics who participated in a non-learning style-based
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       clinical orientation program during the first six months of nursing practice

       in three Bakersfield, California, acute healthcare facilities.

               HA: New RNs who participate in a learning style-based clinical

       orientation program will show lower turnover rates than new RNs of

       similar demographics who participated in a non-learning style-based

       clinical orientation program during the first six months of nursing practice

       in three Bakersfield, California, acute healthcare facilities.

                                     Research Question

       Chapter 4 provides a summary of the analysis, which sought to address the

research question related to the use of learning style-based clinical orientation

methodologies with new RNs: What effect will a learning style-based clinical

orientation program have on turnover rates of new RNs during the first six months

of nursing practice in three Bakersfield, California, acute healthcare facilities?

The research question was designed to provide information that may assist in

improving the clinical orientation process for new RNs, to provide a methodology

to better equip new RNs for nursing practice, and to assist in improving retention

of new RNs in the acute care setting.

                                        Data Collection

       The data collection process consisted of six steps, (a) identifying the new

RNs who were hired by each of the study sites, (b) conducting an information

session with potential study participants and site preceptors, (c) obtaining consent

to participate from study participants and site preceptors, (d) obtaining

demographic information from study participants, (e), obtaining learning style
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preference information from study participants, and (f) collecting the data of both

the non-learning style clinical orientation group and the learning style clinical

orientation group on turnover rates from each study site.

       The turnover data were derived from turnover rates of a previous cohort of

new RNs who began employment as RNs at these study sites between December

2006 and January 2007 and who participated in a non-learning style-based clinical

orientation process. The second set of data consisted of turnover rates of a cohort

of new RNs who began employment at these study sites between December 2007

and January 2008 and who participated in a learning style-based clinical

orientation process.

       The human resource departments of each study site provided the turnover

data. These data for the non-learning style-based clinical orientation group and the

learning style-based clinical orientation group consisted of the following

variables: (a) age, (b) ethnicity, (c) gender, (d) education, and (e) time since

completion of RN program. These demographic data were used to compare

similarities and differences with respect to demographic characteristics between

the previously-graduated non-learning style-based clinical orientation cohort and

the learning style-based clinical orientation cohort.

       The non-learning style-based clinical orientation cohorts’ demographic

information was collected and compiled on individuals who were hired at the

study sites between December 2006 and January 2007. Since direct contact with

these individuals was not possible, information from the non-learning style cohort

was obtained from archived information provided by the human resource
                                                                                  109

departments of each study site. These data were presented in aggregate form and

did not include information that could be used to identify the subjects. The

learning style data was not collected on the non-learning style-based clinical

orientation cohort due to the lack of availability of the individuals to complete the

learning styles inventory and the lack of applicability to the study design or the

study findings.

       The demographic data for the learning style-based clinical orientation

cohort were obtained from participants through completion of a demographic data

form (see Appendix D). The data forms were collected, and the data were

compiled and reported in aggregate form. The demographic data form did not

include the identifying information in order to maintain the anonymity of the

participants.

                  The learning style data were collected using the VARK Learning

Style Inventory (see Appendix C). The learning style of each participant was

determined based on the scoring of the learning styles inventory. The participants

in accordance with the scoring guidelines as outlined by the inventory author

conducted the learning style inventory scoring. The learning style data collection

tool does not include data that can be used to identify the study participants.

                                        Intervention

       Twenty-one clinical preceptors and clinical educators, scheduled to work

with the new RNs and the study participants, attended a two-hour education

course (see Appendix E). The content of the course included the overall theory

behind learning styles, a summary of the four primary perceptual learning styles,
                                                                                      110

and an overview of methods to incorporate learning style-based instructional

methods into the clinical orientation process. Each preceptor was required to

complete the learning styles inventory in order to assist the preceptor in

understanding the process and to identify each preceptors learning style. A portion

of the course was dedicated to assisting preceptors in revising precepting

processes to incorporate the new RNs learning styles. Preceptors were provided

with teaching guidelines that outlined teaching processes for each learning style

and study tools that may be used to assist new RNs in collaborating with the

preceptor in developing an effective orientation process. Each study site adapted

its clinical orientation processes to reflect activities appropriate to the various

individual or combined learning styles. Scenarios were used to provide practice

opportunities for the preceptors to apply the concepts learned in the course. Study

participants attended the training with the preceptors to ensure all parties

possessed a clear understanding of learning style processes and learning style

application in the clinical setting. Preceptors and new RNs agreed to work

together to ensure that learning style concepts were included in the clinical

orientation process.

        Monthly meetings were held with each preceptor to evaluate the need for

further reinforcement of instructional methodologies and to facilitate adherence to

the learning style-based clinical orientation process. During the monthly

meetings, each preceptor was asked to provide a verbal summary of the past

month’s experiences with the learning style-based clinical orientation process.

Evaluation of adherence to the learning style-based clinical orientation process
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and a subjective assessment of the new RNs’ receptivity to the orientation

processes were obtained during each meeting. Each preceptor was provided the

opportunity to clarify any areas of uncertainty or concern. All questions were

addressed until the preceptor confirmed that no additional information was

required.

                                        Sample Size

       The target population for the non-learning style-based clinical orientation

group consisted of new RNs who were hired by the study sites between December

2006 and January 2007. Data were collected on 14 new RNs from all three

facilities. This sample group represented 100% of all new RNs hired by the study

sites and 26% of new RNs who graduated from local nursing programs during

between December 2006 and January 2007. Hospital A hired 8 new RNs, hospital

B hired 4 new RNs, and hospital C hired 2 new RNs.

       Sixty new RNs from the local RN programs comprised the target

population for the learning style-based clinical orientation cohort in this study.

The target population was derived from a list of new RNs who graduated from

Associate’s and Bachelor’s degree RN programs and those who were hired by the

study sites between December 2007 and January 2008. The sample size for the

learning style-based clinical orientation cohort consisted of a combined total of 25

new RNs from all three facilities. Hospital A hired 11 new RNs, hospital B hired

10 new RNs, and hospital C hired 4 new RNs. The sample size of the learning

style-based clinical orientation cohort represented approximately 41% of the new

RNs that completed their RN training between December 2007 and January 2008.
                                                                                  112

The study group represented 100% of the new RNs hired by the study sites

between December 2007 and January 2008.

       A convenience sampling technique was used for the study due to the

inability to randomize participants. Convenience sampling is the most commonly

used type of sampling in research; however, it is prone toward bias due to self-

selection of participants into specific types of groups (Polit & Beck, 2004). In the

case of this study, the focus of the study was on new RNs, which although self-

selected as RNs, may lend to increasing the homogeneity of the study cohort.

Study participants were not randomized due to the limited availability of

participants and the pre-existing condition of RN designation.

                                  Demographic Statistics

       The non-learning style-based clinical orientation group was comprised of

a total of 14 new RNs. Of the 14 new RNs, 100% were female, 72% were

between the ages of 26-30, and 28% were between the ages of 31-35. Fifty seven

percent were Caucasians, 28.5 % were Hispanic and 14.5 % were of East Indian

descent. One hundred percent of the non-learning style-based clinical orientation

group completed their RN training between 4-8 weeks of the data collection

period. Of the 14 individuals included in the non-learning style-based clinical

orientation group, only six indicated their level of education, therefore this

variable could not be sufficiently analyzed with respect to any difference between

the two groups.

       The learning style-based clinical orientation group was comprised of 25

new RNs. Of the 25 new RNs, 88 % (n=22) were female; 32 % (n=8) were
                                                                                    113

between the ages of 20-25; 28 % (n=7) were between the ages of 26-30; 4 % (n-

=1) was between the ages of 31-35, 16 % (n=4) were between the ages of 36-40,

and 20% (n=5) were greater than 40 years old. Fifty-two percent (n=13) self-

identified as Caucasian, 28 % (n=7) self identified as Hispanic, 4% (n=1) self

identified as African American, 8% (n=2) self identified as Filipino, 4% (n=1)

self identified as Asian, and 4% (n=1) self-identified as other. Ninety-two percent

(n=23) of the learning style-based clinical orientation group were Associate’s

degree-prepared RNs, 8% (n=2) were Bachelor’s-degree prepared RNs. These

data are outlined in aggregate for both the learning style-based clinical orientation

group and the non-learning style-based clinical orientation group in Table 2 and

2a.

                                       Data Analysis

       In order to test the null hypothesis three separate analyses were

implemented. The first analysis included a logistic regression analysis where the

dependent variable of interest was whether the new RN was still working at their

position six months after they were hired. The independent variable that was

included with this analysis was whether the new RN in the learning style based

clinical orientation program or whether they participated in a non-learning-style

based clinical orientation program. The logistic regression procedure was

appropriate for this analysis because the response variable was dichotomous

meaning it consisted of two categories. These were either “yes” meaning that the

participant was still in their position six months after they were hired and “no”
                                                                                   114

meaning that the participant was not still in their position six months after they

were hired.

        The second analysis was to test the null hypothesis was another logistic

regression procedure where the dependent variable was comprised of the “yes”

meaning that the participant was still in their position six months after they were

hired and “no” meaning that the participant was not still in their position six

months after they were hired variables. In this analysis, however, the demographic

characteristics of the participants were included in the model in order to determine

whether there was a significant relationship between the learning style based

clinical orientation and non-learning style based clinical orientation groups when

controlling for the demographic characteristics of the participant. The control

variables were included in the model one at a time due to the relatively small

sample size. In this instance, the small sample size could result in a problem of

overfitting the model, which could result in poor estimates (Babyak, 2004).

Overfitting the model is a term used to describe when the analysis includes too

many variables in the model, resulting in inflation of the variances or standard

errors (Babyak, 2004). For this reason, because of the smaller sample size and the

potential of overfitting the model, the control variables were included one at a

time.

        The third analysis consisted of a test comparing the turnover rates of the

individuals who participated in the learning style-based clinical orientation

program and those who participated in the non-learning style-based clinical

orientation program. A Chi Square Test was implemented where the total number
                                                                                   115

of employees leaving in the past six months was divided by the number of

employees that were hired during the study period. The Chi Square Test was

conducted in order to compare the turnover rate between the two groups

specifically; the proportion of participants that left the learning style-based

clinical orientation group was compared with the proportion of participants that

left the non-learning style-based clinical orientation group. Some exploratory

analyses were conducted prior to completing this portion of the analysis. The

exploratory analysis consisted of descriptive statistics for the variables included in

the analysis. The descriptive analysis includes calculating the frequencies and

percentages of occurrence for each one of the categorical or discrete variables in

the study. The analysis was accomplished by presenting frequency tables for each

one of the variables. The results for the descriptive statistics are presented in the

following section.

Descriptive Statistics

       The descriptive statistics for each one of the independent variables used in

the study are presented in Table 2. This includes the frequency and percentage of

the age, ethnicity, gender, orientation group type and whether the employee was

still present after six months. The descriptive analysis also includes a cross-

tabulation of the results for the learning style-based clinical orientation group and

whether the employee was still present after six months.
                                                                                 116

Table 2

Descriptive Statistics for Variables Included in the Study (Still With the

Organization, Age)

Variable                                                     Frequency       Percent

Still with the Organization        Yes                            36          92.3

                                   No                             3            7.7

Age                                20-25                          6           15.4

                                   26-30                          18          46.2

                                   31-35                          7           17.9

                                   36-40                          4           10.3

                                   Over 40                        4           10.3
                                                                                      117

Table 2a

Descriptive Statistics for Variables Included in the Study (Ethnicity, Gender,

Degree, and Orientation Type)

Ethnicity                            African American               1           2.6

                                     Asian                          1           2.6

                                     Caucasian                     21          53.8

                                     East Indian                    2           5.1

                                     Filipino                       2           5.1

                                     Hispanic                      11          28.2

                                     Other                          1           2.6

Gender                               Female                        36          92.3

                                     Male                           3           7.7

Degree                               Associate’s                   29          74.4

                                     BSN                            2           5.1

                                     Missing                        8          20.5

Orientation Type                     Learning style                25          64.1

                                     Non-learning style            14          35.9



         Table 2 and 2a reflects that the majority of the participants in the study

remained in their position six months after they were hired (92.3%). Almost half

of the participants (46.2%) in the study were between the ages of 26 to 30, while

over half of the participants were Caucasian (53.8%), followed by Hispanic
                                                                                     118

(28.2%). The other ethnic groups in the study were combined into the “Other”

category because there were not enough observations for each ethnicity to be able

to make appropriate inferences. The majority of the participants in the study were

female (92.3%) with most of them possessing their Associate’s Degree (74.4%).

Twenty percent of the participants were missing this information. For this reason,

the educational level of the participants was not included in the analysis because

the missing values would reduce the number of observations used in the study. As

for the orientation groups, of the total data collected in the study, 64.1% of the

new RNs participated in the learning style-based clinical orientation program

(post) while 35.9 % of the participants participated in the non-learning style-based

clinical orientation program (pre). Table 3 presents the results of the cross-

tabulations between the learning style-based clinical orientation group and the

non-learning style clinical orientation group, and whether the participants were

employed in their position after six months.
                                                                                    119

Table 3

Cross-Tabulation Results for Orientation Groups and Employment Status


                                                           Orientation Group

                                                                    Non-

                                                                   learning

                                                      Learning      style

                                                     style based    based     Total

Still with the Organization                  Yes         24          12        36

                                             No           1           2         3
                                             Total       25          14        39



       Table 3 reflects that the number of participants that were not employed six

months after being hired in the learning style-based clinical orientation group was

one, while two were not employed six months after participating in the non-

learning style-based clinical orientation group. This means that the turnover rate

for the learning style-based clinical orientation group was .04 (1/25) while the

turnover rate for the non-learning style-based clinical orientation group was .14

(2/14). The results of the analyses are presented in the following section.

                               Results and Findings

       The first set of results are for the logistic regression analysis that was

implemented including the “yes” meaning that the participants were still in their

positions six months after they were hired and “no” meaning that the participants

were not in their position six months after they were hired as the dependent
                                                                                   120

variable. The independent variable was whether the individuals participated in the

learning style-based clinical orientation program or whether they participated in

the non-learning style-based clinical orientation program. The results of this

analysis are presented in Table 4.

Table 4

Parameter Estimates for Logistic Regression Comparing Orientation Type and

Whether They Were Still Employed After Six Months




Parameter               B      Std. Error       Chi-Square         df Sig.    Exp(B)

(Intercept)           1.792      .7638             5.504           1 .019     6.000

Post Orientation      1.386     1.2748             1.183           1 .277     4.000



       Table 4 reflects that there was not a significant difference between

whether the individuals who participated in the learning style-based clinical

orientation program or whether they participated in the non-learning style-based

clinical orientation program X2(1, N=39) = 1.18, p = .277. This indicates that a

participant not employed after six months for those in the learning style-based

clinical orientation program does not differ statistically from those who

participated in a non-learning style-based clinical orientation program. Although

it was found that the relationship was not significant, the model still predicted that

an individual still employed after six months of being hired for those who

participated in the learning style-based clinical orientation program would be four

times greater than participants who participated in a non-learning style-based
                                                                                 121

clinical orientation program. One reason for the discrepancy between the actual

number of individuals still employed and the statistical findings of still employed

is that the sample sizes for each group were relatively small meaning that the

standard errors for the test would be larger than expected (Moore & McCabe,

2006).

         The second set of results represent findings from the logistic regression

analysis that was implemented including the “yes” meaning that the participants

were still in their position six months after they were hired and “no” meaning that

the participants were not in their position six months after they were hired as the

dependent variable. The independent variables were whether the individual

participated in the learning style-based clinical orientation program or whether the

individual participated in the non-learning style-based clinical orientation

program and the control variables of age. The results of this analysis are presented

in Table 5.
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Table 5

Parameter Estimates for Logistic Regression Comparing Orientation Type,

Control Variable of Age and Whether They Were Still Employed After Six Months




Parameter               B     Std. Error       Chi-Square        df Sig.        Exp(B)

(Intercept)          -19.665 23483.3063            .000          1 .999 2.880E-9

Post Orientation     20.764 23483.3062             .000          1 .999 1.042E9

Age=20-25            21.467 32440.2228             .000          1 .999 2.105E9

Age=26-30            21.863 23483.3063             .000          1 .999 3.125E9

Age=31-35            20.764 23483.3063             .000          1 .999 1.042E9

Age=36-40            21.467 39730.9965             .000          1 1.000 2.105E9



       Table 5 reflects that there was no significant difference between whether

the individual participated in the learning style-based clinical orientation program

and whether they participated in a non-learning style-based clinical orientation

program X2(1, N=39) = .00, p = .999, after controlling for the age of the

participants. This indicates that a participant not employed after six months for

those in the learning style-based clinical orientation program does not statistically

differ from those who participated in the non-learning style based clinical

orientation program, after controlling for the age of the subject.

       The independent variables included in the next analysis were whether the

participant had participated in the learning style-based clinical orientation
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program or whether they participated in the non-learning style-based clinical

orientation program and the control variables of gender. The results of this

analysis are presented in Table 6.

Table 6

Parameter Estimates for Logistic Regression Comparing Orientation Type,

Control Variable of Gender and Whether They Were Still Employed After Six

Months




Parameter               B      Std. Error       Chi-Square         df Sig.    Exp(B)

(Intercept)
                     21.313 45877.3934              .000           1 1.000 1.804E9
Post Orientation
                      1.253     1.2771              .962           1 .327      3.500
Age=36-40
                     19.522 45877.3934              .000           1 1.000 3.326E9

       Table 6 reflects no significant difference between whether the individual

participated in the learning style-based clinical orientation program and whether

they participated in the non-learning style-based clinical orientation program X2(1,

N=39) = .962, p = .327, after controlling for the gender of the participants. This

indicates that an individual not employed after six months for those in the

learning style-based clinical orientation program is not statistically different from

those who participated in the non-learning style-based clinical orientation

program, after controlling for the gender of the participant.

       The independent variables included in the next analysis were whether the

participant had participated in the learning style-based clinical orientation or
                                                                                   124

whether they participated in the non-learning style based clinical orientation

program and the control variables of ethnicity. The results of this analysis are

presented in Table 7.

Table 7

Parameter Estimates for Logistic Regression Comparing Orientation Type,

Control Variable of Ethnicity and Whether They Were Still Employed After Six

Months




Parameter                 B     Std. Error      Chi-Square          df Sig.   Exp(B)

(Intercept)
                         .884    1.2874             .471            1 .492    2.420
Post Orientation
                        1.518    1.3179             1.327           1 .249    4.563
Caucasian
                         .654    1.3714             .227            1 .634    1.923
Hispanic
                        20.916 23028.6804           .000            1 .999 1.213E9

       Table 7 reflects no significant difference between whether the individual

participated in a learning style-based clinical orientation program and whether

they participated in the non-learning style-based clinical orientation program X2(1,

N=39) = 1.33, p = .249, after controlling for the ethnicity of the participant. This

indicates that an individual not employed after six months for those in the

learning style-based clinical orientation program is not statistically different from

those who participated in the non-learning style-based clinical orientation

program, after controlling for the ethnicity of the participants.
                                                                                   125

       The last results presented are for the Chi Square Test for the turnover rate

comparing the learning style-based clinical orientation group and the non-learning

style-based clinical orientation group. This means that the proportion of

participants that terminated employment from the learning style-based clinical

orientation program group was compared with the proportion of participants that

terminated employment from the non-learning style-based clinical orientation

program group. The results of the Chi Square Test to determine whether the

turnover rates differ between these two groups are presented in Table 8.

Table 8

Chi Square Test Results Comparing Turnover Rates

                                                      Value           df       P

Pearson Chi-Square                                    1.337           1      .248



       Table 8 reflects that there was no significant difference in the turnover

rates of individuals who participated in the learning style-based clinical

orientation program and those who participated in the non-learning style-based

clinical orientation program X2(1,N=39) = 1.34, p = .248. The turnover rates did

not significantly differ from one another for the different groups in the study. This

once again could be due the limited observations for each one of the groups, due

to the sample size, resulting in an inflated standard error term, which resulted in

non-significant results.

                           Acceptance/Rejection of Hypothesis
                                                                                  126

       The results of the data analysis indicate that an individual not being

employed after six months for those in the learning style-based clinical orientation

program was not statistically different from those of a person who participated in

the non-learning style-based clinical orientation program. After controlling for the

demographic characteristics of the participants, it was found in each case that

there was no statistically significant difference between the learning style and the

non-learning style-based orientation programs. Similarly, when comparing the

turnover rates of each group it was found that there was not a statistically

significant difference between the two groups. Based on these findings the null

hypothesis is accepted.

                                     Summary

       Chapter 4 provides a summary of research data and results of the study

analyzing the impact of learning style-based clinical orientation on new RN

turnover rates during the first six months of nursing practice. The focal point of

the study was to identify how incorporation of a learning style-based clinical

orientation program would affect the orientation process for new nurses and

subsequently affect turnover rates. In order to test the null hypothesis three

separate analyses were implemented.

       The first was a logistic regression analysis where the dependent variable

of interest was whether the new RN was still working at their position six months

after they were hired. The independent variable was whether the new RN in the

learning style based clinical orientation program or whether they participated in a
                                                                                      127

non-learning style based clinical orientation program. There were no statistically

significant differences between the two groups based on this analysis.

       The second was a logistic regression analysis where the dependent

variable was comprised of the “yes” meaning that the participant was still in their

position six months after they were hired and “no” meaning that the participant

was not still in their position six months after they were hired variables. In this

analysis, however, the demographic characteristics of the participants were

included in the model in order to determine whether there was a significant

relationship between the learning style based clinical orientation and non-learning

style based clinical orientation groups when controlling for the demographic

characteristics of the participant. There were no statistically significant

differences between the two groups based on this analysis.

       The third consisted of a test comparing the turnover rates of the

individuals who participated in the learning style-based clinical orientation

program and those who participated in the non-learning style-based clinical

orientation program. Raw data from this analysis demonstrated that individuals

who participated in a learning style-based clinical orientation program were four

times more likely to remained employed six months after date of hire as compared

to those who participated in a non-learning style-based clinical orientation

program. Although the raw data suggested a difference between the two groups,

the statistical analysis showed that there was no statistically significant difference

between the two groups. Therefore, for the purpose of this study, the null

hypothesis is accepted.
                                                                                128

       Chapter 5 includes a brief summary of the study, the conclusions drawn

from the study findings and a summary of a broader application of these findings

with respect to social significance. Chapter 5 also includes suggestions as to how

these findings may be applied to a larger body of knowledge including leadership

and application in academic and other vocational settings. Finally, chapter 5 will

include a summary of recommendations of future research in this area.
                                                                                  129

         CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS

       California ranked as one of the lowest states when evaluating the number

of nurses per capita with regard to actual and projected nursing supply over the

next 23 years (Spetz, 2006). More specifically, in a study looking at the regional

registered nurse workforce forecast for the Central Valley Region of California,

Bakersfield received an “F” grade, meaning that this area of California was one of

the worst regions with respect to the number of RNs per capita (Lin, Juraschek,

Xu, Jones, & Turek, 2008). In response to the increasing deficit of nursing

personnel, California nursing schools have increased the number of individuals

admitted to nursing program by either increasing the number of people per class

or increasing the frequency of admissions. California nursing schools have also

directed additional resources toward instruction and examination preparation

methods to improve licensing examination pass rates (Spetz, 2006). These efforts

have been successful in increasing the number of nurses graduating from

registered nursing programs, but have been less successful in adequately

preparing new nurses for actual clinical practice. This lack of preparation has

resulted in a 25-50% turnover rate among new RNs during the first six months of

nursing practice (Hom, 2003; DHHS, 2005). Similarly, the National Council of

State Boards of Nursing (2007) reports “new RNs continue to struggle with

mastery of clinical skills such as managing and organizing an increased and

complex patient care assignment, communicating with physicians and delegating

tasks. The turnover rates for new RNs within the first year of practice remains

high, ranging from 33-50%”. (¶ 2)
                                                                                   130

        Baltimore (2006) suggests that consideration of the employee learning

style when developing and implementing orientation programs might prove

beneficial in assisting the employee in progressing through the orientation process

at a more comfortable pace, and may create a more effective learning

environment. As a result, this study was developed to identify if this process

could be effective in the orientation process for nurses and to determine what

impact use of a learning style-based clinical orientation program would have on

the turnover rates of new RNs.

        Chapter 5 contains a summary of the interpretation of the conclusions

drawn from the literature review, the approach to the study and an analysis of the

data. Chapter 5 also contains a summary of the implication of the study and

recommendations for future research in this area. Information and suggestions on

broader application and social significance of the study findings will also be

briefly addressed.

                                 Responding to the Problem

        The purpose of this research study was to analyze the effect of learning

style-based clinical orientation on turnover rates for new RNs in three acute

healthcare facilities in Bakersfield, California. Results of this study indicate no

statistically significant difference in turnover rates between individuals who

participated in a learning style-based clinical orientation program and those who

participated in a non-learning style-based clinical orientation program. The target

population for the study consisted of new RNs who were recently hired at the

study sites.
                                                                                   131

       Of the 25 new RNs hired by the study facility, 100% participated in the

study. The data on the non-learning style-based clinical orientation group was

obtained from archived demographic and employment data provide by the human

resource department of the study sites. The majority of the study participants on

which data was collected were female (n=36). Twenty one percent of the

participants were Caucasian and 46.2% of the participants were between the ages

of 26 and 30 years. Of the 39 participants on which data was collected, 14

participated in the non-learning style-based clinical orientation program and 25

participated in the learning style-based clinical orientation program. Of the 14

new RNs who participated in the non-learning style-based clinical orientation

program, two were not employed at the end of the six-month period. Of the 25

new RNs who participated in the learning style-based clinical orientation

program, only one was not employed at the end of the six-month evaluation

period. The learning style-based clinical orientation group represented 100% of

the new RNs hired by the study sites during the research period. Evaluation of the

most recent literature on application of learning styles yielded no studies on the

use learning styles in new RN clinical orientation.

                                        Limitations

       The scope of this study focused solely on the methods used to orient new

RNs into the clinical setting. The specific emphasis of this study was to determine

what affects the adaptation of the clinical orientation process, to include

individual learning style preferences of new RNs, would have on turnover rates.

Several limitations were noted as most prevalent. The first was the availability of
                                                                                     132

new RNs during the study period. Since the study was focused on one geographic

area, the availability of new RNs in that area was solely dependent upon the

graduating classes of one of the two nursing programs in the area, as the second

program only graduates new RNs in June of each year.

       The study was also limited by the availability of data on the reliability and

validity of the learning style inventory. The tool had previously been used in

similar studies and was considered, anecdotally, as an accurate tool for assessing

the sensory portions of learning style preferences. The learning style inventory

was used to determine the learning style of the study participants that determined

certain components of the orientation adaptation process. However, the tool itself

was not directly related to the analysis of the turnover data.

       The third limitation was the level of understanding possessed by the study

participants and clinical preceptors regarding learning style concepts. The level of

exposure that each participant and each preceptor had of the concept of learning

styles varied. This limitation was mitigated by providing education to the

preceptors and study participants with respect to the learning styles concepts and

by providing regular opportunities for clarification of any concern or uncertainly.

       The next limitation was the lack of comprehensive data on level of

education. Twenty percent of the study participants failed to complete the

demographic questionnaire section on level of education. The absence of this data

prohibited the analysis of this characteristic with respect to any contribution it

may have had to the turnover data. Comprehensive data in this area may have
                                                                                  133

contributed to a clearer picture of any variance related level of education and may

have altered the overall results of the study.

       The last significant limitation was the lack of data on job satisfaction. As

previously discussed, RN turnover has been attributed to lower levels of job

satisfaction among study respondents. Data on levels of job satisfaction may have

provided additional insight on other potential factors that may have contributed to

RN turnover rates, thus expanding the study and providing a more comprehensive

view of RN turnover factors.

                         Interpretation of Literature Review

       Review of nursing shortage data and other literature related to the supply

and demand for nurses with respect to numbers and quality indicates a need for

intense evaluation of all aspects of nursing orientation and training. The average

mean age of practicing nurses and the anticipated exodus of nurses from the

workforce within the next 10 years supports the need for increased focus on

adequate preparation of new RNs and on strategies to retain new nurses in the

workforce. In addition, the current deficit of nurses in the area requires

development and implementation of innovative ways to retain the current nursing

workforce and increase the number of individuals entering the nursing workforce

(Lin et al., 2008). Evaluation of research data on turnover in both nursing and

non-nursing professions indicates consistent findings related to job satisfaction,

lack of advancement opportunities, and other work-related issues (Lindsey &

Kleiner, 2005; Steensma, van Breukelen, & Strum, 2003-2004;). Research data on

new RN turnover confirms the existence of a major deficit in preparation for
                                                                                     134

practice, appropriate work environments, and transition management (Bowles &

Candela, 2005; Casey, Fink, Krugman, & Propst, 2004). Intense focus on the

methods of training and orientation of new RNs and methods to ensure ongoing

competence in nursing skills are essential in order to address the nursing shortage

issue and ensure optimal quality of health care providers and the care they provide

to health care consumers. This study focused on one particular approach that may

assist in ensuring that nurses who are trained remain in the workforce by

providing one method of individualizing their orientation process.

                             Research Question and Hypothesis

        Understanding the effect that learning style-based clinical orientation will

have on new RN turnover rates will provide information that may be used by

healthcare organizations and academic settings to develop and implement more

effective educational strategies. In light of the current deficit in the nursing

workforce in Central California, and the subsequent need to identify methods to

reduce new RN turnover, this research study explored the following research

question:

        Research Question. What effect will a learning style-based clinical

orientation program have on turnover rates of new RNs during the first six months

of nursing practice in three Bakersfield, California, acute healthcare facilities?

        Hypothesis.

        The independent variable under study was the use of a learning style-

based clinical orientation program for training of new RNs in the clinical setting.

This study provides data to determine the effect that a learning style-based clinical
                                                                                     135

orientation program had on the turnover rates of new RNs six months after

graduation. The study also documents data in order to test the following

hypothesis:

               H0: New RNs who participate in a learning style-based clinical

       orientation program will not show lower turnover rates than new RNs of

       similar demographics who participated in a non-learning style-based

       clinical orientation program during the first six months of nursing practice

       in three Bakersfield, California, acute healthcare facilities.

               HA: New RNs who participate in a learning style-based clinical

       orientation program will show lower turnover rates than new RNs of

       similar demographics who participated in a non-learning style-based

       clinical orientation program during the first six months of nursing practice

       in three Bakersfield, California, acute healthcare facilities.

         Discussion and Answers to Research Question and Hypothesis Findings

       The research question on which this study was based was focused on

identifying the effect that the use of a learning style-based clinical orientation

program would have on the turnover rates of new RNs in three acute healthcare

facilities in Bakersfield, California. To address this question required analysis and

comparison of turnover rates of a group of individual who participated in a non-

learning style based clinical orientation program and those of individuals who

participated in a learning-style based clinical orientation program. In order to

ensure accuracy of the findings, demographic data on both groups was considered

and a logistic regression analysis was conducted to control for the demographic
                                                                                   136

characteristics of age, gender and ethnicity. The demographic characteristic of

level of education was also under consideration; however, a logistic regression

analysis to control for this variable was not conducted due to the lack of data on

eight of the 39 study participants.

       The analysis on each of these demographic characteristics indicated no

statistically significant difference with respect to turnover when controlling for

age, gender or ethnicity. The analysis of the raw data on turnover rates indicated a

turnover rate in the learning style –based clinical orientation group of .04 (1/25)

and a turnover rate in the non-learning style-based clinical orientation group of

.14 (2/14). According to these findings, new RNs who participated in a learning

style-based clinical orientation program were four times more likely to remain

employed six months after they were hired than those who participated in a non-

learning style-based clinical orientation program. A Chi Square Test was

conducted to analyze the turnover rates of the learning style based clinical

orientation group and the non-learning style based clinical orientation group. The

Chi Square Test analysis indicated a p value of .248 indicating no statistically

significant difference between the two groups. The variation between the raw data

analysis and the statistical analysis may have resulted from the small sample size

of both groups. Based on these findings, the null hypothesis is accepted.

                                 Implications of the Study

       This study included a small sample of new RNs in one geographical area.

Although the study findings suggest no statistically significant difference in

turnover rates between the non-learning style-based clinical orientation group and
                                                                                  137

the learning style-based clinical orientation group, the application of the concepts

for use of learning style-based instruction still provides an avenue to enhance

instructional modalities in both vocational and academic settings. Variation in

instructional methodologies can be beneficial in appealing to different learning

styles by creating consistencies between learning styles and teaching methods.

This process enables the learner to “focus on learning, synthesize knowledge, and

integrate ways of knowing, being and doing that comprise clinical practice”

(Billings & Halstead, 2009, p.26).

Broader Application to Leadership

       Information identified in this study has broad reaching implications with

respect to academic teaching modalities, vocational training skills development,

and orientation modalities. By analyzing workplace instruction focused on

flexible delivery of workplace educational programs, Smith (2003) found that

even though the five stages of skill development were clearly understood by

employers, modification in learning environments based on level of skill

development did not occur. Use of expert learning models were insufficient in

workplace settings, essentially indicating that individualized instruction had not

been thoroughly incorporated into workplace orientation modalities (Smith).

Learning style concepts highlight the importance of individualized instruction and

learning style-based orientation. Individualizing learning experiences through

learning style-based orientation allows learners to “use their strengths and not be

marginalized by having to focus on traditional ways of learning which is even

more important as we consider the increased diversity of students in today’s
                                                                                   138

society” (Barrington, 2004, p. 423). Although this study was not sufficient in

identifying the plausibility of the use of learning style-based education in the

workplace, application of these concepts on a larger scale may prove beneficial in

identifying successful applications of individualized educational models.

       Effective leadership requires a willingness to step outside of pre-existing

practices and embark upon new and innovative processes to create an

environment for ongoing growth, enhance learning opportunities, and facilitate

awareness of additional opportunities for skills enhancement (Keller, Meekins, &

Summers, 2006). Application of this concept in nursing orientation may

potentially lend toward an enhanced learning environment, thus enabling the

nurse to better retain information, increase the level of motivation, and improve

the learning experience. This form of leadership creates an environment that

facilitates employees’ willingness to take risks and try new things, thus expanding

their abilities and levels of competence (Butler & Hardin-Pearce, 2005).

Social Significance

       Evaluating new and innovative methods to transition the orientation

process for new employees from a generalized process to a more individualized

process presents an opportunity to better equip individuals to function in a more

comprehensive manner and to improve quality of products produced. Recognizing

that quality of care is vital in health care, development of comprehensive methods

to train health care providers and ensure optimal skills development, fine tune

critical thinking ability, and maximize concepts application will significantly
                                                                                   139

contribute to improve the quality of healthcare and ensure optimal use of health

care resources. Greater attention must be focused in this area.

                                     Recommendations

       The current nurse supply and demand requires development and

implementation of new ways to train nurses and to ensure that nurses remain in

the workforce. Learning style-based education has proven beneficial in academic

settings and has contributed to improved orientation in some vocational settings

(Dracup & Bryan-Brown, 2004); therefore, it could be beneficial to conduct

further research in the application of learning styles in the education and training

of both new RNs and practicing RNs. Although this research study did not

demonstrate a statistically significant difference between the learning style-based

clinical orientation group and the non-learning style-based clinical orientation

group due to the limited sample size, the raw data does suggest the possibility that

learning style-based clinical orientation may lead to improved retention.

Therefore, specific research should be directed toward evaluating learning style-

based clinical orientation using a larger sample of nurses. This type of study will

assist in obtaining additional information on learning style-based interventions. In

addition, future research on the impact of use of learning style-based clinical

orientation on the new RNs perceived level of comfort and confidence with skills

development and execution would provide a more comprehensive view of utility

of learning styles in individualizing education both within and outside of the

clinical settings. Additional research in learning styles inclusive of the component

of job satisfaction might provide a more robust study and may provide additional
                                                                                 140

variables to consider for future research. Future research in the differentiation of

learning styles and the association to new RN turnover may also provide valuable

data. These data may perhaps identify efficient ways to prepare RNs for nursing

practice. These data may also assist incoming RNs in identifying areas of

specialty that may be more consistent with their individual learning style. An

additional study on use of learning style instruction in simulation laboratory

settings might be beneficial in enhancing instructional methods for skills

development.

                                         Summary

       The current state of the nursing supply suggests that changes need to be

made in how nurses are trained and the methods used to train them. Additionally,

the turnover rate for new RNs is such that the gap between supply and demand

will not be sufficiently narrow without a comprehensive retention strategy.

According to Baltimore (2006) consideration of employee learning styles when

developing and implementing orientation programs might prove beneficial in

assisting the employee in progressing through the orientation process at a more

comfortable pace and may create a more effective learning environment.

Although this study did not provide concrete data to support the use of learning

style-based clinical orientation as a retention strategy for new RNs, it does

provide information that may be used for further study with respect to potential

benefits of using learning style-based orientation modalities to individualize the

methods used to train new RNs in the work setting. Use of learning styles or

some other form of individualized orientation process may prove some assistance
                                                                              141

in retaining new RNs in their positions, thus potentially narrowing the gap

between nursing supply and demand.
                                                                                 142

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                                                                                      162

                                       Appendix A

                              Interview with Neil Fleming

                                      May 22, 2007

              University of Colorado, Colorado Springs, Colorado (UCCS)

                                Faculty Freshman Retreat

Kimberly             How did you get interested in Learning Styles?

Horton (KH)

Neil Fleming         I will do this fairly quickly because it is my life, really. I

(NF)                 started as a high school teacher teaching geography. I

                     then went into what we call a Teachers College in New

                     Zealand, which is where we train teachers but it is a

                     separate institution from the University under the British

                     system. We tend to have separate institutions, so we had

                     nurses training which was not done in the University until

                     quite recently, it was always a separate institution. So I

                     became a trainer of teachers for a few years and then I

                     went into a position that you don’t have in the United

                     States where I was an inspector of high schools. So I

                     went and sat in the back of classrooms all the way on the

                     south island of New Zealand and watched other people

                     teach. At the end of my time at that particular school, I

                     would write a report on the quality of the teaching that I

                     saw going on, and the curriculum and the students and on
                                                            163

anything that I thought would help to improve learning at

that particular school. I did that for nine years. Nine

thousand hours I watched people teach, 9000 lessons.

And that is when I learned about learning. Because when

you watch other people teach and you see learning

happening and not happening you get interested. At the

end of those nine years I had some questions and this is

partly what will be mentioned this afternoon, so you may

get some repetition. I had a couple of burning

questions… Why is it that some of the students still

learning with the very worst of teachers? Because I saw

that happening in sports. How can that be, there should be

no one learning because this teacher is so terrible, they

should all go home and in another situation here we have

an excellent teacher doing wonderful stuff and we yet

still have some students who will not learn so that can’t

be true so there must be something wrong there with the

theory and the practice of how to teach. So I got into, like

you, I went and thought well maybe we will look at this

learning style stuff and I stumbled across it almost by

accident and thought there could be some answers in

here, maybe the lights too strong in some students don’t

learning in bright lights.
                                                                   164

KH   Or it’s too cold

NF   Yes, too cold or the temperature is too high or they prefer

     to learn on their own all the different dimensions of the

     learning style. Dunn and Dunn, as you know have 15 or

     18 of these different dimensions of the learning style.

     And I thought, I can’t change the lighting, I can’t change

     the heat, I can’t feed all of my students, I can’t teach at

     10:00 in the morning and end at 2:00 at night just to suit

     someone’s learning style. But there is one hear that I can

     do something about and that is the modal preferences,

     sometimes called perceptual preferences. That seems to

     have some good oil in it that it is something I can use

     because of the possibility of that the teacher can change

     or the possibility that the student can change while most

     of the other seems rather fixed or semi fixed. In the sense

     that you can give a class at 900 in the morning and switch

     it to the afternoon because I know three of you learn

     better in the afternoon. You can’t do that or we can’t in

     our country so that is how I got into it. So I had a position

     at a university, Lincoln University for eleven years where

     my role was to improve the quality of teaching and

     learning in the institution. We had a very good president

     who said Neil this is your job to improve teaching and
                                                                    165

     learning in the institution. You have seen all this stuff in

     high schools you need to find out how we can do better

     with our teaching and learning. So I became a sort of

     teacher student mentor, students came in one door and

     faculty came in the other. They say you should never

     have them come in the same door, especially if it is

     remedial because they do not want to be seen, so I

     followed this pathway for the next 11 years trying to find

     a way to use people’s preferences to alter the way they

     teach. That started in 1987 and I knew some questions

     that might tease out this difference. I started with one

     question and I got added another then another. At one

     point I had 17 questions.

KH   Yes, I believe you had between 15 and 17 last time I

     checked.

NF   And then I took some out because I was not very doing

     well as questions and there was duplication and things.

     But another place where I started was that when I got into

     this area of preferences, I realized that with my wife, who

     is just met, she has no use whatsoever for maps to find

     the way from Boulder to Denver and from Denver to

     Colorado Springs. Well Neil being a geographer lives on

     maps and a map is almost essential for me if I am going
                                                                 166

     to drive the car anywhere. So I thought, what is this VAK

     thing about, Visual, Auditory, Kinesthetic which has been

     around for a couple of centuries, it might go back to the

     Greek since is certainly kinesthetic is a Greek word. So

     VAK has been around so I wanted to start with something

     like that. And I realized because my wife has no facility

     at all or preference for map, graphs, charts, etc... and I do,

     that is my preference those things, both visual should be

     in separate categories and so R got put into the VAK mix

     because there was visual text as opposed to visual

     symbolic.

KH   And that is where you separate the Read Write out?

NF   Yes, that is where the read write came out. Some people

     say to me I live in a visual world and so forth and so on

     and it is when you just use VAK in other words if all the

     text learners lump into the V category the same as the

     symbolic one then it is the biggest category I suppose,

     although I don’t know I’ve never seen any statistics come

     out of the VAK think ‘cause its more something people

     used rather than something people researched. It was just

     a known thing. So that’s how it jumped out V category

     and shifted to its space overtime (referring to the R for

     Read write).
                                                                   167

KH   Did you delve into theories around it very much?

NF   I did when I decided that I would have to back this up

     with some writing. Because since I was going to produce

     a book that would be used for teachers, there were

     teachers who would not believe anything that was in the

     book unless it was backed by research. I am not a heavy

     researcher, I am a practical… do it, if it works with a

     student then try it with another student until it doesn’t

     work and come up with something different. I am not

     informed by theory, I try something kinesthetically and as

     a practical person and if it doesn’t work I might retreat to,

     I call it retreat to theory. When I was working in the

     university, some of the faculty that I work with, or one of

     the faculty, I worked with gave me a little cartoon, it said,

     “this is too good to be just theory”. She said that’s Neil.

     So the practical component is really important to me.

KH   What did you zero in on as far as the theoretical

     foundation?

NF   Well it was really a hunt. Why I suppose it was I knew

     what I was looking for, but I didn’t know where the

     theories were that would back it up. So it was a matter of

     almost cherry picking, hunt around and see where the

     things are that will support you.
                                                                  168

KH   Oh, what fits?

NF   Yes, What fits? Here is a woman in the Netherlands, in

     Holland and she’s done some work that says that people

     filter things in different ways as they come in. And there

     are verbalizers and visualizers and we have, the notion

     that she had is that here is a mediator, a crossroads when

     we communicate this mediator in our brain is sorting out

     which way we would like it. If it is comes in as verbal

     then we will switch it to visual. So I grabbed her work

     and that seemed to support where I was. I think I was

     looking to find something to support the separation of

     “R”. There was lots of stuff around visual, auditory,

     kinesthetic, but what Neil had to do was to say is there an

     R, is there a separate category. So I didn’t really spend

     time looking for theory around the whole things, just to

     justify the fourth dimension.

KH   Okay. I started using Gardner’s Theory of Multiple

     Intelligence and there is just a small piece of that that

     branches off into this.

NF   Myer’s Briggs has a small piece.

KH   Yes, they do.

NF   That you can map VARK back to, it doesn’t quite fit here

     and it doesn’t quite fit there.
                                                                     169

KH   Loosely

NF   Yes

KH   I read probably three of his books and several of his

     lectures to try to find out where is this, and there is

     enough of it in that theory to build on. Another thing that

     I identified, I termed it in my paper, a learning language

     and make it synonymous with Spanish versus French,

     etc… If you don’t communicate in the appropriate

     learning language, the language that the recipient

     understands then the message won’t be conveyed.

NF   That’s nice, that’s nice

KH   So that has worked out very well.

NF   Excellent, excellent. In much the same way as

     mathematics, they say, math is the language of science

     and so forth. A little piece of the research thing is that to

     try to back up the VARK, various pieces have been added

     on the way through. There is a man by the name of

     Richard Mayer; he is in California, in Santa Barbara. His

     research does not support VARK, per se, but he is into

     the verbalizer, visualizer distinction so that is good for

     me. Because if he can find that some people like it in oral

     form and some people like it in print some people like it

     in diagram form, then I am for him and he is my model
                                                                  170

     and I will grab whatever he does.

KH   One of the things that I did with my first preceptor class

     before embarking upon this project and even before

     embarking on the doctoral program, before I tested them,

     I said I would like for you all to give your partner, I

     teamed them up, give you partner the directions to

     Disneyland. That is all I told them. And then I stood back

     and watched to see which one’s used words versus who

     drew diagrams versus who pointed. Then I made a mental

     note of my own as to who did what. After I tested them, I

     compared my own observations to their test results to see

     if there was some what to see if there was some what that

     you can watch a person to see what type of learner they

     were. And it matched up pretty much. I think I missed

     one. It was really interesting though. Who was your first

     test group?

NF   Before we go there, just to respond to what you just said,

     people often say to me if there is one question we can use

     or one observation we can make that would tell us the

     whole of VARK so we don’t have to do the quiz, because

     they are in a social situation and it is the question in fact,

     it is the direction question. If you want to distill that

     down to one question instead of 16, and that is how
                                                                    171

     would get somebody from here to some where else or

     how would you like someone to direct you from here to

     somewhere else. It works flips side as well.

KH   It was interesting because I asked those who were being

     given direction if they were frustrated and many said they

     were because they wanted their partner to tell me and she

     was showing me. And this brought down to their

     understanding the whole concept of this whole thing and

     how the other students might feel if they are teaching

     them in a manner that they do not learn well.

NF   It’s a great question. I don’t like reducing things to their

     simplest because people tend to run off with just a single

     idea, but between you and me, it signifies the difference

     between the different categories. And because there are

     four very viable options and it is borne out in life now,

     we have GPS systems in cars. I had a man in the

     workshop yesterday at the US Airforce Academy who

     said that he just bought a GPS system and he only bought

     one that talked to him. He doesn’t use the GPS map or

     any other thing because he has to have this voice telling

     him to turn left at the next corner.

KH   I have a GPS system and I have been wanted to change it

     to a male bass voice. But I don’t know how to do it. I
                                                                 172

     would follow that voice anywhere. (Laugh)

NF   Yes, those plastic voices are not so good are they?

     (laugh)

KH   No, I don’t necessarily like them (laugh)

NF   So going back to your question about where is the

     research, I have added pieces as I have run across them

     where they have lined up which is not the best way to do

     research. You should look for things that invalidate what

     you have done. You should test the null hypothesis, there

     is no such thing as people’s preferences and that sort of

     thing, but I am naughty and I live on feedback from e-

     mails and things like that which are not research, just

     anecdotal. And as I said in my seminar yesterday, it

     appears that VARK does no harm and that is the lowest

     common denominator.

KH   Exactly and there is so much good that can come out of

     it. The way you describe yourself, the word

     ‘pracademician’ comes to mind. It’s a new term that they

     used in my program. It a new term. Essentially a

     pracademician is someone who takes academics and

     practice and uses them both equally. The university says

     they are training use to be pracademicians.

NF   I love reading a research paper and then finding a
                                                              173

practical way to use it in the classroom. So I use people

and filter their ideas into programs and other things that

can be done. And a big part of VARK, well maybe your

next question was how I used the VARK, in the situation

I described before, I am in the university and I have the

job of trying to improve teaching which is a wonderful

task to be given. You have a whole playground to play on

and the faculty. This is a small university with 3500

students and 200 faculty members that I knew by name

and I worked equally with the staff. I made no distinction

between those referred to as faculty and those referred to

as staff. So to me they were part of the same unit. I put a

flag up for the students that said if you are having trouble,

turn up here. Then I put a flag up that said if you are

faculty member interested in teaching, turn up here. The

first groups that I started using were individuals and those

things you see on the web which is the list of things you

should do if you are a visual, etc. either as a student or as

a teacher. They all came from sitting with people and

saying, let’s do the test, now tell me what you do. And

sometimes I would shift something out of one category

and put in into another because more people were starting

to tell me hey I, I am a read write but I don’t do that, I do
                                                                   174

     this. I was shifting things around for a while and putting

     them in the right places. It didn’t come from theory and it

     didn’t come from my head. I’m just listening to teachers

     talk about students who do well in their classes by saying,

     the students who do well in my class do this. And

     students who did well saying, I do this. I never worked

     with a particular student group. I gathered lots of data at

     the university. I did a really crazy thing where I tried to

     pretend that there must be a better school for VARK. I

     had to do it to know that there was not. I looked at all of

     the students I could get a hold of and looked at all of their

     data and I found absolutely nothing.

KH   Well how did your work change how they taught? How

     did they change their curriculum?

NF   Well its impact on students was in an individual way first

     because I was working one on one. So I had students

     come back to me as say ‘oh I got a B+ or I got an A’ or I

     used it and I passed. Before that I was teaching study a

     skill at the university that is how I thought I should

     behave was to be a study skills presenter. I would invite

     myself to dormitory meetings and teach the traditional

     study skills, try mind mapping, try mnemonics, try

     writing your notes this way or that way. Write your notes
                                                                 175

     ten times and all this. I looked at study skills books and I

     felt like I needed to peddling these things and people will

     learn better. Once I started working on the VARK I had

     to stop that because I realized that all I was doing was

     giving students a generalized idea that everything would

     be used but I knew from the VARK that these things

     could be unhelpful for students and that telling students

     to do things at certain times were unhelpful for a large

     group of students who may not learn with pen in hand. So

     my study skills presentations at the university became

     VARK presentations. I would walk in and hand out the

     VARK and give them the questionnaire. We would put

     the profiles up on the white board and they would look at

     realize ‘oh we are different’. Isn’t that strange. From

     difference became ‘well let’s look at the differences, talk

     among yourselves and let’s see what you do that works

     for you. Have you got some strategies that you know

     work rather then copying someone else’s strategies?

KH   Right, exactly

NF   That was for the students, it was either one on one with

     these little presentations that I would do to for 30 or

     whatever number. And then for faculty, it was because I

     was sort of in charge of orientation for new faculty. We
                                                                 176

     had a president who said who really needs to learn about

     this institution and its culture of teaching even if they

     taught for 25 years in America, or the UK, or Australia.

     They need to go through an orientation program. So, new

     meant new to the university, not new in terms of new to

     teaching.

KH   Okay.

NF   So we had the whole age range and the whole experience

     range and the president who said I think it should be a

     course lasting a week and they would have to come. We

     don’t have the edge on the thing that you have in this

     country so much with everybody’s full-time. So, they, if

     you like they were paid to come and this was held the

     week before class started. And I put on a small array of

     things. Not everyone came to it and we couldn’t insist on

     it, but that was part of that presentation. So I cajoled them

     to the fact that Lincoln university was addicted to this

     form of teaching and learning preferences and if they

     were coming here to teach they realized that teaching

     involved recognizing the differences in their students.

     And out of that came some of the teaching strategies that

     might be used for the university.

KH   Did you see any impact on attrition or grade point
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     average or anything like that?

NF   Well we don’t have GPAs so that is not how.

KH   Okay.

NF   We can’t, we can’t go to a single number and say this

     improved or that improved and I wouldn’t, know, I

     wouldn’t say there was a change in teaching attrition or

     whatever. No, you would have to have more data that I

     had to do that. On an anecdotal level those students who

     stayed on at university because they found that they were

     having success and so they would stay on for a master’s

     whereas they might have left otherwise and gone

     overseas. But that is all anecdotal and those students who

     came to me and said I was thinking of leaving and

     becoming something else. I don’t think this university is

     meant for me who decided that they might stay and

     change. There was some sad cases that I don’t know

     again were anecdotal in a sense that came from

     interviews, that are documented anywhere, where people

     said to me they would, I’m talking a student, and I would

     say well have you learned and they say well, I do this and

     I do that and I do this and I do that and there would be a

     great hodgepodge of thing in there and I would say to

     them, well why did you do those and they would say well
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     my best friend Amy she does that and she gets A pluses.

     And I’d say well what you are getting. I’m, I’m getting

     Cs and so I realized that there were a grand number of

     students who were using as role models people who

     preferences were quite different from their own. And I

     could always remember one student who said I try what,

     we’ll use Amy as the name, well I tried doing what Amy

     does which is write things out and she just throws them in

     the rubbish when she’s written them, but it all goes in her

     head, it goes up around through the pen and into her

     head. It’s amazing so I’m going to do that and you know

     you see that student three weeks later and you say, well

     what happened. I write it out lots of times and I threw it

     away, but nothing went up the arm. So you know that

     was reinforcing to know that there were, well it was sad

     to know that I think the worse thing is to realize that a

     large number of students who follow strategies that are

     not aligned with their preference. And I think you know

     probably know in nursing that there are a lot of things out

     there in the community who follow health fads or

     nutrition fads that are not in line with their body shape or

     their body chemistry or their body…

KH   Because it worked for someone else.
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NF   Yeah, it worked for somebody else, but for goodness

     sake, don’t copy and why we allow students to copy other

     students and why we allow teachers to copy other

     teachers, I don’t know. That’s ah…and so my answer

     going full circle in a way why is it that some students

     don’t learn in the best of classes and why is it that some

     students learn in the worst of classes became I got an

     answer! It’s because, not just modal preferences cause

     that 1/15th or 1/18th of a learning style. It’s because there

     was a mismatch between the teacher and the students in

     the way one presents and one learns.

KH   You know it is very interesting that you would say that

     because one of the first things I did after I began studying

     this was to look at the clinical educators at the hospital

     and the one who leads out the education she would say to

     people you don’t need to write this down, I have it on my

     slide. And I thought to myself, I just told her you know

     you just disenfranchised all of your read/write learners so

     they are going to sit there but they are not going to

     understand what you’re saying because you took away

     their ability to translate what you said into what they

     understand. And she went wow, I never thought about

     that so she stopped saying it at that point. But just
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     something as simple as that would have made such a

     difference for people and it would change their

     perception of the whole experience.

NF   I had in a similar way, I had teachers who always talked

     through the overhead or the PowerPoint, you know so

     these students had to decide should I read this or should I

     listen to this? And some students don’t have that

     multitasking ability to read and listen, especially when

     words are the same. Some students and read a book and

     hear a conversation at the table next door but this is

     hearing the same thing is two different modes. They say

     that freaks me out why doesn’t she be quiet and let me

     read it and the others are saying why do they have to have

     those things on the PowerPoint when I just have to hear

     it. And in a practical state I started teaching the teachers

     at the university the faculty, I started saying to the faculty

     just put the overhead down and say nothing, just put the

     words on the screen and say nothing let them read it. Let

     the readers read it and then you can come in and you may

     even want to turn the words off, push button B on the

     PowerPoint take the focus away from the words on the

     screen and say it and catch another group of learners. But

     don’t assume that they want you to talk through the
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     words they are busy reading or visa versa.

KH   I have found that since I am not an auditory you know

     what I hear most times is… are you familiar with Charlie

     Brown?

NF   Yeah.

KH   Do you remember the teacher?

NF   Yeah

KH   Wah, wah, wah, wah, that is what is sounds like after a

     while.

     Blah, blah, blah.

     And, and, and, so I…

     My auditory score is low so I had to learn to teach school

     is a new way. I am not someone who learns through the

     auditory track yet people say to me, but you speak so well

     and you can explain things so well. I say well that’s

     because it’s a preference from my learning, it’s not

     something about my ability.

NF   Ah. And we now, when I go back I should send

     you…that would be a good idea; I should send you some

     profiles. Can we just divert for a moment?

KH   Sure, we can go wherever you want to go.

NF   Yeah, but I realize that you got some questions.

KH   Oh, I’m getting lots of good information.
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NF   Um, a long story and I’ll cut it short. A woman in New

     Zealand contacted me because her daughter was having

     trouble learning and this was not in an institute. We

     weren’t in the same institution, we were actually in

     another town and I sent her some stuff and told her to do

     the questionnaire with her daughters, two daughters. And

     we met at one stage and she said to me that was so

     helpful, she said you know my daughter has improved

     and this is now going on so forth and so on. She said why

     don’t you do that for other people and she was a business

     person, she was a high ranking in banking, no telephone

     company, Ma Bell or Cingular or something like that.

     And she an entrepreneur and so she saw dollar signs and

     said Neil you should be running something and I thought

     about it for a while and I’m not very entrepreneurial so I,

     so VARK is given away free if it is used in education.

     Lots of people said you should have charged for that.

KH   I wondered about that myself.

NF   There is a course, Connie here has just made a course

     about emotional intelligence which is a big thing in the

     States now and the basic document costs $14 to do. So if

     you are looking at it from an institutional cost, this school

     here cannot afford $14 per student.
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KH   That is true.

NF   So I was always determined VARK should be free for

     students. Cause that is who I was out to help.

KH   So it is a mission for you.

NF   Yeah, oh yeah, patient well patient and a mission. And its

     fun, I mean you get so much excitement. Talking to you

     is fun and it’s affirmation that something is happening.

     You’re in America and in Nursing. I’m in New Zealand,

     I’m retired and we’re connecting about something and

     something is flowing that’s valuable. But this woman

     said you know, you should provide VARK as a

     questionnaire online why don’t you do profiles for

     people. Where somebody tells you their scores and you

     give them some advice, written advice, narrative or phone

     advice is you would like and they pay for that and they

     get a full description on how they can improve their

     learning. So I have been doing these online and students

     can fill in the questionnaire and there is a little note that

     the bottom. If you would like a profile, then send me $35

     dollars, $35 New Zealand dollars, that’s about $20 of

     yours. And he’ll write a little story about it. And if you

     want to have an engaged conversation with Neil via e-

     mail afterward, then you have to pay him $35 U.S.
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     dollars, which is $50 New Zealand dollars. So you know

     there is a two step thing in there. So I’m thinking now

     that I should really send you some of those profiles, for

     particular or peculiar profiles you know things were

     somebody scored a 0 or something or send you the 4 or 5

     basic ones so you can see how I would advise someone

     on how to use that and they are mainly written for

     students of course.

KH   Oh, that sounds great. I’d love that.

NF   And you could and then what you could do if you come

     up with someone who is very read/write and need help

     then you could just send them the profile. Cause in the

     manner it’s written of course. I would love to have an

     audio profile and a kinesthetic profile and see one of the

     things that has is very difficult for me is that if I walk the

     walk and talk the talk, why isn’t there a questionnaire

     which is kinesthetic or visual or auditory?

KH   Okay.

NF   And why is all of Neil’s website got so many words on it

     dealing with the read/writes? Why isn’t is full of

     diagrams, videos, pictures? My answer is we will get

     there one day.

KH   It’s coming.
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NF   And, yes, and we are talking about an auditory

     questionnaire, which should be too hard. The kinesthetic

     one captures the brain and presents all those 16 questions

     as a kinesthetic experience thing for people who learn in

     that manner.

KH   You know with a web cam, the kinesthetic would be a lot

     easier now as compared to before.

NF   And it’s possible, the difficulty, one of the difficulties is

     not the technology, I think we can do all of the things we

     want to do and we will be able to. If we cannot do them

     now, we will do them in five years time. The difficulty is

     that people’s own equipment at home is not always as

     smart. It does not always have the bells and whistles and

     if you are talking to somebody who is, if you working

     with somebody who is in a poor economic state then its

     not much you saying to them you know get a web cam

     and get a more powerful computer with broadband

     because I am going to send am going to send you through

     some live video. I don’t, I that would be against my

     inclination. So I am waiting for the technology, the very

     basic technology that might allow more opportunities to

     walk the walk and talk the talk.

KH   I like it.
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NF   So these profiles, I should send you some so that you can

     have a look at what I have and what I have been getting.

KH   That would be very, very helpful

NF   And in fact what you should do is start a list of the things

     that Neil is going to send you.

KH   And then I’ll e-mail you the list.

NF   Yes, e-mail me and say well when are those profiles

     coming? But one of the interesting things is that with the

     profiles is that I get four or five a week, I suppose. They

     clearly, I think are people that are having some difficulty.

     They think here is something that I can do, pay some

     money and maybe that will help me get an A which is a

     bit sad. But it seems that the opportunity to e-mail me

     which is only a few more dollars. We get quite a few

     people paying the money and never follow-up. So do they

     get enough in what I send as the basic response? There

     has only been, it’s been running now for almost a year

     and I’ve only had about two people; I get four or five of

     these a week and I only got two people who’ve actually

     followed up and who e-mailed me and said that was

     interesting and what about this and I’m in nursing or I’m

     in science and what would you do with this. I was

     looking forward to that conversation.
                                                                   187

KH   Do you think that maybe it’s because they are looking to

     you to fix it rather than then guide them in fixing it?

NF   Yeah, yeah it could be

KH   And I guess when it comes back and they actually have to

     do something themselves, they’re saying well this was

     supposed to be the answer, he was supposed to send me

     the answer.

NF   I’m sure, yeah.

KH   Well you know I like the thought of actually

     disseminating that out further because in looking at what

     I am doing, I’m focusing on nursing students, but I also

     want to send it out to patients. Not necessarily saying I

     want to test all the patients, but I’d like to be able to, like

     I did earlier, something that we can identify or certain

     questions we can ask them so that when we give them the

     information toward their health, they will be able to

     comprehend and understand that we are telling them.

NF   Look at the dietician who is in the health clinic which is

     part of the medical practice that I go to if I have

     something fixed or get something. I’m a fairly healthy

     individual; I don’t go very often, but when I go there and

     look at her room which is a sick room, outside she’s got

     please fill in this questionnaire about your learning styles
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     before you come into the clinic.

KH   Wow.

NF   Now, not met her yet, I don’t need to go and see her but I

     think she is a nutritionist and maybe I should imagine

     there is something wrong with me and get in there to see

     what she is doing. But she is clearly finding from her

     patients and it’s before their get in the door so she is not,

     you make the appointment and while you are sitting

     outside would you mind filling in this little questionnaire.

     It’s not VARK, I don’t know what it is, but it is

     something about it has questions about how do you learn

     and so on.

KH   Interesting, I love it.

NF   And in to pick up on your idea about using it with

     patients, I would put a group of three respiratory; well no

     not respiratory nurses sorry. Three nurses who will be

     responsible for educating patients about injecting

     themselves for diabetes

     Diabetes and their success rate weren’t very high. In

     other words they were having a lot of people turning up

     with bad needles and with unclean hands and other

     things. Even though they did it and so I said to them well

     have your patients just been diagnosed with this problem
                                                                   189

     of diabetes and they are going to go home and they are

     going to inject themselves for the first time and so on, so

     what is your training program look like? Oh, well they

     get this manual, you know. 55 pages of how to wash your

     hands and how to do this and do that and all done in note

     form or all done with lists and all done with 1, 2, 3, 4s.

     Not a diagram to be seen for, forever. And I said well

     what’s happening and they said well we are not doing

     very well quite a few people don’t follow it. When we

     check up on them afterwards, you know they jump from

     step 1 to step 4 and you know there are problems with

     doing that if you are… and I said well let’s talk about

     VARK because I had heard something about this. Oh I

     see okay, let’s do this and the end of the story is that they

     re-write the whole thing and they didn’t call it a manual

     and they did many more demonstrations before people

     were, they were stabbing oranges and things before of

     course, but essentially when people went out the door

     with this thick book.

KH   Um hum and an orange (laughing)

NF   And an orange, yes and the orange didn’t have diabetes.

     It did look anything like their arm or whatever they were

     going to be sticking.
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KH   And it didn’t look anything like their arm. (laughing) I

     love it.

NF   So they rewrote the manual so that’s a little example of

     what people might do to.

KH   That’s great.

NF   And I, that and the dietician whose got it outside her door

     to say fill in this form before you come in. I think there is

     huge potential to find out from patients and clients before

     then and I work with uh, some other groups I worked

     with are realtors and uh, you know if you are going to

     make the sale of a house, which is one of the exercises

     we’ll do this afternoon, um how are you going to appeal

     to the people who walk up your drive and who clearly

     want to learn that the house visually, orally, read/write,

     kinesthetic. And they say to me, I’m a salesman, I’m a

     successful salesman, man, person, agent, whatever. I sell

     about a hundred million a year, yeah okay, you might be

     selling to only one type of person or you may be real

     good and you may have searched out that people are

     different and you may review things which. You

     mentioned something before I just need to go back to

     because I diverted myself successfully onto another

     digression.
                                                                      191

KH   (Laughing) it’s interesting information though.

NF   Preferences and abilities in the profiles, which is where

     we diverted which was about 30 minutes ago. So bad. In

     those profiles there is a little diagram that says that it’s a

     little four part diagram that says you can have a

     preference it may not be your ability, you may not be

     very skilled at it. You can have a preference and be

     skilled at it. You can have a skill and not be interested in

     it and you can have a skill and be interested in it. So there

     are four categories. Just sort these things out for yourself

     beforehand because VAC will tell you nothing about your

     ability.

KH   That’s true.

NF   And it, but it will tell you about your preferences and you

     need to keep those things separate. Sometimes you will

     have ability and the preference will be the same thing. Go

     for it. Sometimes you will have a preference for

     something and have no ability for it, okay you can learn.

     Chase it, go for it. Sometimes you will have no

     preference and no ability, forget it.

KH   (Laughing) Wash that out.

NF   Delete, yeah. So it is just a little diagram that just says

     those words you know. Forget it, go for it or whatever.
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     Because I do find that it’s quite, when you put student’s

     profiles up on our white board or blackboard they may

     see them for the first time and they see other people’s,

     they see a zero or one as being a significant gap in the

     person. And they want to know how they can fill it up.

     And I say, forget it, this is not saying I got a score of one

     for auditory, does that mean I’m not actually a good

     listener or a good speaker or whatever?

KH   No.

NF   No, it just says that Neil doesn’t learn by sitting in a

     lecture room and listening to other people talking about

     something.

KH   You know we tend to put so much emphasis on good and

     bad in reality it’s all relative. You know, it doesn’t mean

     that because you are not an auditory person that you are

     going to be less intelligent then someone else. But, but,

     but we tend to want to pull things in and say those sorts

     of things. We talked a little bit about healthcare

     application and I actually delved into the literature to try

     to find where VARK had been used in healthcare and I

     wasn’t able to find it. I found the VAK, but not the

     VARK.

NF   Okay, but again mentally note that I should send you
                                                                 193

     stuff because I’ve got a few papers where people have

     done posters of conferences which report the use of

     VARK in clinical applications.

KH   Oh good that will be helpful. Okay. Have you found um

     in addition to what you mentioned before any other areas

     that might be helpful to me in I guess making my study

     more robust? As far as healthcare application?

NF   No and yes. I’m wondering whether when I get e-mails

     from people who are in the nursing profession who want

     to use VARK whether I should copy those to you so that

     you can see who is using it and where it is and maybe we

     can start an e-mail chain or network or just give you the

     opportunity to contact these people as well. I mean, I

     could easily say to them because they are usually asking

     permission, may I use the VARK? So it’s straight

     forward and I could easily say to them, I notice that you

     are in nursing in this particular area of focus). Are you

     aware that Kimberly is working this area and would be

     interested in any conversation you. Might I give her your

     contact information?

KH   That would be great if you would do that.

NF   I could set that up but I don’t know whether that is what

     you are hinting at or whether that would be helpful. Any
                                                                   194

     information that I can get because this is more that just a

     degree and a paper for me. And I’ll sort of give you an

     idea of the connection for me. I just wrote a grant and

     was given $100,000 to do enhance cultural diversity

     training for healthcare providers, including physicians.

     And the whole foundation of it is that most of the times

     when you talk about cultural diversity people think about

     ethnic and geography. But this is a totally different thing.

     Small “c” culture.

KH   Exactly. Who are these individuals and how can we tailor

     the services we provide based on the individuals and how

     can we also use the same theoretical concepts to better

     function amongst ourselves, recognizing our differences.

     The example that I gave them was if you look at me you

     see an African American female and if I told, there would

     be certain ideas that were formed around that then if I

     said well no, my family heritage is American Indian and

     Jamaican okay, that changes things.

NF   I have guessed that.

KH   Yeah, then you add to it that I have a religious

     preference, I’m a vegetarian, you know, I’m a baby

     boomer and I start adding all these difference elements

     and with each element they said okay, well that would
                                                               195

     change my and that would change and by the time I

     finished with them, I said now if you had determined how

     you would relate to me based on your first initial

     impression it would have lead you down the wrong road.

     And so the whole grant is about teaching people, not

     these people do this and those people do that, but just

     working with people individually and I plan to

     incorporate some of this into that whole training. How do

     people learn? What are their views of health? What are

     their views of death? You know that sort of thing. So it’s

     such a much bigger picture for me, this is just such a

     small part of where my head is.

NF   Um hum, well with a $100,000 grant I can understand

     where you head is.

KH   Well I was excited to get it.

NF   You have to dilemma there and congratulations on

     getting it.

KH   It was the first grant I ever wrote.

NF   Excellent.

KH   And I thought it was great.

NF   Well not many people will have a one/one win situation

     with the first grant delivered.

KH   Yeah, I was just floored and I feel that with the success of
                                                                  196

     that, successes that I’ve seen I must be going down the

     right road. And as long as I continue to focus on helping

     man and not myself, I think I’ll continue to see those. Is

     there any other tidbit that you can give me that would

     help me to be able to apply this better?

NF   Well one of the new things some of the new things that

     we are finding and I don’t know where you are with this

     multimodality. There is a great lump of people leaned up

     as mixtures, which I am quite happy with 60 percent of

     people, 55, 58, 56 end up in that multimodal soup with

     being a bit of A, a bit or R, a bit of V and so forth. And

     1/3rd of the people who visit the website; which is highly

     biased of course because of the VARK are on a website

     which is for read/writers, so people have to be computer

     competent and in fact with 100 people in your town and a

     100 people in my town. I don’t know what they are, I

     don’t have a clue. We might find that visual seems to be

     low; I thought it would be high. The auditory seems to be

     low; I thought it would be high. It maybe that there is an

     ethnic thing as well, I don’t know. Perhaps with people in

     New Zealand I would find that because they have no

     written history then there would be much better in

     institutions where most of the teaching learning is done
                                                            197

orally. Because they tend to hand that culture down and if

I was in Australia where there is Aborigine, straight

island people, maybe they would want a visual learning

because they are people whose art and culture is very

cultural big “C” is very much based on visual images and

seeing food sights and seeing water sights and traveling

long distances and so forth. So, maybe there are different

dimensions in that area and in the mix, but putting affects

and so forth aside, in that multimodality where you’ve

got two-thirds of or close to two-thirds of the people, one

third of VARK. Now what I’m saying at workshops and

seminars and things is that what’s the nature of somebody

who is VARK and it is easy to talk about visual, etc and

we can just combine it and say oh VARK is all four.

Yeah well that’s helpful but they’ve got some special

characteristics of their own other than just being a

combination of four things. And what I’m coming to

now, what I’m hearing from people with the faculty and

student population is this, if they had chosen 16 options

so that only chosen one for each question and their scores

are say 4, 4, 4, 4. Beautifully multimodal. I call it

squares. I don’t like to (unable to discern). Then these are

quite decisive people because they are choosing only one
                                                              198

option per question and they are choosing presumably to

leave this one because the situation calls for a visual

response. By choosing A in this case because they

definitely looked close and something around read/write,

auditory. So they are being very selective, but very

decisive… In a sense they are not all over the shop. Now

compare that with somebody who is multimodal, VARK,

and has chose sixteen, not sixteen options, but sixty four

options? And their score is 16, 16, 16, 16? Now, I’m not

saying these are on the VAK website. We do have 4, 4, 4,

4’s, but probably not 16, 16, 16, 16 because that is being

so indecisive. But lets say that its 12, 12, 12, 12, or 14,

14. There are lots of people out there on the website, on

the baseline, but on the data. How are they different from

the 4, 4, 4, 4? Because they are both combinations of

four things and what I’m saying to people is that these

people are indecisive. They are unsure. They don’t meet

all four in every situation. They need all four in a single

situation. We have a person, a 4, 4, 4, 4, needs all four

things in the range of different situations. These people,

the 12, 12, 12, 12, need the support of the preference of

four modes in every situation. And I’m choosing to say

quietly these people are slow learners, not slow learners
                                                                   199

     in the sense that we used to use it in the 70’s and 80’s to

     mean somebody who is not intelligent, but these people

     are slow learners. In other words, they don’t get the

     picture until they’ve got all four modes on board and they

     are incomplete learners when they’ve only got two or

     three. They need all of the pieces of the jigsaw puzzle and

     then the whole thing makes sense and they get their ah

     ha. The single preference people get their ah ha with one

     shot. I’m visual, he’s a visual teacher, he or she just drew

     this beautiful diagram to show me how things work, and

     I’ve got it. The multimodal people that, like the 12, 12,

     12, 12s, are saying well I’ve got a piece of the picture

     from him and I’ve got a piece of the picture from her and

     I got something else, but I’m still incomplete.

KH   You know that is very interesting. I am understanding

     you to say that it’s the decisive situational versus the one

     that it is more like a puzzle piece?

NF   Correct.

KH   And they need all four pieces before they truly

     understand the entire concept begin presented.

NF   Yes, correct.

KH   That is interesting. Now how would you apply that to bi

     modal, because I being a visual kinesthetic, I’ve noticed
                                                                  200

     that when I study, I have the television on and muted? I

     write better this way than when there are no visual

     stimuli. It that a good example of what you are saying?

NF   Yes.

KH   And it’s something about the visual stimuli that, that

     sounds to me like it fits a little bit into the concept of

     what you are saying even not only with the multimodal,

     but maybe even with the bimodal.

NF   Yeah, yeah. I think it works for bimodal, multimodal, etc.

KH   Yeah, something stimulating that brain sort of opening up

     the floodgates or whatever so the information can come

     in.

NF   Well in this mental notebook that you are taking through

     this machine, we need to get you in contact with Abby

     Hessler. I may have done that, did I?

KH   No. Not to date.

NF   Okay, well you need to know each other, she is at

     Northern Virginia Community College and she is

     working with VARK in a major way to change their

     teaching modalities. And she’s got data and she can

     answer some of the questions that you have asked me in a

     very practical way too. But Abby’s is to jump to the point

     quickly. Abby runs a sort of learning center as a sideline.
                                                             201

It’s not what she what she does primarily at the college, I

mean that part of her job is that students turn up that need

help and she uses the VARK with them. She has done

some little mini surveys where after 15 students who turn

up in one week for help, 12 used the V, A, R, K, s

(needing to use all four preferences in order to fully

understand the concepts presented). Now 15 that are very

small numbers, nobody would build, statisticians would

have a field day shooting that down out of the skies. But

she is saying that most of the students that she sees in her

life would turn up and say I’m not succeeding, I’m not

learning, I’m not happy, I’m not getting good grades are

V,A,R,K’s. Now the statistics would say a third of them

should be V,A,R,K,’s and the statistics from that database

would say 60 percent would be multimodal in some form

or another, but it’s V,A,R,K’s that she is seeing. And she

was the one who put me on the new line, I think it’s

because they are not confident about their learning until

they have all four puzzle pieces. And to tell you a little

anecdote, which may come, you’ll get some repetition

this afternoon. One of my little anecdote that I was

running a workshop somewhere in this country, it doesn’t

matter and the woman said to me oh, I can tell you about
                                                            202

being VARK and not being sure of things. She said my

son’s haunting me because he’s 16 and we haven’t had a

TV for about 30 days, could we go buy a new one? And

she says, I’m a V,A,R,K. She said I can’t buy that

television. She said, I keep thinking I’ve made a decision

and they I got back and think, no I better find out about

this. No, I better talk to the salesperson, no I need to read

more of the brochure, no, I’ve got to ring my sister and

see what she thinks of her because she’s got a good

television and I want to find from her what’s it like. No, I

want the salespeople to bring the machine around so I can

see it in the room and see how it looks. And she said I

think within 30 days, I don’t know how many days, but

you know it’s been a long time and my son is driving me

crazy. He’s say mom we’ve got no T.V. and we are the

only people in American that do not have a T.V. in their

house. And she said you won’t believe this but the other

day I was going to the mall on a Saturday morning and I

thought, I am going to decide today. I went home and I

on the way home, driving home, I phoned my husband I

said, I just made a decision, we are going to have the

Sanyo 16 inch or whatever, she said have the man load it.

Before I’d even reached my home. I said no, I’m
                                                               203

     canceling the order. Because I still want to find out some

     more about it. Isn’t that lovely?

KH   That is what you called analysis paralysis.

NF   Yes well, I like thinking that it’s somebody who would

     probably say well you know she needs psychological

     help. I just say, she is a wonderful example of a V,A,R,K,

     multimodal, large size. It’s almost now we’ve got two

     distinctions, distinctions here between those who are,

     situationally indecisive and those who are... you can

     invent a name, you could create a whole new category.

KH   Yeah, I was actually sitting here trying to figure out what

     you would call that person. You don’t want it to have a

     negative connotation, so you don’t want to call it

     indecisive.

NF   No, no. But you could call them…I’m going to play on

     the flight on the way home and come up with a term and

     we will add it to the VARK.

KH   I’ll e-mail it to you (laughing)

NF   And when I, now the other thing is that when I write

     these profiles like I said before, most of them are

     VARKs. More than there should be. And they can’t

     figure it out. I write very few for single preference

     people. Quite rare for me to have a single preference
                                                                  204

     person saying, please send me a profile it helps me. But

     it’s almost like people in my life will say to me, any

     profiles come in today and I’ll say yes, there is one there.

     What is it, and I’ll say its V,A,R,K.

KH   I understand

NF   You know the term fragment or segment is coming to

     mind, but I still can’t put it together.

KH   There is a good task for you on the way home.

NF   Yes, I’ve got some time.

KH   And I’ll buy whatever you come up with.

NF   Currently we get approximately 6,000 profiles a week.

     And when I look, we’ve just put on the region question

     you know, what region are you in. We’ve just made that,

     the North America, South America, Africa, Asia, etc...

     But 90% of the participants are North Americans. So you

     can define this word in American terms if that’s an

     American situation. I like your situationally decisive one.

KH   Yes, we’ve got half of it. Now we just get the other half.

NF   And I think people find that helpful and in the workshop

     this afternoon, I think you’ll find that some people will

     see the differences that I’ve talked about. We will this

     afternoon when we get some scores up on the board,

     which is something that I always do. When we get the
                                                                  205

     scores up on the board you’ll see that there will be the

     situationally decisive who will have scores somewhere

     between 16 and the others who use the multimodal

     approach differently. I wonder when this changes.

KH   We don’t know, I mean somewhere it must change.

NF   Right and where does that actually occur?

KH   Where does that happen and I don’t want to follow it

     because I don’t think VARK is that precise that you

     would say, you know, that if you total score is 28, you are

     situationally this and if it’s 29 then I’m not whatever term

     we choose to use.

NF   But clearly somebody who has answered 48 of the chosen

     48 options is a different learner from somebody who has

     chose 17 of the options available.

KH   Maybe it’s more of a continuum than an actual black and

     white differentiation.

NF   Yes, yes, I think you’re right. Of course, the other thing

     that happens is that some people still approach the

     questionnaire as though they must find the right answer

     and therefore their totals always end up 16. One of the

     things I do is, and this is a tip for you, something that you

     might do is that whenever I present in a paper format, I

     always interrupt people thirty seconds after they start
                                                                  206

     because you know they’ve got their pen out and they

     think I am saying would you please fill this in for a yes or

     no and I always interrupt and say there is no right answer,

     just the answer that is right for you. They look up and

     they get a bit frustrated when I interrupt them.

KH   You are breaking their concentration.

NF   Breaking their concentration, doing all the wrong things.

     And I say look I do this because I know that there are

     some people in this room now that did not read the

     instruction at the top of the page that says you may chose

     more than one option. And they will be puzzled at the end

     because they will say that other people have got big

     numbers and they’ve got small numbers. So how did they

     get their big numbers, it’s not a different questionnaire,

     it’s how they answered. So, just to reinforce orally, you

     may have more than one answer for each question, you

     can have two, three, four, whatever you like.

KH   Are you going to do that this afternoon?

NF   Yes, you will see me do that this afternoon.

     There is only one other thing that I won’t do this

     afternoon that I normally do, which is a bit sad about this

     afternoon. Connie, the woman that’s running this

     afternoon’s seminar asked them to do the VARK before
                                                                 207

     they came so I won’t actually be administering the

     VARK. That is sad because I like it live. I like to stop the

     workshop and I give the VARK very quickly, I don’t

     dwindle on about information about me or where it came

     from because I don’t want them to stop guessing, second

     guessing oh he is something that VARK. I think I’m

     visual and need to see how things manifest naturally. So I

     don’t even tell them anything in advance. I introduce it,

     And I say; now we might find that the answer is there. So

     the questionnaire is in your bag, pull it out and do it.

     Let’s see this afternoon, that’s going to be cut short

     because I’m going to say you’ve done this last night at

     home, last week, what are your scores and then we will

     go…

KH   Okay, is the afternoon group student’s or faculty?

NF   This afternoon is all of the faculty, the people that you are

     with, same people

KH   Same group.



NF   They are in there having lunch now, but you may you

     stay here because I desire to give you all of the

     information you need.

KH   No I actually, I’m done.
                                                            208

NF   Are you sure?

KH   I am. Thank you very much for your time and for what

     you have done to improve the learning process

NF   My pleasure and thank you for your interest.

     ( End of interview)
                                                                                    209

                                        Appendix B

                                  Informed Consent Form

                             Learning Style Orientation Group

                 The Impact of Matching Clinical Orientation Process

               To Preferred Learning Styles for New Registered Nurses

Dear

       I am a student at the University of Phoenix working on a Doctorate

Degree in Health Administration. I am conducting a research study entitled “The

Impact of Matching Clinical Orientation Process to Preferred Learning Styles of

Registered Nurses”. The purpose of the study is to learn more about the impact of

learning style-based clinical orientation on the turnover rate of new graduate

registered nurses during their first six months of nursing practice.

       Your participation will involve completion of a demographic

questionnaire and completion of a learning style assessment to determine your

perceived learning style (visual, aural, read-write and/or kinesthetic).

       You will also participate in a new graduate clinical orientation plan that is

based on the results of your learning style assessment. Your participation in this

study is voluntary. If you choose not to participate or to withdraw from the study

at any time, you can do so without penalty or loss of benefit to yourself. If you

choose not to participate in the learning style-based clinical orientation process,

the traditional clinical orientation process will be made available for you. The

results of the research study may be
                                                                                   210

                                APPENDIX B (continued)

published, but your name will not be used and your results will be maintained in

confidence. There are no foreseeable risks to you as a result of this study.

Although there

may be no direct benefit to you, the possible benefit of your participation may

result in improving your orientation experience. Documents obtained during the

course of this study will be maintained in a locked cabinet and accessed only by

the investigator for a period of 36 months. At the conclusion of the 36 month

period, all study related documents will be destroyed by the investigator. If you

have any questions concerning this research study, please call me at (661) 607-

7441.

        Sincerely,

        Kimberly Carol Long Horton, Doctoral Student
        University of Phoenix
        School of Advanced Studies/Health Administration

By signing this form I acknowledge that I understand the nature of the study, the

potential risks to me as a participant, and the means by which my identity will be

kept confidential. My signature on this form also indicates that I am 18 years or

older and that I give my permission to voluntarily serve as a participant in the

study described. The original signed consent form may be delivered to Kimberly

Horton in person or U.S. mailed to her at P.O. Box 11503, Bakersfield, Ca. 93389

in the stamped envelope provided.

_________________________________________ _____________________
        Print Name/Signature                                         Date
      (Signature must be in black ink, e-signatures are not acceptable)
                                                                                211

                                      APPENDIX C

           RESEARCH SUBJECT INFORMATION AND CONSENT FORM



TITLE:                        The Impact of Matching Clinical Orientation
                              Process to Preferred Learning Styles of Registered
                              Nurse

PROTOCOL NO.:                 None
                              WIRB® Protocol #20062230

       SPONSOR:               Kimberly C. Horton, R.N.
                              Bakersfield, California
                              United States

       INVESTIGATOR: Kimberly C. Horton, R.N.
                     Doctoral Student, University of Phoenix
                     P.O. Box 11503
                     Bakersfield, California 93389
                     United States

       SITE(S):               Hospital A
                              Hospital B
                              Hospital C


       STUDY-RELATED
       PHONE NUMBER(S):               Kimberly C. Horton, R.N.
                                      661-607-7441 (24 hours)
                                      661-632-5287


You may take home an unsigned copy of this consent form to think about or discuss
with family or friends before making your decision.

         You are being asked to participate in this research study because you are a
new graduate registered nurse in your first six months of nursing practice. The
purpose of the study is to learn more about the impact of learning style-based
clinical orientation on the turnover rate of new graduate registered nurses during
the first six months of nursing practice.

       Approximately 30 subjects will participate in a 16-week long study.
                                                                                   212

                                 APPENDIX C (continued)

       PROCEDURES

       Your participation will involve completion of a demographic
questionnaire, completion of a learning style assessment to determine your
perceived learning style (visual, aural, read-write and/or kinesthetic).

       You will also participate in a new graduate clinical orientation plan that is
based on the results of your learning style assessment.

       RISKS

In this research, there are no foreseeable risks to you.

       BENEFITS

       Although there may be no direct benefit to you, the possible benefit of
your participation may result in improving your orientation experience.

       COST

       There is no cost to you for your participation in this study

       ALTERNATIVES

       Your alternative is to not be in this study.

       VOLUNTARY PARTICIPATION/WITHDRAWAL

        Your participation in this study is voluntary. You may decide not to
participate or you may leave the study at any time. Your decision will not result in
any penalty or loss of benefits to which you are entitled.

        Your participation in this study may be stopped at any time by the study
nurse or the sponsor without your consent for any of the following reasons:

   •   if it is in your best interest;
   •   you do not consent to changes made in the study plan;
   •   you are not employed at the site; or
   •   for any other reason.

        If you choose not to participate in the learning style-based clinical
orientation process, the traditional clinical orientation process will be made
available for you.
                                                                                 213

                                APPENDIX C (continued)

        The Hospital management does not urge, influence, or encourage anyone
who works for the company to take part in a research study. Your participation in
this study is completely voluntary. You may withdraw from the study at any time
and for any reason. Your decision to not participate in the study, or a decision on
your part to withdraw from the study, will have no effect whatsoever on your
employment status at Memorial Hospital Bakersfield. You may refuse to
participate or you may withdraw from the study at any time without penalty or
prejudice.

       CONFIDENTIALITY

        Information from this study may be given to the sponsor. “Sponsor” includes
any persons or companies which are contracted by the sponsor to have access to the
research information during and after the study. (There is no sponsor for this study;
therefore no information will be shared)

        The information may also be given to the U.S. Food and Drug
Administration (FDA). It may be given to governmental agencies in other countries
where the study drug may be considered for approval. Medical records which
identify you and the consent form signed by you will be looked at and/or copied for
research or regulatory purposes by:

   •   the sponsor;

       and may be looked at and/or copied for research or regulatory purposes by:

   •   the FDA;
   •   Department of Health and Human Services (DHHS) agencies;
   •   governmental agencies in other countries;
   •   Bakersfield Memorial Hospital; and
   •   the Western Institutional Review Board® (WIRB®).

        (There is no use of drug, other pharmaceuticals or medical devices in this
study, therefore disclosure to the FDA or review of medical records will not be
required)

       SOURCE OF FUNDING

       Funding for this research study will be provided by Kimberly C. Horton,
R.N.
                                                                                   214

                                 APPENDIX C (continued)

       QUESTIONS

       Contact Kimberly C. Long Horton, R.N. at 661-632-5287 or 661-607-7441
(24-hours) for any of the following reasons:

   •   if you have any questions concerning your participation in this study,
   •   if at any time you feel you have experienced a research-related problem, or
       • if you have questions, concerns or complaints about the research.
       • If you have questions about your rights as a research subject or if you
            have questions, concerns or complaints about the research, you may
            contact:

               Western Institutional Review Board® (WIRB®)
               3535 Seventh Avenue, SW
               Olympia, Washington 98502
               Telephone: 1-800-562-4789 or 360-252-2500
               E-mail: Help@wirb.com.

       WIRB is a group of people who perform independent review of research.

       WIRB will not be able to answer some study-specific questions, such as
questions about appointment times. However, you may contact WIRB if the
research staff cannot be reached or if you wish to talk to someone other than the
research staff.

       Do not sign this consent form unless you have had a chance to ask questions
and have received satisfactory answers to all of your questions.

        If you agree to be in this study, you will receive a signed and dated copy of
this consent form and the Experimental Subject's Bill of Rights for your records.

       CONSENT

I have read this consent form. All my questions about the study and my
participation in it have been answered. I consent to participate in the learning
style-based clinical orientation process. Failure to participate in the study will
have no effect on my employment, my standing in the organization nor the quality
or quantity of my clinical orientation.
                                                                                   215

        I authorize the release of my medical records for research or regulatory
purposes to the sponsor, the FDA, DHHS agencies, governmental agencies in other
countries, the hospital and WIRB®.

       By signing this consent form, I have not given up any of my legal rights.


                                                                             _____
       Print Name/Signature of Subject                                       Date


                                                                           ______
       Signature of Person Conducting Informed Consent Discussion           Date
                                                                               216

                                APPENDIX C (continued)

                  EXPERIMENTAL SUBJECT’S BILL OF RIGHTS

        Any person who is requested to consent to participate as a subject in a
research study involving a medical experiment, or who is requested to consent on
behalf of another, has the right to:

   1. Be informed of the nature and purpose of the experiment.

   2. Be given an explanation of the procedures to be followed in the
      medical experiment, and any drug or device to be used.

   3. Be given a description of any attendant discomforts and risks
      reasonably to be expected from the experiment.

   4. Be given an explanation of any benefits to the subject reasonably to
      be expected from the experiment, if applicable.

   5. Be given a disclosure of any appropriate alternative procedures,
      drugs, or devices that might be advantageous to the subject, and their
      relative risks and benefits.

   6. Be informed of the avenues of medical treatment, if any, available to
      the subject after the experiment if complications should arise.

   7. Be given an opportunity to ask any questions concerning the
      experiment or other procedures involved.

   8. Be instructed that consent to participate in the medical experiment
      may be withdrawn at any time, and the subject may discontinue
      participation in the medical experiment without prejudice.

   9. Be given a copy of a signed and dated written consent form when
      one is required.

   10. Be given the opportunity to decide to consent or not to consent to a
       medical experiment without the intervention of any element of force,
       fraud, deceit, duress, coercion, or undue influence on the subject’s
       decision.
       ______________________________
       Signature of Subject                            Date
       ____
       Signature of Witness                            Date
                                                                                 217

                                    APPENDIX D

                     VARK Learning Style Questionnaire, Version 7

How do I Learn Best?

Choose the answer which best explains your preference and circle the letter(s)

       next to it.

Please circle more than one if a single answer does not match your perception.

Leave blank any questions that do not apply.

   1. You are helping someone who wants to go to your airport, town centre or

       railway station. You would:

           a. Go with her.

           b. Tell her the directions

           c. Write down the directions (without a map)

           d. Draw, or give her a map

   2. You are not sure whether a word should be spelled "dependent or

       dependant". You would:

           a. See the words in your mind and choose by the way they look.

           b. Think about how each word sounds and choose one.

           c. Find it in a dictionary.

           d. Write both words on paper and choose one.
                                                                               218

                          APPENDIX D (continued)

3. You are planning a holiday for a group. You want some feedback from

   them about the plan. You would:

       a. Describe some of the highlights.

       b. Use a map or website to show them the pieces.

       c. Give them a copy of the printed itinerary.

       d. Phone, text or e-mail them.

4. You are going to cook something as a special treat for your family. You

   would:

       a. Cook something you know without the need for instructions.

       b. Ask friends for suggestions.

       c. Look through the cookbook for ideas from the pictures.

       d. Use a cookbook where you know there is a good recipe.

5. A group of tourist wants to learn about the parks or wildlife reserves in

   your area. You would:

       a. Talk about or arrange a talk for them about parks and wildlife

            reserves.

       b. Show them internet pictures, photographs or picture books.

       c. Take them to a park or wildlife reserve and walk with them.

       d. Give them a book or pamphlets about the parks or wildlife

            reserves.
                                                                               219

                          APPENDIX D (continued)

6. You are about to purchase a digital camera or mobile phone. Other than

   prices, what would most influence your decision?

       a. Trying or testing it.

       b. Reading the details about its features.

       c. It is modern design and looks good.

       d. The salesperson telling me about its features.

7. Remember a time when you learned how to do something new. Try to

   avoid choosing a physical skill, e.g. riding a bike. You learned best by:

       a. Watching a demonstration.

       b. Listening to somebody explaining it and asking questions.

       c. Diagram and charts-visual clues.

       d. Written instructions- e.g. manual or textbook.

8. You have a problem with your knee. You would prefer that the doctor:

       a. Gave you a web address or something to read about it.

       b. Used plastic mode of a knee to show what was wrong.

       c. Described what was wrong.

       d. Showed you a diagram of what was wrong.

9. You want to learn a new program, skill, or game on a computer. You

   would:

       a. Read the written instructions that came with the program.

       b. Talk with people who know about the program.
                                                                            220

                           APPENDIX D (continued)

       c. Use the controls or keyboard.

       d. Follow the diagrams in the book that came with it.

10. I like websites that have:

       a. Things I can click on, shift or try

       b. Interesting design and visual features.

       c. Interesting written descriptions, lists and explanations.

       d. Audio channels where I can hear music, radio programs or

           interviews.

11. Other than price, what would most influence your decision to buy a new

   non-fiction book?

       a. The way it looks is appealing.

       b. Quickly reading parts of it.

       c. A friend talks about it and recommends it.

       d. It has real-life stories, experiences, and examples.

12. You are using a book, CD or website to learn how to take photos with

   your new digital camera. You would like to have:

       a. A chance to ask questions and talk about the camera and its

           features.

       b. Clear written instructions with lists and bullet points about what to

           do.

       c. Diagrams showing the camera and what each part does.
                                                                             221

                             APPENDIX D (continued)

       d. Many examples of good and poor photos and how to improve

           them.

13. Do you prefer a teacher or a presenter who uses:

       a. Demonstrations, models, or practical sessions.

       b. Question and answer, talk, group discussion or guest speaker.

       c. Handouts, books, or readings.

       d. Diagrams, charts or graphs.

14. You have finished a competition or test and would like some feedback.

   You would like to have feedback:

       a. Using examples from what you have done.

       b. Using a written description of your results.

       c. From somebody who talks it through with you.

       d. Using graphs showing what you had achieved.

15. You are going to choose food at a restaurant or cafe. You would:

       a. Choose something that you have had there before.

       b. Listen to the waiter or ask friends to recommend choices.

       c. Choose from the descriptions in the menu.

       d. Look at what others are eating or look at pictures of each dish.
                                                                         222

16. You have to make an important speech at a conference or special

   occasion. You would:

       a. Make a diagram or get graphs to help explain things.

       b. Write a few key works and practice saying your speech over and

          over.

       c. Write out your speech and learn from reading it over several items.

       d. Gather many examples and stories to make the talk real and

          practical.
                                                                        223

                                APPENDIX E

                          Demographic Questionnaire

       (Please check the box next to the response you wish to submit)

1. What is your age?

          20-25 years

          26-30 years

          31-35 years

          36-40 years

          Over 40 years

2. What is your gender?

          Male

          Female

3. What is your ethnic background?

          Caucasian

          Hispanic/Latino

          African American

          American Indian

          East Indian

          Asian

          Other:________________

4. What is the highest degree you have earned?

          Associate Degree

          Bachelors Degree
                                                                                224

                              Appendix E (continued)

        Masters Degree

        Doctorate Degree

----------------------------------------For researchers use only--------------------

Participant Number: _____________________________
                                     225

           APPENDIX F
        Preceptor Training Program




      Learning Style
    Preceptor Training
VARK Learning Style Concepts

  Kimberly C. Horton, RN, MSN, FNP




          Introduction
   Learning Style: What is it?
                                      226

         APPENDIX F (continued)



Principle One


    Regardless of academic ability
        everybody can learn
     but each learns differently.




Principle Two


  Motivation for learning increases
   where different learning styles
        are accommodated.
                                        227




            APPENDIX F (continued)



Principle Three


      New material is best learned
   through using perceptual strengths
           and preferences.




  VARK Learning Style Inventory
• Created by Dr. Neil Fleming
• Has been completed by over 100,000
  people worldwide
• Based on Howard Gardner’s Theory of
  Multiple Intelligences
• Reflects preferred learning methods
                                      228

             APPENDIX F (continued)



          Let’s take the test
• What kind of learner are you?




       Learning Preferences
                                          229

                APPENDIX F (continued)



              Visual Learners
• Learn through visual stimuli
• Attach meaning:
    –             to placement of thing
    – use of colors
    – CAPITAL LETTERS
    – Highlights
    – Sizes




         Visual Learners Prefer
•   Maps
•   Charts
•   Graphs and Symbols
•   Diagrams
•   Flowcharts
•   Colors and Pictures
                                           230

             APPENDIX F (continued)



    Visual Teaching Strategies




            Aural Learners
• Prefer to take in auditory information
• Attach meaning to:
  – What others say
  – Forming Ideas and speaking of them
• Refine ideas outside of themselves
                                                                 231

                   APPENDIX F (continued)



       Aural Teaching Strategies
•   Develop Presentation and/or classes
•   Provide discussions and tutorials
•   Discuss topics with students
•   Provide opportunity for the student to discuss topics with
    others
•   Allow the student to explain new ideas to you and other
    people
•   Allow them to use a tape recorder, if desired
•   Remember to use examples, stories, etc
•   Use words to describe the overheads, pictures and other
    visuals.




            Read Write Learners
• Attach meaning to:
    – Printed word
• Prefer
    – Hand outs
    – Quizzes
    – Reports
    – Essays
                                                 232

                 APPENDIX F (continued)



    Read Write Teaching Strategies
• lists
• headings
• dictionaries
• glossaries
• definitions
• handouts
• textbooks
• readings - library
• notes (often verbatim)
• teachers who use words well and have lots of
  information in sentences and notes
• essays
• manuals (computing and laboratory




          Kinesthetic Learners
• Attach meaning to experiences
• Prefer activity and concept application
                                            233

               APPENDIX F (continued)



  Kinesthetic Teaching Strategies

  •Real life experiences
  •Hands on application
  •Exhibits, samples,
  photographs
  •Laboratory and practical
  sessions
  •Teach from the known to
  the unknown




  A Word on Multimodal Learners
• Bi-modal, tri-modal or multi-modal
• May use more than one mode of learning.
• Some can switch depending on learning
  environment or content.
• Preceptors should use each mode
  depending on desire of preceptee
                              234

     APPENDIX F (continued)



Putting Theory to Action


     Practice Exercise




        Discussion
                                                    235

               APPENDIX F (continued)




      Summary and Conclusion




                 Reference
Fleming, N. (2005). Teaching and learning styles:
  VARK strategies. Microfilm Ltd: New Zealand.
Fleming, N. (2002). 55 strategies for better
  teaching. Fleming Publishing: New Zealand.
Drago, W. A & Wagner, R. J. (2004). Vark
  preferred learning styles and online education.
  Management Research News, 27(7), 1-13.
  Retrieved May 20, 2006 from the University of
  Phoenix Proquest database.
Dunn, R. & Griggs, S. (1998). Learning styles and
  the nursing profession. New York: NLN Press.
                                                                                  236


                                     APPENDIX G

                            UNIVERSITY OF PHOENIX

               PERMISSION TO USE AN EXISTING SURVEY


Date November 11, 2007


Ms Kimberly C. Horton
P.O. Box 11503
Bakersfield, CA. 93389


Thank you for your request for permission to use VARK Learning Styles
Inventory in your research study. We are willing to allow you to reproduce the
instrument as outlined in your letter at no charge with the following
understanding:

•   You will use this survey only for your research study and will not sell or use it
    with any compensated management/curriculum development activities.

•   You will include the copyright statement on all copies of the instrument.

•   You will send your research study and one copy of reports, articles, and the
    like that make use of this survey data promptly to our attention.

If these are acceptable terms and conditions, please indicate so by signing one
copy of this letter and returning it to us.



Best wishes with your study.

Sincerely,




I understand these conditions and agree to abide by these terms and
conditions.
Signed/s/ Kimberly C. Horton Date: November 11, 2007
Expected date of completion: January 30, 2009
                                                                                 237

                                     APPENDIX H




                                Letter from Neil Fleming

 Neil D Fleming                                            Fax: (64) 3 3519939

 50 Idris Road                                   Email: flemingn@ihug.co.nz

 CHRISTCHURCH 8052                            Website: VARK-LEARN.COM

 New Zealand

       August 29, 2006

Kimberly C. Horton
Doctoral Student, DHA Program, University of Phoenix
P.O Box 11503
Bakersfield, Ca. 93389


Dear Kimberly

Thank you for your interest in the VARK workshops that I will be running on my
forthcoming visit to three universities in Colorado. Because of our previous
conversations over a lengthy period of time it would be appropriate for you to join
one of these workshops. I should be able to clear some space and schedule a time
to talk with you in depth about your project work with learning preferences.

       Kind Regards




       Neil D Fleming
       Designer of the VARK Questionnaire
                                                                                238

                                 APPENDIX I
                            UNIVERSITY OF PHOENIX



        INFORMED CONSENT: PERMISSION TO USE PREMISES, NAME

                             AND/OR SUBJECTS

            (Facility, Organization, University, Institution, or Association)

                          Hospital A, Bakersfield, California

       I hereby authorize Kimberly C. Long Horton, student of University of

Phoenix to use the premises, name and/or subjects requested to conduct a study

entitled "The Impact of Matching Clinical Orientation Process to Preferred

Learning Styles for New Registered Nurses”.
                                                                                239

                                APPENDIX I (cont’d)


                            UNIVERSITY OF PHOENIX

        INFORMED CONSENT: PERMISSION TO USE PREMISES, NAME

                             AND/OR SUBJECTS

            (Facility, Organization, University, Institution, or Association)

                          Hospital B, Bakersfield, California

       I hereby authorize Kimberly C. Long Horton, student of University of

Phoenix to use the premises, name and/or subjects requested to conduct a study

entitled "The Impact of Matching Clinical Orientation Process to Preferred

Learning Styles for New Registered Nurses”.
                                                                                    240

                                    APPENDIX I (cont’d)

                               UNIVERSITY OF PHOENIX

         INFORMED CONSENT: PERMISSION TO USE PREMISES, NAME

                                AND/OR SUBJECTS

              (Facility, Organization, University, Institution, or Association)

                             Hospital C, Bakersfield, California

        I hereby authorize Kimberly C. Long Horton, student of University of

Phoenix to use the premises, name and/or subjects requested to conduct a study

entitled "The Impact of Matching Clinical Orientation Process to Preferred

Learning Styles for New Registered Nurses”.

        Kimberly C. Long Horton will not mention or reference Hospital C by

name or in connection with any results of the study in any materials published,

distributed, or otherwise shared with any third parties, including, but not limited

to, any papers, reports, dissertations, studies, conclusions related to this project at

the University of Phoenix.
                                                                                                           241

                                                   APPENDIX J

                                            TEACHING GUIDE
                            V                                                       A
                   Visual” Teachers                                 “Aural” Teachers
                         I prefer:                                   I prefer:
•   to use visuals to explain things.               •   to use my voice to explain things.
•   Worldwide web pages that have strong            •   tapes, conversations, phone calls.
        graphics, hot boxes, etc..                  •   discussion in class.
•   diagrams, slides, charts, graphs, arrows,       •   my students to discuss issues among themselves,
        circles and boxes.                                  to work together, and to contribute their
•   the clever use of graphics, fonts...                    ideas.
•   complex ideas to be shown first in a            •   the clever use of speech and making a point
        diagrammatic model.                                 well.
•   important words and ideas to be placed          •   argument, discussion, and debate.
        on the board so that they are spatially     •   to say the important words to emphasize a point
        interesting (scattered) rather than left-   •   seminars, oral examinations, group
        aligned boxes.                                      presentations, student interaction, and
•   texts that are dense with diagrams and                  dialogue.
        graphics, pictures, color and white         •   group work involving planning and discussing
        space.                                              ideas together.
•   videos.                                         •   to create written exams using these words--
•   to create written exam questions using                  explain, describe, discuss and state.
        these words-- illustrate, show,             •   the students to listen, speak, discuss, hear and
        outline, label, link and draw (a                    comprehend.
        distinction between...).
•   the students to visualize and see the point
                             R                                                      K

          “Read/Write” Teachers                                       “Kinesthetic” Teachers

                         I prefer:                                               I prefer:
•   to use written text to explain things.          •   to use real life examples to explain things.
•   to give handouts.                               •   guest lecturers, case studies, practical work,
•   my students to read articles and come to                visits to sites and laboratories.
         class having done so.                      •   exhibits, samples, newspaper stories, working
•   the clever use of interesting words.                    models, products and people (things that
•   argument and discussion in a written                    bring reality to a teaching session).
         form.                                      •   the clever use of metaphors, examples and
•   to place important words that I use on the              analogy in written work.
         blackboard or overhead.                    •   to bring objects to class to make a point.
•   put words in some order using priorities,       •   role plays, demonstrations, practical tests, lab
         categories....                                     tests, lab reports and open book
•   lists of points in vertical and left-aligned            examinations.
         columns.                                   •   texts that are dense with cases, conversations,
•   texts that are dense with text, summaries,              stories, biographies and life.
         abstracts.                                 •   to create written examinations using these
•   prefer essay exams.                                     words-- give examples, apply, demonstrate,
•   to create written exam questions using                  using your...
         these words-- define, develop the          •   the students to construct, experience, dissect,
         case for, justify, and analyze.                    apply, develop, work on..., demonstrate,
•   the students to comprehend, understand,                 grasp the point, get a handle on..., get or
         write, define and to use words well.               grab the ideas, get up to speed,...

				
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