The relationship between learning preferences (styles and approaches) and learning outcomes among pre-clinical undergraduate medical students

The learning styles and learning approaches constitute the learning preferences of undergraduate medical students. The “learning styles” are preferred methods of learning adopted by students in attaining, analysing and interpreting their knowledge [1]. The Visual, Auditory, Read/Write, Kinesthetic (VARK) model, developed by Fleming and Mills [2] is an acronym for Visual (V), Auditory (A), Read/Write (R) and Kinaesthetic (K) modalities which are used to assess learning styles.

The Visual (V) learner learns best by visualizing the information e.g., use of charts, diagram and mindmaps. The Auditory (A) learner learns best by hearing the information. The Read/Write (R) learner learns best when the information is displayed in words. The Kinaesthetic (K) learner learns best with practice or simulation [2].

The Approaches and Study Skills Inventory for Students (ASSIST) questionnaire which was developed by Entwistle and Ramsden [3] helps in the identification of students’ preferences in adopting any of the deep, surface or strategic approaches for learning. In the deep approach, the students actively relate their own ideas to the learning principles [4], use evidence and examine its logic and continue to monitor their own level of understanding [5].

In the strategic approach, students aim to achieve the highest scores possible. This involves good time management and study organization. Hence, they pay more attention to the content as well as assessment requirements [5]. In surface approach, learning of the students is restricted to routine memorisation as their intention is merely to complete the task [5]. The deep/strategic approach has been reported to be associated with better academic outcomes as compared to those with the surface approach [6].

Assessment is an important determinant which affects the way students learn and subsequently determines the learning outcomes [7]. It is a goal oriented approach which drives learning. Harris and Bell, [8] reported that students often modify their learning approaches in order to cope with the demands of assessment [8]. Many studies were conducted in the past to determine the association between learning approaches and summative examination results as a measure of learning outcomes. A majority of them had reported contradictory results on the relationship between learning approaches and outcomes [9-11]. The learning styles (VARK) were found to have a significant impact on the academic performances of undergraduate students of physiotherapy, nursing, dentistry and allied healthcare professional programmes [12-15].

The “meshing hypothesis” states that the learning outcomes could be highly achieved if learning was matched with predominant learning style of the learner [16,17]. However, Pashler et al. argue that the meshing theory was not necessarily correct because the undergraduate medical students were not always exposed to multiple types of learning styles for the same subject. Different subjects required different kinds of learning styles and instructions to optimally potentiate and benefit the students [17].

In the past, study methods were limited to lectures, tutorials and self-study. Major part of knowledge acquisition depended heavily on lectures. A shift to the skill of self-acquiring knowledge via information technology had widely changed the preferences and adaptation modes of knowledge acquirements of our 21^st century learners. In Asia, students are not spared from the advancement of technology, therefore their learning preferences had also changed with time along with this advancement. Many Asian higher institutions already have adopted information technology as one of their platforms for student learning and assessments [18,19]. With a variety of learning aids available these days, there is need to identify the most efficient way to match and deliver the teaching and learning instructions to help the undergraduate medical students to become more capable learners.

An in-depth understanding of modes of approach to learning would be beneficial for medical teachers to improve their delivery of learning materials. It would also help in tailoring the classroom instructions to suit the needs of undergraduate medical students in a more efficient and cost-effective manner. A majority of the previous studies on learning styles and learning approaches were conducted in western countries. This is the first study undertaken in a Malaysian context that examines the relationship between the learning preferences of pre-clinical undergraduate medical students and learning outcomes by using the VARK and ASSIST questionnaires. This study was conducted to investigate the learning preferences (styles and approaches) of the pre-clinical (Year 2 & 3) undergraduate medical students and also to associate the learning preferences (styles and approaches) with learning outcomes as performances in the summative examinations.

This cross-sectional study was conducted for four months (September 2013 to December 2013) at the Clinical Skills and Simulation Centre, International Medical University, Kuala Lumpur, Malaysia.

It was observed that most of the respondents in this study were Kinesthetic learners (30.1%) regardless of their gender, age, nationality and educational backgrounds. This finding was similar to those reported by Kharb et al. for Indian medical students [1] as well as Baykan and Nacar for Turkish medical students [22].

Lujan and DiCarlo reported that the most preferred learning style of first year medical students from Indiana, USA was of Read/Write (R) modality [23]. In this study, the same was observed amongst the medical students who already possessed a primary degree prior to their entry to the medical school (postgraduate students). However, Nuzhat et al. reported that the most preferred learning style among medical students in Saudi Arabia was the auditory mode [24]. The dental students in Philadelphia were found to prefer the Visual (V) learning more than the Kinesthethic (K) learning [25]. These variance in learning styles according to countries could be due to cultural differences as well as previous exposures to different teaching styles during the years at pre-medical schools.

A majority of the participants in this study had unimodal learning style (81.9%). A study by Fleming on 31,243 students reported that the ratio of unimodal against multimodal learning style preference was 42:58 [20,25]. Other studies reported the preferences for multimodal learning styles with percentages ranging between 53% and 85%. The proportions of students preferring multimodal learning style from various studies were as follows: proportion reported by Dinakar et al. was 58% [26], Lujan et al. was 63.8% [23], Baykan and Nacar was 63.9% [22], Nuzhat et al. was 72.6% [24], Bahadori et al. was 59% [27] and Ding et al. was 85.7% [28]. However, in this study, only a small proportion of Malaysian students adopted the multimodality learning style. This could be due to their exposure to different kinds of teaching learning instructions at pre-medical schools. In Malaysia, the educational system is mostly didactic in nature, with very minimal hands-on, discussion and practical sessions. However, a majority of the respondents with multimodal learning styles belonged to the age group of (20-29) years as they were graduates before joining the medical programme. This finding was similar to a study conducted by McKean J et al. during 2009 in Hong Kong [29].

There was no significant difference in learning styles and performances at the summative examinations. This could be due to the fact that learning styles mainly focussed on strategies adopted by students in acquiring knowledge. There was no evidence in this study that any particular learning style in itself was superior as compared to others in the attainment of academic success. However, there were some reports that the knowledge and understanding of one’s own learning style could greatly enhance one’s success in the summative examinations [30,31]. The students in this study were not provided with any specific teaching and learning method which was tailored according to their preferred learning style. A blend of activities covering all the learning modalities were made available to them. The response of the participants would have been different if they were exposed to matched learning strategies according to their respective learning styles.

In this study, a majority of the students among the mid/high achievers category (79.4%) embraced the deep/strategic learning approach. Interestingly, a majority of the low achievers were also found to be deep/strategic learners. Hence, this difference was not found to be statistically significant. However, some of the previous studies reported that students with deep/strategic learning approaches performed better during their final summative examinations as compared to their superficial learning counterparts [32-34]. We concur with a study by Newble et al. which found that undergraduate medical students with deep/strategic learning approach did not perform better during summative examinations [35].

The deep/strategic learning approach was believed to be able to help students to attain more successes in summative examinations as compared to the superficial learning approach [6]. Although there was no statistically significant relationship between the learning approaches (deep/strategic) and learning outcomes in terms of summative examinations in this study, many other studies had reported a positive beneficial association [9-11].

Both the VARK and ASSIST questionnaires analysed only one aspect of the learning preferences (styles and approaches). Hence, multiple aspects of learning preferences (styles and approaches) could not be assessed in this study. The students in this study were not exposed to their preferred learning styles and approaches during their learning activities prior to the summative examinations. This prevented the investigators from studying the true effects of their learning preferences on learning outcomes.

The teaching and learning strategies should be redesigned to promote deep/strategic learning among the pre-clinical undergraduate medical students. The teaching and learning instructions should be tailored according to the learning preferences (styles and approaches) of the students. More active hands-on learning strategies like simulations, role playing, problem based discussions and debates should to be incorporated in the teaching and learning activities. This would create better learning environment for the kinesthetic learners.

This study revealed that the learning preferences (styles and approaches) of the students in this study did not contribute significantly towards their learning outcomes. Tailoring the delivery of teaching and learning instructions matching with the learning preferences (styles and approaches) of the pre-clinical undergraduate medical students followed by a re-assessment of their performances at summative examinations would be beneficial to genuinely gauge the potential of these teaching-learning strategies. This study should be replicated in other medical institutions in this region to confirm the findings.