Relationship between Learning Styles and Academic Performance among Virtual Nursing Students: A Cross-Sectional Study

Virtual University of Medical Sciences, Department of Medical Education, Tehran, Iran Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran Infectious Diseases Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran


Introduction
Today, due to the COVID-19 pandemic, the education of nursing students has undergone fundamental changes, and presentation of theoretical courses has changed from the face-to-face method to the Internet-based method [1,2]. Internet-based instruction is completely different from the usual face-to-face interaction and requires fundamental changes in the teaching methods as well as the students' learning environment [1].
In the meantime, academic performance is an indicator used to evaluate and compare students [3,4]. One of the influential factors involved in academic performance is learning styles [5]. To increase the effectiveness of Internet-based education, it is highly important to know about the students' learning styles [2]. Knowledge of students' learning styles is effective in compiling the online courses effectively, as well as modifying and organizing the teaching-learning process [2,6].
e VARK Questionnaire is a method used to determine the type of learning styles. According to this questionnaire, learning styles include visual (V), auditory (A), reading/ writing (R), and kinesthetic (K) [7]. Visual students learn by watching videotapes, pictures, and diagrams. Auditory students learn by listening to lectures, and reading/writing students learn by reading texts and taking summaries. Kinesthetic students learn by touching and manipulating objects [7,8]. Based on the VARK model, it is possible for students to use several learning styles [6]. Studies that have examined students' learning styles have reported different results, and the most common learning styles have included kinesthetic [9,10], auditory [11,12], and reading/writing [13,14]. Several studies have examined the relationship between learning style and academic performance. e results of some of these studies have shown a significant relationship between these two variables [15][16][17][18][19], but in some other studies, no relationship has been reported [3,14,20].
Considering the contradictory results of these studies and the importance of nursing professors' knowledge of virtual students' learning styles, the current study was aimed to determine the relationship between learning styles and academic performance among virtual nursing students in Kermanshah, who have been taught through Internet-based instruction. Since learning ability involves both educators and learners, the results of this study may benefit both groups.
1.1. eoretical Background/Model. One of the factors affecting students' learning is the type of their learning style [4]. Learning styles are the methods that people use to acquire knowledge or skills [21]. e VARK model is one of the most popular methods designed by Fleming and Mills (1992) to examine students' learning styles [12,21]. is model is a kind of educational approach and learning style. Based on this model, students are divided into one of the following categories based on their abilities: visual style (with good visual function), reading and writing style (with good reading and writing function), listening style (with good auditory function), and kinetic style (with good skill performance) [11,12].

Study Design.
is is a cross-sectional study based on the STROBE reporting guidelines.

Study Sample.
e population of the study consisted of virtual nursing students in the first semester of the academic year 1300-1499 (N � 616). Study subjects included undergraduate students in the second and higher semesters. e students were selected by a convenient sampling method. e inclusion criteria were employment in the second semester and above. e sample size was calculated to be 237 students using Cochran's formula, with 95% confidence and an error of 0.05.

Data Collection Tools.
Data collection instruments included a demographic form and VARK questionnaire. e demographic form included six questions about age, sex, marital status, residence, semester, study resources, and grade point average(s) (GPA) of the previous semester(s). e VARK questionnaire is an instrument used to determine the type of learning style [22]. e reliability of this questionnaire has been confirmed by Zhu et al. [10]. e internal consistency of the Persian version of this tool has been confirmed by Cronbach's alpha method [12,23].
e VARK Questionnaire has 16 four-choice questions that are used to identify learners' learning styles. e questions consist of four options, and each question is related to a specific learning style. Students should choose one of the options according to their preference. If one response alone does not express their views, they should choose more responses and leave questions that have never happened to them before. Achieving a higher score in each of learning style is considered to indicate a person's greater desire for that style. If a person acquires equal points in more than one style, his/her learning style is considered "hybrid or multimodal." In each style, the minimum and maximum scores are 0 and 16, respectively. Earning equal points in two styles is considered bimodal. Earning points in three or four styles is equivalent to trimodal and quadmodal styles, respectively. To determine the status of academic performance, the GPA of the previous semester(s) was used, which was completed by self-report method. Students with a GPA above and below 15 were assigned to one of the strong and weak groups, respectively.

Data Gathering
Method. First, the study permit was obtained from the Virtual University of Medical Sciences and presented to the officials of the Kermanshah School of Nursing and Midwifery. Since all students were members of the Telegram social network, it was used for sampling. e questionnaires were then uploaded to the nursing students channel in Telegram.
ey were asked to complete and submit the questionnaires if they were willing. Data were then fed into SPSS software and analyzed statistically.

Statistical Analysis.
For data analysis, version 18 of SPSS software and descriptive and inferential statistics were used. e research spreadsheet created by Neil Fleming was used to calculate the distribution of learning styles. Chi-square test was used to examine the differences between students' academic performance and learning styles. e level of significance was less than 0.05.

Ethics.
e study was approved by the Ethics Committee of the Virtual University of Medical Sciences (IR.VUMS.REC.1399.018). e objectives of the study were stated for all participants, and written informed consent was obtained.

Results
e results showed that 8 (57.1%) subjects in the strong group were aged >22 years, 10 (71.4%) were male, and 11 (78.6%) were single. As for residence, most of the subjects (78.6%, n � 11) lived in the dormitory. Most of the students (42.9%, n � 6) were in the fourth semester, and the source of study for 71.4% of students (n � 10) was the professors' slides. e preferred method of virtual education for most students (64.3%, n � 9) was the synchronous method. In the In terms of academic performance, most of the subjects (94.1%, n � 223) were in the weak group. e GPAs of the strong and weak students were 17.2 ± 1.1 and 13.9 ± 0.5 out of 20, respectively.
In both groups of strong and weak students, most of the subjects were unimodal (with frequencies of 92.9% and 78.5%, respectively), and the rest were multimodal. e most common learning styles in the strong and weak students were kinesthetic (57.1%, n � 8) and auditory (37.2%, n � 83), respectively. Among the strong group of students, none of the subjects was bimodal and only 7.1% (n � 1) were trimodal (including a mixture of visual, reading/writing, and kinesthetic styles). In the weak group of students, 1.7% (n � 4) were trimodal and 19.7% (n � 44) were bimodal, with the highest frequency 7.6% (n � 17) related to the combination of auditory and reading/writing styles (Tables 2 and 3) (Figure 1). No statistically significant difference was found between students' learning styles and academic performance (Table 4).

Discussion
is study was aimed to determine the relationship between the dominant learning styles of virtual nursing students and their academic performance. e most common learning style in strong students was kinesthetic, which is consistent with the results of Bangcola in the Philippines and Zhu et al. in China [9,10], but in contrast with the results of Arbabisarjou et al. and Jafari et al. in Iran [13,14]. Reading/writing style was the predominant    Education Research International learning style in these two studies. e superiority of auditory learning style goes back to the structure of the education system in Iran, in which the predominant teaching style during school and university is lecturing. On the other hand, students adapt to the teachers' teaching method; therefore, the use of auditory style can be related to the teachers' teaching method [11]. Furthermore, the predominance of teacher-centeredness in nursing education and the unity of teachers strengthen and emphasize the auditory learning style and students' note-taking [24]. It should be noted that the mere use of auditory learning style by nursing students may lead to their illiteracy in the practical and clinical fields. However, nursing professors should consider learning styles of students when choosing their teaching methods. e preferred learning style in the present study was not consistent with some studies [9-11, 13, 25], which might be related to differences in individual characteristics of research subjects (including experience and motivation) as well as different educational environments.
In the present study, most of the subjects were unimodal in both strong and weak groups. In the strong group, none of them was bimodal and only about 7% were trimodal (a mixture of visual, reading/writing, and kinesthetic styles). In weak students, less than 2% were trimodal (a mixture of visual, auditory, and tactile styles), and one-fifth were bimodal, with the highest frequency being a combination of auditory and reading/writing styles. e results of a study in Iranian students showed that the trimodal method was the predominant learning style in students with multimodal learning method. Among students with the trimodal learning method, the most common methods were auditory, reading/writing, and kinesthetic [11]. e results of Mehdipour et al. showed that the most common multimodal learning method in students was the bimodal method [12]. In the study of Behnam et al. in Iran, about one-third of the subjects had a multimodal learning style [26]. e results of Peyman et al. showed that 56% of the nursing and midwifery students preferred to use the multimodal learning method, and among them, the use of all four learning styles was the most common [27].
e results of the current study are in contrast with the above studies, possibly due to differences in the individual characteristics of the subjects as well as their educational conditions. In this regard, one of the reasons for the prevalence of auditory style or a combination of auditory and kinesthetic styles in the current study may be related to the common teaching method in Iranian universities or the use of various audio-visual aids. However, due to its operational nature, the field of nursing requires teachers who use a variety of active teaching methods such as role-playing, practice and repetition, brainstorming, simulation, and drama to teach students the principles of nursing care [11].
In the current study, no statistically significant difference was found between learning styles and academic performance of students. Our results are consistent with some studies [3,13,14,20,22,28,29] but contradictory with others [9,[15][16][17][18][19]. Although, in the present study, there was no relationship between academic performance and learning style nursing professors need to adapt their teaching methods to the students' learning style. In this way, students can be expected to boost their interest in studying and actively attend classes. However, inattention or insufficient attention to students' learning style reduces the effectiveness of teachers' educational activities and students' academic motivation and leads to their academic failure [25].

Limitations.
is study faced two limitations. Due to the data collection method, which was self-reporting, it was not possible to determine the accuracy of the answers, although the anonymity of the questionnaires could reduce this limitation. Another limitation is related to the nature of cross-sectional studies; since in these studies, the variables of exposure and outcome are measured simultaneously, it is not possible to determine the cause-and-effect relationships between them [30], and our study is no exception to this principle.

Conclusion
Being aware of students' learning style are effective in improving the learning situations, compiling online courses effectively, and improving and organizing the teachinglearning process.
e results showed that the dominant learning styles in strong and weak students were kinetic (57.1%) and auditory (37.2%), respectively. Furthermore, most students were unimodal in both groups. ere was no statistically significant difference between learning style and academic performance. Further studies with different designs are recommended.
Data Availability e identified datasets analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest
e authors declare there are no conflicts of interest.

Authors' Contributions
NK, MJ, MR, and AK contributed in designing the study. AK and MJ collected the data, and data were analyzed by MR. e final report and manuscript were written by NK, MJ, MR, and AK. All the authors read and approved the version for submission.