A Review on the Effectiveness of Online Learning in Cultivating Self-Directed Learning of Medical and Nursing Students
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Transforming students into independent learners is the ultimate goal of almost all medical and nursing undergraduate programmes in the world as learning independently is an essential soft skill in lifelong learning . Amongst varieties of learning approaches, online learning is one of the most common self-directed learning approaches adopted by medical and nursing faculties in course design and delivery. It is believed that, with the help of advanced technology, students can learn by themselves according to their own preferences and at their own pace without restrictions of time or space [1-5]. As such, this review explores the effectiveness of online learning in cultivating the independent learning of medical and nursing students. It summarizes the available evidence from relevant literature published in the past 20 years. Recommendations are put forth at the end of the paper to provide readers the future direction of further work.
Is Self-Directed Learning Really Enhanced by Online Learning?
Relevant literature published over the past 20 years available in Medline, CINAHL and Science Direct databases was reviewed. During the literature search, courses with integration of online components were included and regarded as online learning. The author hardly found quantitative studies examining the effect of online learning on the acquisition of self-directed learning. Instead, almost all of the outcomes examined students’ competency in knowledge, skills and attitude in clinical practice [3,6-9]. A systematic review discovered that integration of traditional classroom learning and online components was significantly associated with improved competency in knowledge, skills and attitudes . Bernardo et al.  conducted a one-group pretest-posttest study to examine the change in medical knowledge of undergraduate medical students after they completed a 5-week web-based course. It revealed that students had a significant increase in knowledge on experimental surgery6. Similar findings were also reported in Curran et al.‘s study  of a post-registration medical programme. They found that students had a significant knowledge gain and significant improvement in clinical practice after completing the course. In contrast, other studies, of both undergraduate and post-registration programmes, report that online learning is just as effective as traditional classroom learning in terms of knowledge gain, attitude change and skill change [10-12]. A review by Chumley-Jones et al.  concluded that available studies could not demonstrate online learning was better than traditional classroom learning in both learning efficiency and knowledge gain. Cook et al.  compared undergraduate medical students’ change in knowledge, skills and behaviour after internet-based learning and after classroom learning. Students in the internet-based learning group had a similar change in all three outcomes as compared to those in classroom learning group. Wutoh et al.  reported that an internet- based CME course was only as effective as other CME courses in knowledge gain.
One of the reasons for the varied findings might be due to the fact that the extent of integration of online learning into traditional classroom learning varied between the studies. Most of them integrated online components into traditional learning such as asynchronous discussion, online presentation, practice exercises, and online lectures via e-learning platforms. Also, the interactivity of the online activities, the types of e-learning technology being used and the availability of technical support were discrepant . On the one hand, so many variations might contribute to the varied findings. On the other hand, the varied findings might imply that some sorts of online components might be more effective in improving the learning outcome than others. Unfortunately, consideration of this possibility is out of the scope of this review paper .
Experience of students in online learning is another focus in the past literature [2-4,6,8-10,14-16]. Medical students perceive the online environment as a flexible and convenient way of learning as it is less restricted by space and time [2-5]. It can facilitate and motivate learning by presenting interesting and fascinating course materials with ample interactive formats. It can stimulate students’ interest, motivate them to learn, and then offer them the means to learn independently [2,6,15,16]. It can also help passive and quiet students to interact and contribute more, be more vocal and bravely present their ideas through e-learning platform . Some reviews found that medical and nursing students were more satisfied with online learning as compared to the traditional classroom learning because online learning was more interactive and user-friendly, and because they could easily access more resources [3,10]. Online learning also facilitates collaborative learning as it provides a convenient medium for soliciting feedback from and offering feedback to both peers and faculty in real time [3,6,17]. Nevertheless, students did stress that online learning could only be a complement to the traditional classroom learnings  as they preferred having face-to-face consultation whenever encountering difficulties in their study.
Possible Factors Affecting the Effectiveness of Online Learning in Promoting Independent Learning among Medical and Nursing Students
In summary, a review of the literature shows there is no consistent and concrete evidence that online learning enhances students’ self-directed learning. Revisiting the definition of self-directed learning suggests an explanation. Self-directed learning is defined as, ‘a process in which individuals take the initiative, with or without the help of others, in diagnosing their own learning needs, formulating learning goals, identifying human and material sources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes.’  To take the initiative implies pre-existing motivation; it implies students have already assumed ownership for their learning  including having a desire for learning, and being capable of self-management and self-control [19,20]. In reality, this is not the case. It is therefore no wonder there are inconsistent findings as summarized above. The varied learning skills of undergraduate and postgraduate students, including problem-solving skills, self-regulation and motivation to learning, were underlying factors contributing to their self-directed learning. In other words, the students first had to have the ability to self-learning before they could selflearn. Developing this ability is the crux of the issue. Self-directed learning is not universally applicable to all students unless they are well-prepared for it .
Students’ Readiness for Self-Directed Learning
Inadequate preparation for online learning might compromise students’ learning . And the exact degree to which any student can take advantage of self-directed learning opportunities will largely depend on the individual student’s learning style and readiness for self-directed learning . A classroom experiment from Dyan et al.  demonstrated that a structured and tailor-made course design contributed to the enhancement of self-directed learning skills as students could model the skills through interacting with other students and faculty. Some studies found that medical and nursing students did grasp some self-directed learning skills well while some other were still underprepared. Klunklin et al.  found that nursing students in Thailand rated high on their openness to learning opportunities, self-concept as an effective learner, initiative and independence in learning, informed acceptance of responsibility for one’s own learning, creativity and the ability to use basic study and problem solving skills using Self Directed Learning Readiness Scale. Smedley , using the same scale as Klunklin et al.  to examine the self-directed learning readiness for year one nursing students in Australia found that they rated low in self-management which implied that their time management, self-disciplined ability, problem solving and information search etc. skills were insufficient to meet the expectations of the programme. The contradictory findings from different studies might alert us to the possibility that the characteristics of students in different countries are different as they are products of different education systems in which different degrees of self-directed learning skills are cultivated in their secondary schools. It reinforces the necessity of setting up a screening mechanism to examine the self-directed learning of those newly entering tertiary education. Blind introduction of self-directed learning in undergraduate programme will possibly hinder the learning pace, lead to rejection of this learning style, or even contribute to failure in students’ studies [1,21].
Faculty’s Readiness for Self-Directed Learning
Faculty play a pivotal role in assisting students throughout the learning process. Their readiness for devising and implementing courses with self-directed learning elements such as online components is worthy of in-depth investigation. Though they may be interested in and devoted to self-directed learning, their wrong perception on self-directed learning and incapability of implementing it properly and efficiently could have a detrimental impact on students’ desire for learning [25,26]. Grow and Wiley’s experiments [27,28] demonstrated a correlation between students’ readiness for self-directed learning and their preference for the amount of instructions received from teachers. Whenever a mismatch of a student’s self-directed learning with a teacher’s teaching style occurred, it led to high anxiety in the student. Also, Lunyk-Child et al.  found that teachers did doubt their abilities to plan and deliver a course with self-directed learning elements and rated self-directed learning as one area in which staff development resources were needed.
Unlike students’ and faculty’s readiness for self-directed learning, which are intrinsic factors to the acquisition of self-directed learning through online learning, technology literacy is an extrinsic factor potentially hindering a fruitful online learning experience. A poor learning experience definitely restrains students from building up their self-directed learning skills. The growing popularity and continual advancement of technology assumes that all people, including secondary school leavers, are competent and comfortable with all sorts of technologies. Many studies did find that this was not the case. Kenny  emphasized that the stress and anxiety students face when taking an online course never disappear. A systematic review found that technical issues is one the most commonly reported challenges in online learning . Sandars and Schroter  revealed that medical students lacked both knowledge and skills in using new technologies. The incompetence in using technology results in negative consequences for both their emotions and study. Students were prone to not choosing courses with computer-assisted learning, although it is a trend, and so limited their learning choices ; they felt anxious, fearful and even had a feeling of intimidation when enrolling in courses with computer components [30-35]. Sufficient technical support may be able to resolve many technical problems and relieve parts of the students as well as faculty’ worries [2,4,5].
Peer and Teacher Support
Peer and teacher support is another extrinsic factor important to a satisfactory online learning experience. Students did have varied perceptions of their virtual peers on the internet. Some students did perceive virtual peers as part of a warm, friendly, and supportive online community; others perceived them as a group of strangers and could not get sufficient support from them [4,36]. Tang, Wong and Wong  pointed out that peer support could refer to either mutual support among peer or competition among peer. Some students especially those with good academic performance are more preferable to know the performance of other students in order to motivate them working harder. As to the support from teacher, students preferred getting help from teacher in person when encountering difficulties and having face-to-face teaching such as lecture [4,10]. The findings might reflect the varied need of support that students have in the process of becoming independent learners .
Assessing the readiness of self-directed learning of students is a crucial step to the successful development of self-directed learning through online learning as the teachers can integrate online components into the courses in various extents according to the students’ varying degree of assuming responsibility [26,37]. Technical support includes an orientation programme, familiarizing students with the common systems to be used during their study; knowledge needed for manipulating the hardware and software; information about technical personnel from whom they can seek help if necessary, etc. This should be clearly and thoroughly presented to students in order to familiarize with the facilities and personnel they might encounter over the course of their study. Also, preparation of faculty in developing both the skillsets required for designing and implementing online learning and their understanding of self-directed learning is as essential to the successful implementation of online learning [1,38,39]. Considerable resources should be dedicated to developing staff with sufficient competency in online learning . Perhaps, a universal guideline for integrating online learning into classroom learning may be required to facilitate the faculty to design courses with online components. More, the relationship between online learning and self-directed learning of students should be substantiated by studies with a more stringent methodology.
To conclude, the effectiveness of online learning in promoting self-directed learning of medical and nursing students is still under investigation. Readiness of self-directed learning of both students and faculty, technical support and peer support are the potential factors of successful integration of online learning into classroom learning.
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