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ORIGINAL RESEARCH PAPER
Year : 2011  |  Volume : 24  |  Issue : 2  |  Page : 552

Change in Medical Students' Readiness for Selfdirected Learning after a Partially Problembased Learning First Year Curriculum at the KIST Medical College In Lalitpur, Nepal


KIST Medical College, Imadol VDC, Lalitpur, Nepal

Date of Submission21-Sep-2010
Date of Acceptance06-Jul-2011
Date of Web Publication10-Aug-2011

Correspondence Address:
R Shankar
P.O. Box 14142, Kathmandu
Nepal
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Source of Support: None, Conflict of Interest: None


PMID: 22081659

  Abstract 

Introduction: Modern medical education and the requirement for lifelong learning place increasing emphasis on self-directed learning. Studies have not been done on readiness for self-directed learning (SDL) among medical students in Nepal. The present study was carried out to (1) measure and compare readiness for SDL among medical students, and (2) note differences in readiness for SDL according to students' personal characteristics at the beginning and end of the first year of the MBBS course for medical students at the KIST Medical College in Nepal.
Methods: The study was done using the Self-directed Learning Readiness Scale. Respondents' agreement with each of forty statements pertinent to self-directed learning readiness using a modified Likert-type scale was noted. The mean total and scores on the subcategories 'self-management', 'desire for learning' and 'self-control' were calculated and compared across subgroups of respondents and in January and August 2010 using appropriate parametric and non-parametric tests (p<0.05).
Results: All 100 students participated in January while 90 participated in August. The mean scores varied with certain demographic and background characteristics. The mean total score increased from 152.7 to 157.3 while the self-management score increased significantly from 48.6 to 50.2 from January to August. There were small increases in the mean desire for learning scores from 46.9 to 47.7 and in the self-control scores from 58 to 59 from January to August, but not in other scores.
Conclusions: Self-directed learning scores were lower among these Nepalese students than reported elsewhere in the literature. Total scores and self-management scores improved at the end of the first year, but not scores on desire for learning and selfcontrol.

Keywords: Measurement, medical students, Nepal, readiness for self-directed learning, self-directed learning


How to cite this article:
Shankar R, Bajracharya O, Jha N, Gurung S B, Ansari S R, Thapa H S. Change in Medical Students' Readiness for Selfdirected Learning after a Partially Problembased Learning First Year Curriculum at the KIST Medical College In Lalitpur, Nepal. Educ Health 2011;24:552

How to cite this URL:
Shankar R, Bajracharya O, Jha N, Gurung S B, Ansari S R, Thapa H S. Change in Medical Students' Readiness for Selfdirected Learning after a Partially Problembased Learning First Year Curriculum at the KIST Medical College In Lalitpur, Nepal. Educ Health [serial online] 2011 [cited 2020 Sep 28];24:552. Available from: http://www.educationforhealth.net/text.asp?2011/24/2/552/101434

Introduction:

Self-directed learning (SDL) is becoming increasingly important in medical education1 as the rapid increase in knowledge information requires medical students develop SDL skills to prepare for lifelong learning2. Developing effective programs to teach SDL is hindered by the field’s lack of understanding of how medical students develop SDL skills and how they use learning resources3.

SDL can be defined as the process of deciding what to learn, to what depth and breadth; it occurs in a social context and includes decision-making and metacognitive thinking4. SDL can also refer to a broader process that includes autonomy and self-actualization; overall, it means the learner controls the process of learning5. Not all students are equally skilled in SDL and willing to make decisions about their learning. Some rely on their teachers to take the major responsibility6.

Problem-based learning (PBL) might support the development of SDL skills. A review concluded that PBL students are active library users, employ deep-level learning strategies and believe they are continuing to improve their SDL abilities7. However, there have been studies that show the contrary, including a United Kingdom (UK) study that showed student learning in PBL is not self-directed but rather concerns ideas socially agreed among by the peer group and directed by resources provided by faculty8.

In Nepal students enter medical school after completing 12 years of schooling, with physics, chemistry, biology and English taken during the last two years. Only students with a science background are admitted into medical school. Most medical schools in Nepal are private9. Two categories of Nepalese students are admitted: scholarship students who are selected on the basis of an entrance exam conducted by the Ministry of Education and who do not pay tuition or fees, and other, non-scholarship students who pay for their own tuition costs and must pass entrance examinations conducted by different universities. Tribhuvan University and Kathmandu University are the two universities to which medical schools are affiliated, and both conduct entrance examinations for undergraduate medical students. Foreign students are also admitted. Schooling prior to medical school for most students principally encourages rote learning and information recall. Self-directed learning and understanding of concepts are not commonly stressed. In the first two years of the undergraduate medical (MBBS) course in Nepalese medical schools, students learn the basic science subjects of anatomy, physiology, biochemistry, pathology, microbiology and pharmacology.

KIST Medical College (KISTMC) is a new medical school in Lalitpur district of the Kathmandu Valley affiliated with the Institute of Medicine of Tribhuvan University. The curriculum has been designed to integrate basic medical sciences with clinical disciplines10. There is a strong community orientation and emphasis on self-directed and problem-based learning. Students learn to solve problems on their own working in small groups during pharmacology practical sessions11. Subjects are taught in an integrated organ systems-based manner, and a correlation seminar or problem-based learning session is conducted towards the end of each system. Students work in small groups finding information, collating it, applying it to a patient problem and presenting their findings under the guidance of faculty members. Students are also posted in semi-rural communities, analyze health problems, and develop solutions with the involvement of the local community. Considering all these factors we expect the SDL of students to increase by the end of the first year. The basic science subjects at KISTMC are taught in an integrated, organ systems-based manner with early clinical exposure. Pharmacology practical sessions are conducted in small groups and are activity-based11. The sessions concentrate on teaching students to use essential medications rationally. Students take increasing responsibility for their own learning as the session progresses and faculty act as facilitators.

A medical humanities module called ‘Sparshanam’ (meaning ‘touch’ in Sanskrit, an ancient South Asian language) is also conducted in small groups once a week during early clinical contact hospital postings12. Paintings, case scenarios and different activities are used to explore various aspects of the humanities. As the principal learning modality continues to be didactic lectures, the curriculum is best described as partially problem-based.

A study of learning styles carried out in a medical school in western Nepal found that students mainly used deep and strategic learning styles13. Differences in preference for learning styles were noted according the respondents’ personal characteristics. Learning styles may be associated with approaches to learning and readiness for SDL. Deep learning is motivated by a desire for personal understanding and students integrate knowledge across different learning domains. A problem-based learning curriculum has been shown to encourage a shift to deeper learning approaches14.

Studies on readiness for SDL among medical students have not been carried out in Nepal. Studies have been carried out among students in developed nations who differ in many respects from our student population. Our students are generally younger (18-19 years) than Western students; they are less independent, more dependent on family and teachers, less trained for SDL during their school years, and more accustomed to a rote learning style. Our hypothesis was that SDL readiness scores would increase over the course of the first year sessions at our school and that there would be differences in scores for students with differing demographics and backgrounds. Hence, the present study was carried out to (1) measure and compare the readiness for SDL among medical students at the beginning and end of the first year of the MBBS course at the KISTMC, and (2) note differences in SDL according to students’ demographic and background characteristics.

Methods

A variety of scales have been developed to measure readiness for SDL among health science students. Fisher et al. had developed a scale for use among nursing students15 which was recently validated among medical students16. Our study was carried out among first year medical students using the Self-directed Learning Readiness Scale (SDLRS) developed by Fisher et al15. with permission obtained from the authors. The SDLRS measures three components of SDL, namely self-management, desire for learning and self-control. A number of studies have used the SDLRS developed by Guglielmino17. This SDLRS has an eight-factor structure. The factors being openness to learning opportunities, self-concept as an effective learner, initiative and independence in learning, accepting responsibility for one’s own learning, love of learning, creativity, future orientation and ability to use problem-solving skills.

The aims and objectives of the study were described to first year medical students at KISTMC, who were then invited to participate. Written informed consent was obtained. The study was approved by the Institutional Research Committee of KISTMC.

Students were administered the instrument twice, once in January 2010 at the beginning of the first year MBBS course and again in August 2010 when they had finished the classes and practical sessions of the first year. Basic demographic and background information including gender, method of financing of medical education, occupation of parents, caste or ethnic group, town or village where their parents live, place of pre-university schooling, whether it was a private or government school, and language of instruction at school were noted. Respondents’ agreement with a set of 40 statements was studied using a Likert-type scale. To avoid response set bias certain items were phrased negatively and their scores were reversed while calculating the total and subscale scores. Students were encouraged to answer questions according to their perceptions and avoid giving answers which may be desired by the researchers. Students responded anonymously, with no recorded names connected to individual responses, so as to encourage truthful answers. Subscale scores on the subcategories ‘self-management’, ‘desire for learning’ and ‘self-control’ were calculated using pre-determined items of the tool. The Kolmogorov-Smrinov (K-S) exact test was used to analyze whether the total score and subcategory scores followed a normal distribution. Based on the result of the K-S exact test, the mean total scores, self-management and desire for learning subscale scores were compared using t-test and analysis of variance (ANOVA) whereas self-control scores was compared using Mann-Whitney test and Kruskal Wallis test. Since the identity of participants was kept confidential, we were not able to compare scores using paired data analysis methods. We also calculated Cronbach’s alpha as a measure of internal consistency, which is a simple yet comprehensive measure of reliability. A p value of less than 0.05 was taken as statistically significant. Data were entered, cleaned and analyzed using SPSS V 15.0.

Results

All 100 students participated in the study in January 2010 and 90 students participated in August (90%). Table 1 shows the distribution of respondents according to demographic and background characteristics in January and August 2010. The gender ratio was nearly equal. Most students were paying for their own schooling and most had non-physician parents. The three dominant groups within Nepal - Brahmins, Chettris and Newars - accounted for majority of the students. Janajatis are the indigenous people of Nepal, who were traditionally oppressed and had low status in a caste dominated society. Recently, seats have been reserved for them in educational institutions. Prior to medical school, most students had been educated in private, English medium schools. In English medium schools the language of instruction in all subjects is English. Nepali is taught as a second language.



Table 1:  Distribution of student respondents according to demographic characteristics in January and August 2010  







In January, at the start of the students’ first year, the mean total SDLRS score was 152.7 and the standard deviation was 14.6, with a maximum possible score of 200. The mean score (standard deviation) for the subcategory ‘Self-management’ was 48.6 (5.6) (maximum score 65). For the subcategories ‘Desire for learning’ and ‘Self-control’ the mean (standard deviation) scores were 46.9 (4.42) and 57.24 (7.95) (maximum scores being 60 and 75, respectively). For the January 2010 data the Cronbach's alpha were: 0.87, 0.75, 0.56 and 0.83 respectively for the total, self-management, desire for learning and self-control scores. Table 2 shows the mean scores and the p values according to demographic and background characteristics in January 2010. The mean total score was significantly higher among scholarship students, students educated in government schools and those educated in the Nepali language. The median self-management and self-control scores were significantly higher among scholarship students, students from government schools and students educated in schools with Nepali as the language of instruction.



Table 2:  Mean total and subcategory scores in January 2010 according to demographic characteristics of respondents







Table 3 shows the mean total SDLRS and subcategory scores among different groups of respondents in August 2010. For the August 2010 data the Cronbach's alpha were: 0.83, 0.66, 0.64 and 0.70 respectively for the total, self-management, desire for learning and self-control scores. The mean total score was significantly higher among scholarship students, government school students and students educated in the Nepali language. Self-management scores were significantly higher among scholarship students, students from government schools and those educated in the Nepali medium. Desire for learning and self-control scores also varied according to certain demographic characteristics of respondents.



Table 3:  Mean total and subcategory scores in August 2010 according to demographic characteristics of respondents







Table 4 compares the mean total and subcategory scores (except self-control scores) in January and August 2010. The t-test was used for the comparison. The mean total score and self-management scores were statistically significantly higher in August. Table 5 shows that the self-management score also increased but was not statistically significant.



Table 4:  Mean total and subcategory scores in January and August 2010









Table 5:  Median self-control scores in January and August 2010 







Discussion

In January 2010, the median total SDLRS score was 154 while in August 2010 the score increased modestly to 156. The self-management score also increased, but the desire for learning and self-control subscores did not. There were significant differences in certain scores according to demographic and background characteristics of respondents.

In a bachelor of nursing program in the US there was no significant increase in SDLRS scores at the end of year one18. The SDLRS instrument was administered to PharmD students before and after completing an advanced pharmacy practice experience (APPE)19. Readiness for SDL using Guglielmino’s SDLRS was studied among graduate nursing students during different years of study in Thailand20. Our overall scores and the subscale scores were lower than those reported among PharmD students. Among PharmD students demographic and baseline characteristics were not associated with differences in scores19. In our study, in contrast, the scores varied according to selected demographic and baseline characteristics. In the Thai study among nursing students the mean scores were significantly higher among fourth year students compared to others20. In the US, self-direction in learning did change over time from the first to the final semester among different health science students21. In Turkish nursing students, fourth-year scores were significantly higher than in earlier years, and SDL scores were higher than those reported in our study22.

Thus our scores were lower than those reported in the literature. We know that the age of our students, although not directly measured in the present study, is comparable to that mentioned in the Turkish study, but less than that in the American PharmD study. Studies have shown that readiness for SDL increases with age, maturity and as students progress across a course20-22. In Nepal and South Asia rote learning and reproduction of factual information predominates in school. The entrance examination for the MBBS course also concentrates on factual information. In our study, the self-management score (49 out of a maximum of 65) and the self-control scores (58 out of 75) were low. The scores increased at the end of the first year. The increase, however, was minimal and may not be of importance in the real world. The increases in the three categories of scores were minimal. These results may be a matter of concern.

From the current academic year we have taken many steps to increase student readiness for SDL. We have started interactive sessions of problem-based learning and more directly teach how to be an effective self-directed learner during the orientation program.

We have also started PBL sessions involving all six basic sciences subjects, community medicine and relevant clinical departments at the end of certain organ system during the second year. A major challenge remains that the university’s theory exams stress factual recall and hence students’ learning is directed towards rote learning and information recall to do well in the exams. We have also introduced skills training of facilitating small groups during the teacher’s training program for faculty. SDL occurs mainly during pharmacology practical sessions and during the medical humanities module. The humanities module concentrates more on reinterpretation and putting already known information in context rather than finding new information. Another opportunity for SDL occurs during correlation seminars held at the end of each organ system. A particular topic is presented under different subjects by the students. In each subject there are usually two learning objectives and students prepare for a five-minute presentation on each objective using resources available in the library. Faculty members act as facilitators, evaluate students and provide constructive suggestions at the end of the seminar.

We found that in January 2010 total SDLRS, self-management and self-control scores were higher among scholarship students. These students are stronger academically and perform consistently better as a group than their self-financing counterparts. It was surprising that students from government schools had higher scores than those from private schools, since in Nepal government schools suffer from a shortage of teachers and poor infrastructure and are usually said to have poor quality teaching. It may be that for the above mentioned reasons, students from these schools have to take more responsibility for their own learning. The number of students who studied in government schools was low and the majority of them were scholarship students. Students in government schools are educated in the Nepali medium where all the subjects are taught in Nepali and English is taught only as a language.

Our study had limitations. The sample size was small and the study was carried out only among first year students. There are many instruments measuring SDLR and debate about the properties of each instrument continues. The differences we detected were small and in some cases, while they may be statistically significant, the changes may not have been meaningful. In August 2010 ten students who participated in the study in January 2010 dropped out. Mainly male students and self-financing students dropped out and this may have influenced the results. Reliability analysis using Cronbach’s alpha showed that the value for desire for learning subscale was low in January 2010 and the subscales for self-management and desire for learning were low in August 2010. The study may hold true in other private medical schools in the south Asian region which attract a similar type of student. Government medical schools admit students through an open competition and may attract students who are academically stronger. We administered SDLRS in English, the language of instruction. It was not pre-tested and validated in a Nepalese population. Student participants, however, did not mention having difficulties understanding the statements in the instrument. Also, as we did not collect identifying information. We did not know the scores of individual students in January and August, so we could not use paired tests for comparison; instead overall scores were compared using t-test and Mann-Whitney test. 

Conclusions

The present study shows that self-directed learning scores of Nepalese first year medical students in a new medical school that emphasizes student-focused learning and self-directed learning were lower than those noted in the literature in other parts of the world. There were differences in the SDL scores according to demographic and background characteristics of respondents, with students on scholarships, students from government schools and students whose secondary education was in the Nepali language having higher scores. Scores improved at the end of the academic sessions of the first year but significant improvement was seen only in self-management scores. Studies involving other entering classes and as students progress through medical school are required, and readiness for SDL should be studied in other medical and health professions schools in Nepal.  



Acknowledgements



The authors would like to acknowledge the support of Dr. Murray Fisher, Faculty of Nursing and Midwifery, University of Sydney, Australia for giving us permission to use the SDLRS developed by her in this study. We would like to thank the academic management of KIST Medical College for their support. We thank Ms. Renu Mahat for logistical help and data entry. We thank all the first year students who participated in the study.

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