Developing and introducing structured cooperative self-directed learning activities for undergraduate medical students

INTRODUCTION

The concept of self-directed learning (SDL) starts from the time a child is born, We need not teach a child how to breastfeed, although they are initially guided and later are self-directed to accomplish the task. There are many examples that we can quote from our ancient history one being the story of Ekalavya from Mahabharat.^[1] Researchers mention that 74% of Indian students are joining private tuition/coaching centres drifting them toward the practical aspect of the taught course and having little way to expand the co-curriculum strength.^[2] Probably, our school education system with the parallel education system is curbing the SDL efficiency of students. Hence, there is a need to recreate activities to enhance students’ skills of being SDL and, subsequently, lifelong learners.

The amended Regulations on Graduate Medical Education-2019^[3] provided a layout for the new model of curriculum, Competency-Based Medical Education (CBME), for undergraduate Indian medical students starting from Batch 2019 to 2020. The curriculum, in its three volumes, enlists the competencies to be attained by undergraduate students to be competent as Indian medical graduates.^[4] Concepts such as Foundation Courses, Early Clinical Exposure, Electives, Professional Development including Attitude, Ethics and Communication Module, Learner-doctor method of clinical training (Clinical Clerkship) and SDL were officially introduced in the formal CBME curriculum.^[3] For the first time, the term lifelong learner was specified in the formal medical curriculum.^[4] Specific time-slot durations are allocated for each module. Mandate specific hour allocation for the SDL activity for each subject in each academic year became the catchword for every faculty of medical institutes across the country.^[3]

In 1975, Knowles^[5] defined SDL as ‘A process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies and evaluating learning outcomes (LOs)’. Over time, different researchers have presented various models for SDL starting from Knowles^[5] in 1975, Long’s^[6] in 1989; Candy^[7] and Brockett and Hiemstra^[8] in 1991; Garrison’s^[9] in 1997; Oswalt^[10] in 2003 and Boyer et al.,^[11] in 2014, have explained the approach of SDL in their manner. All the models of SDL, in sequence, added strategies where students would have accountability for their learning.

SDL is viewed as a complex process that ingrains the quality of critical thinking, problem-solving, analytical and resource search skills over and above that of developing the affective attributes of team-building, communication and interpersonal skills.^[12-15] Attaining the skill of SDL will monitor students’ conceptual understanding of the content and ability to integrate disciple-based information to synthesise their knowledge and apply it in the real practical world, thus being a lifelong learner.

Towle and Cottrell,^[16] in their study, have enlisted SDL activities starting from setting learning goals by learners to monitoring the effectiveness of self-study habits which not only facilitates learning but also helps learners cultivate the critical skills of lifelong learning.^[16]

Numerous studies have shown a variety of teaching-learning strategies such as case-based learning, problem-based learning (PBL) and team-based learning that allow students to be self-directed learners.^[17-20] The study on case-based learning showed a beneficial outcome for motivating students to be self-directed learners and develop analytical and problem-solving skills.^[17] Similarly, the team-based learning approach showed better interaction among learners leading to active engagement and an increase in academic performance.^[18] PBL strategy allows students to work in groups on a problem in 2–3 learning sessions which are well spaced out allowing students to undertake SDL and manage information to be able to discuss in the final session.^[18,20] The challenges of having limited trained facilitators to conduct the sessions, work overload and the time to prepare relevant contextual cases as per students’ milestones and specific time-slot to be incorporated as per regulatory norms^[21] being faced at our level limit its implementation.

Researchers have published plans^[22] or faculty guide reviews^[23] showing ways or approaches for implementing SDL modules/activities.

The shortage of faculties in institutes like Indian medical institutes^[24] may not allow the absolute focus of the facilitators on each learner. There is a need for the development of a model that would provide an opportunity for students to attain SDL skills despite human resources limitations. Thus, the study was devised by amalgamating the SDL approaches with the five principles of Cooperative Learning (CL) of Johnson and Johnson^[25] and termed it Structured Cooperative SDL (Sc-SDL). This model was incorporated for the 1^st-year medical students as per the requirement of a competency-driven undergraduate curriculum prepared by the National Medical Commission, India, earlier named the Medical Council of India, where specific hours have been indicated for SDL sessions in each subject.^[3]

The study aimed to develop and introduce a Sc-SDL activity as a student-centric approach for 1^st-year undergraduate medical students and to identify their perceptions.

MATERIALS AND METHODS

Study design

A prospective, observational and cohort study for 150 1^st-year medical students was done from (June to November 2021) with a sequential mixed-method approach. The study commenced by developing and implementing a Sc-SDL activity in the department of physiology.

Before the initiation of the activity, all seven facilitators, of the department were oriented on the concept, planning and conduct of the strategy. The role of the facilitator, in terms of observing learners throughout the process for each session, scoring them, and providing them with feedback at the end of each session, was explained to the facilitators. Input and suggestions for modifying the strategies were welcomed.

In the next step, students were sensitised regarding each step of the Sc-SDL activity, and their expected roles and responsibilities during the process were highlighted. The key components of Group Dynamics and Group Behaviour Among Adults,^[26,27] such as creating a group, collaborative knowledge building, teamwork, conflict management and practical value were explained. Thus, students were aware that, with each Sc-SDL small group, members had to choose a leader, recorder, reporter and timekeeper and other members’ roles had to be clarified within the group.

For the first Sc-SDL module, the students were selected as per roll number, and subsequently, for each Sc-SDL activity, systemic random sampling was done, dividing students into five/six groups each time under a different facilitator from the department. The systemic random selection was done based on student feedback since they expressed a desire to engage in team building and learning with their classmates.

The entire activity was conducted under three sub-sessions with a specific time duration for each session. They were specified as in Figure 1:

1. Exploring session (60–120 min),

2. Interactive intersession (7–10 days)

3. Sharing session (120 min).

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Figure 1:

Strategy for the structured cooperative self-directed learning (SDL) activity

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Before session 1, a departmental meeting was organised. The topic was identified for the Sc-SDL strategy for 1^st-year medical students by the department of physiology.

A set induction in the form of a clinical case scenario was incorporated to introduce the topic in the form of a trigger. The specific expected LOs were identified by the departmental members for the topic; this allowed all the facilitators to be on the same page during the small group activity.

Exploring session

During this session, students were exposed to the Sc-SDL module using a clinical case scenario as a trigger by the coordinator. Then, the students were subdivided into further small groups as per the number of available facilitators (maximum of 30 students/facilitator), formal task-based groups. Each group initiated their discussion on the topic following the rules of group dynamics. The group identified the LO and primary resources that they would be exploring to understand the topic better. The finalised LOs, task distribution as per the group members and list of primary resources were submitted to the facilitator and shared with the group members.

RESULTS

Descriptive statistics are demonstrated in Table 2 (mean ± standard deviationSD) for the academic scores for the topic taught via the Sc-SDL approach, ranging from 67.62 ± 21.72 (Activity-1: Myasthenia gravis), 78.91 ± 23.53 (Activity-2: Refractory errors), and 83.72 ± 24.34 (Activity-3: Nephrotic Syndrome). Thus, better academic outcomes is achieved by the students once they attain better understanding and adaptability towards Sc-SDL approach of learning.

As shown in Table 3, the statistical significance (P < 0.005) of the academic scores achieved for the topics Activity-1 and 2 and Activity-1 and 3 by the Sc-SDL teaching-learning method. The topics of Nephrotic Syndrome (Activity-3) and Refractory errors (Activity-2) were the last two activities taught by the Sc-SDL approach and thus probably did not show a significant difference as per the paired student t-test.

Descriptive statistics are demonstrated in Table 4 for the learner feedback for the Sc-SDL approach showing ‘agree’ and ‘strongly agree’ for most items of the feedback questionnaire except for the item ‘I would have learned better independently,’ that showed lesser percentage of agreement. The Cronbach’s alpha for the 13 items of the questionnaire was 0.85. The table shows the Friedman Mean Rank Test and satisfaction index of each item. The result showed the highest value (the Friedman Mean Rank Test and satisfaction index) for item 8 ‘Working together we could fulfil the knowledge gap’ (8.80; 93.60) and the lowest value for item 10 ‘I would have learned better independently’ (3.28; 57.83). Twelve out of 13 items have shown satisfaction indexes of >75.^[29,32]

As shown in Figure 2, the themes and sub-themes as per the responses acquired from the open-ended questions from the learner feedback questionnaire for the Sc-SDL student-centric approach.

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Figure 2:

Response to open-ended questions in the learner feedback questionnaire. SC-SDL: Structured cooperative self-directed learning activity.

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As shown in Table 5, the input from the students for the Sc-SDL activity after the completion of the course through thematic analysis showing three major themes need identification, searching skills and outcome attainment. However, students provided suggestions for improving their learning by the Sc-SDL approach. They provided input for each session of the approach.

DISCUSSION

The study demonstrated improvement in cognitive and affective attributional gains by participating through ScSDL. The maximum score achieved for the topic learned through the Sc-SDL activity was 100. Even, a statistically significant difference was observed when comparing the academic score of each Sc-SDL activity of students. However, statistical significance was observed between some of the topics learned by the Sc-SDL except refractive error and nephrotic syndrome. Being the initial stage of learning by the structured approach of SDL probably might be the reason for having a significant difference in the academic scores for the topic of myasthenia gravies and other topics learned by Sc-SDL. The study by Peine et al.,^[33] showed similar results. However, Smythe and Hughes’s^[34] study showed a similar outcome of SDL assessment compared to conventional teaching, initially, but later, the scores decreased. The probable reason highlighted was the difference in content and time investment, other than proper support and communication with the students for the SDL approach. Similarly, Kooloo et al.’s^[35] study for the gross anatomy laboratory sessions showed better outcomes with strictly guided station instructions rather than loosely guided SDL when observed for 8 months duration. The study by LeFlore et al.,^[36] favoured instructor-modelled learning compared to SDL during the clinically stimulated experience.

The present approach of Sc-SDL provided a better cognitive outcome as students took charge of their learning and adapted to SDL. Thus, it fits well into quadrant I (low pedagogical control and high psychological control) of Long’s^[6] model, which infers that the student is demonstrating self-directedness and facilitators are taking less control of the learning situation.

Brockett and Hiemstra,^[8] mentioned in their book that there is a high chance of student success when they have a high level of self-directed readiness score and are being hand-held by the facilitator. This may be because the learner’s experiences are in line with the expectations of the learning situation.^[8] The present method of conducting the SDL activity incorporates all the components of the Garrison^[9] model of SDL, that is motivation, self-management (Control), SDL and self-monitoring (responsibility). In the present study, a clinical case scenario was used for set induction. However, video recording of stakeholders, newspaper write-ups, movie clips, flipped classrooms, reciprocal teaching, technology-enhanced methods, PBL, group projects^[12] and many more can be used depending on the flexibility of the department.

Out of six competencies for SDL mentioned by Patterson et al.,^[37] four were identified in the present Sc-SDL activity and the level of each competency was considered as per the academic milestone of the medical student. The four competencies addressed in our present Sc-SDL activity were (i) teamwork: working in a group and preparing a presentation for the sharing session of the Sc-SDL activity; (ii) reflection: where the students narrated their experiences throughout the activity and writing, (iii) critical thinking: where the student’s responded to the MCQ test prepared by the coordinator of the activity for the topic as per the expected LO and (iv) self and peer evaluation: where student graded themselves and peer through a structured assessment score sheet.

In the present study, the Learner Feedback Questionnaire had items for peer and self-feedback, which showed the highest score (4.56 ± 0.81; 8.80) as per the Friedman Rank test for item 8 ‘working together we could fulfil the knowledge gap’ while the lowest score (2.94 ± 0.99; 3.28) for item 10 ‘I would have learned better independently’ which implies that the group as a team together improved their learning for the topic. The result of the items related to SDL showed that this activity helped students to acquire lifelong learning skills (4.43 ± 0.67; 8.21), and the activity allowed every student to frame learning objectives (4.49 ± 0.85; 8.63), thus allowing them to identify topics that they should explore for further studies. The activity also provides an opportunity for students to manage conflicts (4.49 ± 0.65; 8.47).

Hill et al.,^[38] study demonstrated the successful implementation of a case-based SDL for 1^st-year medical courses, showing a valuable learning experience for the students. Bhandari et al.,^[39] showed students and faculty satisfaction with the SDL approach showing learners to be independent and aware of their learning goals and evaluating LOs. The study by Patra et al.,^[40] also showed positiveness toward SDL by the students, specifying that the approach led to easy access to resources for learning. Although the study suggested sensitising students about the SDL process and its importance rather than using it as a teaching-learning approach for knowledge acquisition.^[40]

The present study, with input from students after passing 1st-year of the medical program, shows improvement in identifying their learning needs, framing the objectives for the topic, searching skills and communication and presentation skills. Thus, other than an increase in the cognitive domain, there is subsequent improvement in their affective attributes, too. The study by Findlater et al.,^[13] also supported the SDL approach to improving student engagement, leading to deeper learning and better understanding and knowledge of anatomy. A systematic review for SDL showed a moderate enhancement in knowledge gain while the effective gain for skills and attitude domains.^[41]

The present study kept in mind the amount of content in the topic learners would need to cover as per their milestone and the length of time to gain knowledge for the topic through the Sc-SDL approach of teaching-learning which was one of the limitations of Smythe and Hughes.^[34] The group performed all the tasks until they attained a metacognitive approach to the topic and significant academic gains other than enhancement of social skills for team building, management skills, digital usage skills and resource search skills.

CONCLUSION

The Sc-SDL approach is an acceptable way of encouraging undergraduate students to attain attributional and social skills, which subsequently promotes them toward the path of being lifelong learners rather than having a cognitive gain. The approach allows learners to adapt to the recent trends of digital technology and makes them ready for futuristic web-based knowledge attainment.