YNEDT-02895; No of Pages 8 Nurse Education Today xxx (2015) xxx–xxx

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Enhancing self-directed learning among Italian nursing students: A preand post-intervention study L. Cadorin a, A. Rei b, A. Dante c, T. Bulfone d, G. Viera d, A. Palese d,⁎ a

CRO Aviano National Cancer Institute, Italy Mental health Centre Health Service No. 4, Friuli Venezia Giulia, Italy University of Trieste, Italy d University of Udine, Italy b c

a r t i c l e

i n f o

Article history: Accepted 4 February 2015 Available online xxxx Keywords: Self Directed Learning Tutorial strategies Clinical learning experience Nursing education

s u m m a r y Background: In accordance with Knowles's theory, self-directed learning (SDL) may be improved with tutorial strategies focused on guided reflection and critical analysis of the learning process. No evidence on effects on SDL abilities of different tutorial strategies offered to nursing students during the 1st clinical experience is available. Objectives: To evaluate the effect of different tutorial strategies offered to nursing students on their SDL abilities. Design: A pre–post intervention non-equivalent control group design was adopted in 2013. For the treatment group, structured and intensive tutorial interventions including different strategies such as briefing, debriefing, peer support, Socratic questioning, performed by university tutors were offered during the 1st clinical experience; for the control group, unstructured and non-intensive tutorial strategies were instead offered. Setting: Two Bachelor of Nursing Degree. Participants: Students awaiting their clinical experience (n = 238) were the target sample. Those students who have completed the pre- and the post-intervention evaluation (201; 84.4%) were included in the analysis. Methods: SDL abilities were measured with the SRSSDL_ITA (Self Rating Scale of Self Directed Learning-Italian Version). A multiple linear regression analysis was developed to explore the predictive effect of individual, contextual and intervention variables. Results: Three main factors explained the 36.8% of the adjusted variance in SDL scores have emerged: a) having received a lower clinical nurse-to-student supervision (B 9.086, β 2.874), b) having received higher level and structured tutorial intervention by university tutors (B 8.011, β 2.741), and c) having reported higher SDL scores at the baseline (B .550, β .556). Conclusions: A lower clinical nurse-to-student ratio (1:4), accompanied by unstructured and non-intensive tutorial intervention adopted by university tutors, seemed to be equivalent to an intensive clinical supervision (1:1) accompanied by higher level and structured tutorial strategies activated by the university tutors. © 2015 Elsevier Ltd. All rights reserved.

Introduction The complexity of the clinical environment, determined among other factors by increasing patient needs, the increasing use of technology, and new evidence as a basis for decision-making, requires the presence of nurses capable of continuing to develop their knowledge through self-directed learning (SDL) (Cadorin et al., 2011). SDL is essentially the ability to search for new information, to critically evaluate and adopt the information retrieved in the clinical decision-making process (Avdal, 2013). From the andragogical perspective, SDL is a process whereby the learner defines the learning aims, ⁎ Corresponding author at: University of Udine, viale Ungheria 20, 33100 Udine. E-mail address: [email protected] (A. Palese).

identifies appropriate methods, and evaluates outcomes, assuming the responsibility for the entire process. Knowles defined the concept of SDL in 1975, emphasising the importance of learner autonomy in 1980 (Knowles, 1989). In its current conceptualisation, SDL is based on specific domains: SDL is connected to learner awareness of personal learning needs; to his/her motivation to learn; to the ability to select appropriate learning resources, aims, and strategies; and to the ability to evaluate achieved outcomes (Cheng et al., 2010). Since the first definition of the concept, several studies have documented the importance of SDL within nursing education (Avdal, 2013). Aimed at preparing students and future nurses capable of learning-for-life, nursing educators play a key role incorporating the principles of SDL both in theoretical and in clinical practice teaching: they can adopt different tutorial strategies as learning contracts,

http://dx.doi.org/10.1016/j.nedt.2015.02.004 0260-6917/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article as: Cadorin, L., et al., Enhancing self-directed learning among Italian nursing students: A pre- and post-intervention study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.02.004

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L. Cadorin et al. / Nurse Education Today xxx (2015) xxx–xxx

personal support, reflective meetings based upon questions regarding the process of learning rather than its content (Timmis, 2008). Plato and Socrates first adopted these methods, stimulating their students, asking them to reflect on themselves, thinking about life and the learning process (Avdal, 2013); also in the context of nursing education, Socratic questioning is the ability to engage students in critical conversations enhancing their thinking and SDL, by investigating the “why” rather than the content or simply searching for the answers (Avdal, 2013). Tutorial strategies, intended as those strategies that may be adopted in the context of clinical nursing education, are based on facilitation, guided reflection, questioning, learning through the critical analysis of experience (e.g., Watts, 2011). Tutors may encourage, support, and facilitate the learning process, progressively developing in the students the ability to self-direct the learning process, to achieve autonomy (Hossein et al., 2010). In the first year of nursing education, students may need a more intensive and structured tutorial approach, requiring support, advice, and direction concerning learning priorities (Nolan and Nolan, 1997; Hughes, 2004). Through these strategies, students may progressively develop the ability to control and direct their learning processes, becoming self-directed learners (Pryce-Miller, 2010). Developing SDL abilities during nursing education may increase student motivation, autonomy, interpersonal communication, and the desire to be a life-long learner (Hewitt-Taylor, 2001; O'Shea, 2003). Nursing students with SDL abilities are more likely to use knowledge in different situations, to develop competence when dealing with new clinical problems, to increase their ability to face more demanding clinical roles (Hevit Taylor, 2001; O'Shea, 2003; Williams, 2004). Despite the importance of SDL abilities, as well as the acknowledged role of tutorial strategies, both in the theoretical and in the clinical practice sessions that should be introduced early in the nursing education, to date no studies have evaluated the influence of different tutorial strategies on SDL abilities. Therefore, evaluating the effect on SDL abilities of different tutorial strategies applied in clinical practice was the main aim of the study. Methods Study Design A pre–post intervention based upon a non-equivalent control group design (Shaughnessy et al., 2000) was adopted on 2013. The study design was decided based upon a quasi-experimental procedure in which comparison was made between control and treated groups that were established on a non-random basis. Settings, Sample and Sampling The participants were chosen as a convenience, cluster sample, and were attending their Bachelor of Nursing Degrees studies in two Italian universities. The Bachelors of Nursing Degrees were preliminarily assessed for their homogeneity in the curriculum pathway (theoretical and clinical) as well as in the enrolment criteria of the candidates and in their faculty resources. During the first academic term, starting homogeneously in October, students attended basic courses for around 400 classroom hours and pre-clinical skill laboratory sessions, made up of around 30 h of basic nursing skills (e.g. patient hygiene) involving small groups (10–15 students), under the guidance of a university tutor. Thereafter, students attended the exams in the 1st term, including basic courses. Similarly for all degrees involved, the 2nd term was dedicated to clinical learning in medical or surgical hospital units for around 200 h. Students awaiting their clinical experience (n = 238) were the convenience sample targeted for the study. Students were approached and informed on the aims of the study. In the pre-evaluation phase, 225/238 was collected (94.5%) and in the post-evaluation phase 214/225 (95.0%). From the pre- to the

post-intervention 11 questionnaires were excluded from those students who had not returned the questionnaire completed (n = 2) and those who had withdrawn from the Bachelors programme (n = 9). Therefore, those students completing the pre- and the post-intervention evaluation were a total of 201. End-point, Individual and Contextual Variables The SDL ability was the main end-point of the study. As an individual variable, student-level data (e.g., demographic) was collected. As contextual-level data, the following information was collected: clinical experience attended (medical vs. surgical ward) and clinical nurse-tostudent ratio as the number of students followed by each Registered Nurse (RN) at the unit level (from 1:1 to 1:2 or more). Independent Variable: Intervention The relevant literature in the field of SDL ability enhancement, and especially those tutorial interventions suggested for implementation at the clinical level (Table 1) was considered as a basis for two different interventions. In accordance with the complex intervention theory (Anderson, 2008), students were treated to two different tutorial interventions: the control group received an unstructured, nonintensive tutorial intervention, while the treatment group received a structured, high intensive tutorial intervention. Both the interventions were delivered by university tutors, RNs with advanced education in nursing and pedagogical sciences, working full-time at the academic level in each degree course. They were experts (Benner, 2001) in tutoring the 1st year students just starting their clinical experience, which is widely recognised as having a strong impact (Brugnolli et al., 2011). The university tutors were on average one for every 15–20 students. Instrument and Data Collection Process The SRSSDL_ITA, originally developed by Swapna Naskar Williamson (Williamson, 2007) in its Italian validated version (Cadorin et al., 2011) after having obtained author authorization, was used. The SRSSDL_ITA, consists of 40 items distributed across eight factors: ‘Awareness’, ‘Attitudes’, ‘Motivation’, ‘Learning Strategies’, ‘Learning Methods’, ‘Learning Activities’, ‘Interpersonal Skills’, and ‘Constructing Knowledge’. The tool is based upon the andragogical theory of SDL (Knowles, 1989) which represents the main theoretical rationale of the present study: the first three factors are considered antecedents to effective SDL; factors four, five and six consist in abilities needed to effectively manage the SDL process; the eighth factor reflects the ability to critically evaluate new knowledge (Knowles, 1989). Each factor contained a variable number of items. On the basis of available knowledge of the tool, the Cronbach alpha (α) is 0.929, while for each factor the internal consistency ranges between 0.682 and 0.813 (Cadorin et al., 2013). The responses for each item were rated by using a five-point Likert scale: 5 = always, 4 = often, 3 = sometimes, 2 = seldom, 1 = never, resulting in a global score ranging from 40 to 200. Data collection was performed before the clinical training experience (April 2013, preintervention evaluation) and at the end of the clinical learning experience (June 3013, post-intervention evaluation). Ethical Issues A preliminary authorisation to approach the students was obtained from the Dean of the identified Faculties. Then, students were informed regarding the aims of the study, and they were invited to participate. They were free to withdraw from the study at any time. Student written consent was collected and, thereafter, the questionnaires were distributed. In accordance with to the fact that each questionnaire collected in the pre-intervention phase was matched with the questionnaire collected in the post-intervention phase, anonymity was not possible.

Please cite this article as: Cadorin, L., et al., Enhancing self-directed learning among Italian nursing students: A pre- and post-intervention study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.02.004

L. Cadorin et al. / Nurse Education Today xxx (2015) xxx–xxx

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Table 1 Independent variable: interventions. Phase Pre-clinical

Peer support

On weekly basis

During the clinical experience (1)

During the clinical experience (2)

Evaluation

Control group Unstructured not intensive tutorial intervention

Treatment group Higher intensive and structured tutorial intervention

Briefing held by a UT in small groups (10–15 students) aimed at explaining aims, standards of care, intermediate goals, clinical tutor role, and student role (session 3 h in length) was offered. The briefing was highly structured: each UT was preliminarily prepared and received a written guide on the minimal information to offer to the attending students. When 1st year students were in the ward, no other nursing students From the first to the second week, students were matched with a 3rd were attending their clinical practice in the same ward. year nursing student, aimed at unit orientation, socialisation with the members of the team, patient introduction, and basic skills introducing. The peers were preliminarily prepared to question 1st year students regarding their learning needs, their priorities, their goals, as well as their explanations regarding the patients' problems (e.g. ‘..our patient was not able to perform any ADLs this morning… Why do you think this happens?’) Debriefing (2 h in length, 5 sessions) discussing difficulties that had Debriefing (2 h in length, 5 sessions) discussing emotional difficulties emerged and strategies adopted in patient assessment, nursing care perceived by students related to the clinical environment impact and plan and evaluation. The approach used by the UT during the possible strategies to overcome. The debriefing sessions were mainly based on the needs of the students as presented at the beginning of each debriefing section was based on the Socrates questioning. During each section. The UT was prepared to address all questions emerged. In section, students were also invited to develop connections between theoretical knowledge developed in the 1st term and the clinical addition, an evaluation of the weekly aims, as well as their degree of achievement, was guided by the UT, and interviewing students on their experience, constructing relationships in a form of conceptual maps. Gaps in knowledge or in patient's problems understanding personal improvements was done. (emotional, physical, social, or spiritual), were left unresolved by UT. Students were invited to query database, clinicians or the same patient to gain new information to help them in understanding the problem that had emerged. No discussion of cases in real time between UT and student was offered. A real time student-UT discussion on patients' problems was performed. With regard to a patient decided by the students and the CT, towards whom the student had the opportunity to take care in a holistic fashion for the last three days, there was a fixed appointment at the unit level. The UT interviewed the student on the decisions and on the underlining rationale undertaken for the selected patient. Students were invited to be prepared, studying in depth, collecting relevant data, and reflecting on the possible nursing implications. Students were invited to consider in deep two clinical cases (selected Students were invited to develop one nursing care plan, documenting the assessment of the considered patient's needs, the nursing problems, with the clinical tutor) using theoretical knowledge to understand and described in a priority fashion, and the expected nursing aims. Students explain the clinical problems emerged in the cases. These cases were were also invited to define the interventions for each individual patient presented to the UT which gave a content feedback (regarding the and to evaluate the impact of the intervention implemented. The UT appropriateness of the decision made for each patient) and a process gave a content feedback (regarding the appropriateness of the decision feedback (stimulating the student to reflect regarding his/her learning made for the patient). process). On individual basis, after 2 (intermediate evaluation) and 5 weeks (final On individual basis, after 2 (intermediate evaluation) and 5 weeks evaluation) by UT and CT. (final evaluation) by UT and CT. Briefing held by UT in small groups (10–15 students) aimed at explaining aims, intermediate goals, clinical tutor role, and student role (session 2 h in length) was offered. The briefing was mainly unstructured: after having assured that the minimal contents and information regarding the needs expressed by the students was offered.

Theoretical rationale Mariani et al. (2013) Dreifuerst (2012) Houghton et al. (2013) Spiva et al. (2013) Christiansen and Bell (2010) Avdal (2013) Baudrit (2012) Hunter Revell (2012)

Avdal (2013) Pryce-Miller (2010)

Avdal (2013) Pryce-Miller (2010)

Zannini, (2005) Klass (2007)

SDL, Self Direct Learning. UT, university tutor. CT, clinical tutor.

Therefore, students were assured with regard to the confidentiality of the data collected which was managed only by researchers. Data Analysis Data analysis was performed with SPSS, version 21. Descriptive statistics were adopted calculating frequencies, percentages, averages, standard deviations (±), and Confidence of Intervals (95% CI). Then, according to the aims of the study, the following analyses were performed: a) Firstly, homogeneity between the treatment and the control group of participants' profiles was assessed, using χ2 test (Fisher when appropriate), t-test (for normally distributed continuous variables) and the Mann–Whitney U test (for non-normally distributed continuous variables, 2 independent samples). b) Then, differences in SRSSDL_ITA subscales, if any at the overall score

level, at the intra-individual level (t-test for paired evaluations), and at the pre- and post-intervention phase were assessed. c) Thereafter, a multi-linear regression analysis was designed and performed to explore the predictive effect of independent variables reporting p b 0.20 (Chao-Yin et al., 2002; Fraas and Drushal, 2004) in the bivariate regression analysis based on simple regression analysis on the dependent variable. The outcome variable was the SDL ability as measured with the SRSSDL_ITA tool in the postintervention phase.

The multi-linear regression model performed was then evaluated in its accuracy and generalisability (Field, 2009). Accuracy was ascertained by analysing residuals and outlier effects. Generalisability was assessed by verifying the normality of the dependent variable distribution (normal p-plot showed that data were lying approximately on a straight line) and assuring the constant variance (scatter plot between

Please cite this article as: Cadorin, L., et al., Enhancing self-directed learning among Italian nursing students: A pre- and post-intervention study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.02.004

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L. Cadorin et al. / Nurse Education Today xxx (2015) xxx–xxx

standardised residual regression and standardised predicted value regression). The statistical independence of the variables and the absence of multi co-linearity between variables were also assured evaluating the correlations. Data regarding tolerance of each independent variable included was N0.2 while the reciprocal of tolerance (VIP) was on average around 1. The statistical significance was fixed at p = .05. Results Participants As reported in Table 2, participants were mainly female (72.1%) and their average age was 21 ± 4.4. Before enrolment in the Bachelor of Nursing Degree, participants had mainly attended lyceum (76.1%) reporting a final score of on average 76.8 (±11.8) out of 100. No significant difference emerged between the control and the treatment groups apart from the clinical nurse-to-student ratio which was always 1:1 among the treatment group and from 1:3 (20; 26.0%) to 1:4 (57; 74.0%) for the control group. In addition, more students belonging to the control group had attended their clinical experience in a medical unit compared with the treatment group (78.9% vs. 63.9%, p = 0.025). SDL Abilities The SDL abilities, in a score ranging from 40 to 200, were on average 150 (± 15.7) in the pre-intervention phase, while, in the postintervention phase, they were on average 157 (± 15.0) (p = 0.000). The treatment group reported an average score of 149 (±15.6) in the pre-intervention phase, and 157 (± 13.8) in the post-intervention, reporting a statistically significant increase of 8 points on average

(p = 0.000). The control group reported, instead, an average score of 153 (± 15.7) in the pre-intervention phase and 158 (± 16.8) in the post-intervention phase, with a statistically significant increase of 5 points on average (p = 0.007). As reported in Table 3, while for the treatment group, a statistically significant increase of the scores has been reported in all factors (p = b.00), excluded that measuring ‘Constructing knowledge’ (p = 0.112), among the control group only for two factors ‘Awareness’ and ‘Learning Strategies’ have the scores increased in a statistically significant fashion (respectively p = 0.015; p = 0.017). Stratifying those students learning in a 1:1 clinical nurse-to-student ratio and those in 1:3 and 1:4, homogeneous average SDL scores emerged in the pre-intervention phase (respectively 149.2 95% CI: 146.2–142.6; 151.1 95% CI: 144.1–158.0; 154.1 95% CI: 159.7–158.4). In the post-intervention phase, statistical differences (p = 0.010) have emerged in SDL scores: for those students learning in a 1:1 clinical nurse-to-student ratio, the average score was 157.5 (95%CI: 155.1– 160.0); for those learning in a 1:3 it was 149.5 (95% CI: 139.7–159.2), while for those in a 1:4 it was on average 161.2 (95% CI: 157.4–159.9).

SDL Abilities Predicting Factors In the bivariate regression analysis reported in Table 4, an increase of one year of age was significantly associated with higher SRSSDL_ITA scores as measured in the pre-intervention phase (p = 0.012), while no association has emerged between age and SDL scores as measured in the post-intervention phase (p = 0.414). Female gender, was significantly associated with higher scores in the post-intervention phase (p = 0.033), while no influence has emerged between gender and pre-intervention scores (p = 0.279). This factor has explained the 2.3% variance in the SRSSDL_ITA scores. Two other factors were

Table 2 Participants characteristics.

Age (average, ±) Gender Female Male Marital status Single Married Secondary school High school Technical school Point of grade secondary school (average,±) Previous university experiences None Completed (with graduation) Abandoned Work experience Before starting the nursing bachelor Yes No During the nursing bachelor Yes No Clinical nurse-to-student supervision ratio1 1:1 1:2 1:3 1:4 Clinical training experience In a medical ward

Total n = 201 (%)

Control group n = 77 (%)

Treatment group n = 124 (%)

MW/χ2 P-values

21 ± 4.4

21 ± 2.5

22 ± 5.2

0.07a

145 (72.1) 56 (27.9)

55 (71.4) 22 (28.6)

90 (72.6) 34 (27.4)

χ2 0.31 0.85

192 (95.5) 9 (4.5)

76 (98.7) 1 (1.3)

116 (93.5) 8 (6.5)

χ2 2.94 0.86

153 (76.1) 48 (23.9) 76.8 ± 11.4

56 (72.7) 21 (27.3) 77.0 ± 12.0

97 (78.2) 27 (21.8) 76.0 ± 11.1

χ2 0.70 0.37 0.64a

117 (58.2) 13 (6.5) 71 (35.3)

47 (61.0) 5 (6.5) 25 (32.5)

70 (56.5) 8 (6.5) 46 (37.0)

χ2 0.46 0.79

99 (49.2) 102 (50.8)

29 (37.6) 48 (62.4)

70 (56.5) 54 (43.5)

χ2 5.91 0.01

37 (18.4) 164 (81.6)

14 (18.1) 63 (81.9)

23 (18.5) 101 (81.5)

χ2 0.00 0.99

124 (61.7) 0 (–) 20 (10.0) 57 (28.3)

0 (–) 0 (–) 20 (26.0) 57 (74.0)

124 (100)

χ2201.00 0.000

138 (69.7)

69 (78.9)

78 (63.9)

χ2 4.997 0.025

a

Mann–Whitney U test. Clinical nurses in charge as clinical mentor supervising the students at the bedside, were expert RNs working for N3 years as full-time nurses; they were experienced in clinical tutorship in both degree courses, having already received the responsibility of students in their 1st year for the last three years. 1

Please cite this article as: Cadorin, L., et al., Enhancing self-directed learning among Italian nursing students: A pre- and post-intervention study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.02.004

L. Cadorin et al. / Nurse Education Today xxx (2015) xxx–xxx

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Table 3 SDL abilities as measured with SRSSDL_ITA tool: pre- and post-intervention scores. Total participants n = 201

Control group n = 77

Treatment group n = 124

Factors (min–max score), average, ±

Pre

Post

P-value1

Pre

Post

P-value1

Pre

Post

P-value1

Factor 1 awareness (7–35) Factor 2 attitudes (8–40) Factor 3 motivation (6–30) Factor 4 learning strategies (5–35) Factor 5 learning methods (4–20) Factor 6 learning activities (4–20) Factor 7 interpersonal skills (4–20) Factor 8 constructing knowledge (2–10) Total Score (40–200 average, ±) min–max

26 ± 3.8 31 ± 3.7 22 ± 3.5 19 ± 2.6 13 ± 2.3 15 ± 2.9 14 ± 3.0 6 ± 2.0 150 ± 15.7 94–194

28 ± 3.4 32 ± 3.4 23 ± 3.4 19 ± 3.1 14 ± 2.6 16 ± 2.6 15 ± 2.9 7 ± 1.9 157 ± 15.0 104–195

0.000 0.000 0.000 0.000 0.000 0.023 0.000 0.112 0.000

27 ± 4.1 32 ± 3.4 22 ± 3.6 19 ± 2.7 13 ± 2.6 15 ± 3.2 14 ± 3.4 7 ± 2.0 153 ± 15.7 113–194

28 ± 3.5 33 ± 3.5 23 ± 3.4 19 ± 3.5 14 ± 2.6 15 ± 2.9 15 ± 3.2 7 ± 1.8 158 ± 16.8 104–195

0.015 0.084 0.062 0.017 0.343 0.620 0.115 0.209 0.007

26 ± 3.6 31 ± 3.7 21 ± 3.3 18 ± 2.6 13 ± 2.1 15 ± 2.8 14 ± 2.7 6 ± 2.0 149 ± 15.6 94–188

27 ± 3.3 32 ± 3.3 23 ± 3.5 19 ± 2.7 13 ± 2.6 16 ± 2.4 16 ± 2.6 7 ± 2.0 157 ± 13.8 120–190

0.000 0.000 0.000 0.002 0.000 0.005 0.000 0.287 0.000

1

t-test for intra-individual paired evaluations.

significantly associated with post-intervention phase SRSSDL_ITA scores: the SDL scores reported by students in the pre-intervention phase and having attended their clinical training in a medical ward, which explained respectively 29.8% and 3.2% of the variance in the SRSSDL_ITA scores. The multi-linear regression model (Table 5) has explained the 38.7% (adjusted R2 scores 36.8%) of the SRSSDL_ITA scores variance. The factors associated significantly were the initial SDL scores as measured in the pre-intervention phase, having received a more intensive and structured tutorial intervention, and having received a lower supervision by the clinical tutor (clinical nurse-to-student ratio 1:4). The main effects were documented for lower clinical nurse-to-student ratio (standardised coefficients beta: 2.874) and for more intensive and structured tutorial intervention (standardised coefficients beta: 2.741) while of less importance were the SDL abilities as measured in the pre-intervention phase (standardised coefficients beta: 0.556). Having received a more intensive and structured tutorial intervention offered by the university tutors, was also associated with a significant increase of 8.011 SDL points after the intervention, while having received a poor supervision by the clinical tutors (1:4) was also significantly associated with an increase of 9.086 points in SDL abilities. For each increase of one point in the SRSSDL_ITA score, as measured in the preintervention phase, there was an increase of around half a point in the SDL scores (unstandardised coefficients beta: 0.550) after the intervention. Discussion Participants A pre–post intervention non-equivalent control group design evaluating the effects of a complex intervention composed of several

components interacting with each other (Anderson, 2008) was conducted in two Bachelor of Nursing Degree admitting students with a demographic profile similar to that documented in previous Italian nursing education studies (Dante et al., 2013). The complex intervention applied to the treatment and control group was based upon the literature available and upon on the standards assured in the Bachelor's during the last three years: therefore, any change was procured by the research project, characterising this pre–post intervention study design as pragmatic in nature (Craig et al., 2012), capturing the differences in the real word. Some differences have affected homogeneity between the treatment and control groups involved: work experience before starting the Bachelor's was more often documented among students receiving the intervention which may have encouraged students to be more independent in SD. The first clinical experience in a medical ward was instead mostly reported by the control group, where the clinical conditions of the patients may have stimulated the critical thinking of students, which is after all the basis of SDL (Chan, 2013). According to the standard of the degrees involved, the clinical nurseto-student ratio was also different between groups and also within the control group: while in the treatment group, students were always supervised by one clinical tutor, in the control group there were two different clinical nurse-to-student ratios: 1:3 and 1:4, meaning that respectively three and four students were supervised in the same period by the same clinical tutor. Students followed by one clinical tutor, devoted to nursing care and to clinical teaching, have received an intensive clinical teaching, shadowing the clinical nurse and progressively developing autonomy (Chuan and Barnett, 2012). On the other hand, a group of three or four students attending the same academic year, supervised by one clinical tutor, were less exposed to clinical nurse supervision; they had the opportunity to develop stronger relationships with each other and with other clinical nurses, searching for learning opportunities by themselves, and activating different strategies.

Table 4 Factors influencing pre and post-intervention SRSSDL_ITA scores: simple linear bi-variate analysis. Pre-intervention

Age (years) Female Marital status: Single Technical secondary education Final point grade secondary education (from 70 to 100) With previous university experience vs. no With previous work experience vs. no With current work experience during Bachelor of Nursing Degree vs. no Exposed group vs. control Lower clinical nurse-to-student supervision ratio 1:4 SRSSDL_ita score obtained in the pre-intervention phase (40–200) Clinical training in medical vs. surgical unit

Post-intervention

Unstandardised coefficients B

P-value

R2

Unstandardised coefficients B

P-value

R2

0.178 0.077 0.096 −.043 0.048 −.011 −.128 −.136

0.012 0.279 0.177 0.546 0.501 0.879 0.071 0.059 0.595

0.032 0.006 0.009 0.002 0.002 0.000 0.017 0.019 0.001

0.058 0.151 0.115 −.068 0.070 0.058 −.060 −.430 .106 .105 0.546 0.180

0.414 0.033 0.103 0.339 0.331 0.410 0.400 0.552 0.134 0.137 0.000 0.011

0.003 0.023 0.013 0.005 0.005 0.003 0.004 0.002 0.010 0.011 0.298 0.032

Please cite this article as: Cadorin, L., et al., Enhancing self-directed learning among Italian nursing students: A pre- and post-intervention study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.02.004

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Table 5 Multi-linear logistic model: factors affecting the SDL score as measured in the post-intervention phase.

Costant Female Lower clinical nurse-to-student supervision ratio 1:4 Clinical training in medical vs. surgical unit Marital status: Single SRSSDL_ita score pre-intervention phase (40–200) Treatment group vs. control group R R2 Adjusted R2

Unstandardised coefficients

Standardised coefficients

B

β

66.715 3.649 9.086 1.399 −3.488 .550 8.011 .622 .387 .368

SDL Abilities On average, after 200 h of clinical experience representing the first contact with patients and nursing care, an increase of 7 points (on a scale from 40 to 200) was documented at the overall level. While in the treatment group there was a significant average increase of 8 points, in the control group the average increase documented was 5 points. The increase in SDL abilities seemed to proceed rapidly, in particular in the group exposed to a more intensive and structured tutoring, but no previous data is available to compare these findings. Both groups were homogeneous in the factor ‘Constructing knowledge’, which has reported no significant increase in the postintervention phase: the factor measures the cognitive disposition to build knowledge in an active and autonomous manner, which is mainly improved by the adoption of conceptual maps (Cadorin et al., 2013). Possibly, more time is needed to affect this factor, which involves the deep structure of the learning process, and the ways that new information is connected with what has already been learned (Hunter Revell, 2012). Analysing the groups, while a significant increase in the treatment group was observed in several factors (‘Awareness’, ‘Attitudes’, ‘Motivation’, ‘Learning Strategies’, ‘Learning Methods’, ‘Learning Activities’, and ‘Interpersonal Skill’), in the control group only two factors have reported a significant increase in scores (‘Awareness’ and ‘Learning Strategies’). ‘Awareness’, ‘Attitudes’, and ‘Motivation’ factors are considered the prerequisite of SDL reflecting the desire to learn (O'Shea, 2003); on the other hand, ‘Learning Strategies’, ‘Learning Methods’, ‘Learning Activities’, and ‘Interpersonal Skill’ factors include competencies needed to effectively manage SDL (Fisher and King, 2010). Therefore, a highly intensive and structured tutorial intervention seems to affect both the prerequisites and the actual competencies of SDL and to affect SDL abilities more widely, universally increasing the students' autonomy. Exploring differences between students receiving a different clinical nurse-to-student ratio (1:1 vs. 1:3 or 1:4) at the baseline, students were homogeneous in SDL scores. After the intervention, higher scores were obtained by those learning in groups of peers composed of four students supervised by one clinical tutor (on average SDL scores = 161.2, + 7 points), followed by those students learning alone and supervised by one clinical tutor (on average SDL scores = 157.5, +6 points) and by those learning in a group composed of three students (on average SDL scores = 149.5, +2 points). This last group has also reported a substantial stability in the pre–post intervention scores, indicating that no improvements in SDL abilities were reported. While a student supervised by one clinical tutor is probably highly stimulated in learning, the same occurs but in a different manner among students learning with peers and under limited supervision (clinical nurse-to-student ratio 1:4): they probably have to rapidly develop strategies to catch different learning opportunities, to cope with a more complex environment due to less mediation assured by the clinical tutor (Williams, 2004). In this context, students may develop more SDL abilities and adaptability. The lack of improvement in SDL abilities among those students (n = 20) learning

.108 .272 .043 −.048 .556 .259

t

P-value

6.461 1.877 2.874 .719 −.836 9.558 2.741

.000 .062 .005 .473 .404 .000 .007

in intermediate conditions (clinical nurse-to-student ratio, 1:3) may be related to the personal characteristics of the students or the clinical tutor but also to the learning processes activated in the specific condition. Future research aimed at discovering the learning processes activated in different levels of clinical supervision ratios should be developed in order to understand the differences that emerged. Factors Predicting SDL Abilities In the bivariate analysis, three factors were associated with the post-intervention SDL scores: female gender, SDL abilities at the baseline, and having the first clinical experience in a medical ward. Previous studies developed in the Italian context have documented the influence of female gender (Cadorin et al., 2012) although data regarding the role of gender are still debated in the international literature (Roberson and Merriam, 2005; El-Gilany and El Sayed Abusaad, 2013) and should be considered with caution in this study because the participants were mainly females. For each increased point in SDL abilities at the baseline, students are more likely to increase SDL abilities during the clinical experience possibly because they already posses learning resources and strategies to activate facing the challenging clinical environment (Chuan and Barnett, 2012); not lastly, those students attending their clinical experience in a medical ward, where the complex conditions of the patients are more challenging, which might stimulate students in a more intensive manner, compared with those students attending their clinical experience in a surgical ward where standard approaches are more common, have reported higher SDL scores. In the multi-linear regression model, which has explained the 38.7% of the SRSSDL_ITA scores variance (or 36.8 as Adjusted R2 square), three factors have remained associated with the SDL abilities increasing after the intervention. While a marginal contribution have reported by the SDL abilities scores as reported at the baseline, two other factors which apparently work in a paradoxical manner, have significantly affected the post-intervention SDL scores: those students having received a highly structured and intensive tutorial intervention, have increased around 8 points in their SDL abilities with respect to those students not receiving the intervention. Conversely, among the latter students, those learning in a group of four students and receiving less clinical supervision have also reported an increasing SDL scores after the intervention of around none points. Therefore, according to the basic principles of the multiple linear regression analysis (Y = β0 + β1 χ1 + β2 χ2+…), those students with basic level of SDL abilities, receiving higher levels of structured supervision performed by university tutors and learning in a higher clinical nurse-to-student ratio (1:1) have increased scores of 74.726 SDL after the intervention while those students receiving unstructured and less intensive tutorial strategies, and receiving a low clinical to students supervision (1:4) have increased scores of 75.801 SDL. Different plausible explanations should be considered, combining the effect of each singular variable in the context of the clinical learning: a) when students are left more autonomous in the clinical environment,

Please cite this article as: Cadorin, L., et al., Enhancing self-directed learning among Italian nursing students: A pre- and post-intervention study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.02.004

L. Cadorin et al. / Nurse Education Today xxx (2015) xxx–xxx

possibly they have to activate several strategies to cope with the complexity of the settings developing more SDL abilities compared with those students receiving higher or intermediate clinical supervision (1:1 or 1:3); b) possibly, due to the difficulties encountered by clinical nurses in supervising several students (e.g. four), more independent learning was stimulated (Chuan and Barnett, 2012) as well as, more independent learning reinforced by the university tutor who offered a less structured and intensive approach to the same group; c) on the other hand, the clinical tutor supervising one student already receiving a more intensive and structured tutorial strategy by university tutors, may adopt more practical teaching, developing mainly practical ability rather that reflective learning (Kuiper and Pesut, 2004); d) also, university tutors may compensate for the lack of clinical teaching due to the increased workloads in the clinical settings, intervening in both academic and practice learning (Braine and Parnel, 2011), also reducing the gap between theory and practice, and progressively sustaining student independence (Hughes, 2004; Rhodes and Jinks, 2005). The interaction of these factors should be considered in future research. Limitations The study has several limitations: short-term effects were measured and, therefore, studies expanding the time of observation as well as longitudinal studies are recommended. In addition, qualitative studies are also recommended to explore student feedback concerning the interventions and their perceived outcomes on SDL abilities and future lifelong learning. The limitations of the non-equivalent group design adopted (e.g., assignment bias, selection bias, the role of other factors such as history, maturation) (Shaughnessy et al., 2000) should also be considered when evaluating the internal and external validity of the study. No individual characteristics (e.g., learning styles) were evaluated and this may have influenced the results. Conclusion Patients, multi-professional clinical teams and clinical environments need nurses capable of being self-directed learners. With the aim of discovering the progress of SDL abilities after the 1st clinical experience of nursing students at the university level, and the related predictors, a pre-post intervention non-equivalent control group design was adopted. The study has several limitations and should be considered a basis for further studies in the field of enhancing our understanding on the effects of tutorial strategies in the clinical environment. In accordance with the preliminary results that emerged, three main factors are associated with increased SDL scores after the first clinical learning experience: a) having received a less intensive clinical nurseto-student supervision, b) having received a higher level and structured tutorial strategy by university tutors, and c) having reported higher SDL scores before the clinical learning experience. A lower clinical nurse-tostudent supervision (1:4), accompanied by unstructured and not intensive tutorial intervention adopted by university tutors, seems to be equivalent to an intensive clinical supervision (1:1) accompanied by more intensive and structured tutorial intervention activated by university tutors. In contrast, the students receiving an unstructured and not intensive tutorial intervention, and supervised in the wards in a group of three students by the same clinical tutor, have reported no increase in SDL abilities. Our aim was to measure the effects on SDL abilities; therefore, studies analysing the effects of different clinical and university tutorial strategies on the clinical reasoning and critical thinking progression of the students are strongly recommended. Author Contributions All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE: http://www.icmje. org/ethical_1author.html):

7

– substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;

– drafting the article or revising it critically for important intellectual content.

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Please cite this article as: Cadorin, L., et al., Enhancing self-directed learning among Italian nursing students: A pre- and post-intervention study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.02.004