The impact of the learning contract on self-directed learning and satisfaction in nursing students in a clinical setting

1 Academic Member of Pediatrics Nursing Department, School of Nursing & Midwifery, Arak University of Medical Sciences, Arak, Iran.

Neda Fayazi

2 Academic Member of Saveh University of Medical Sciences, Kaveh Industrial Estate Company, Saveh, Iran.

Andrew Fournier

3 College of Doctoral Studies, Grand Canyon University, Phoenix, Arizona, USA.

Ahmad Reza Abedi

4 Academic Member of Traditional and Complementary Medicine Research Center, Department of Medical – Surgical, School of Nursing & Midwifery, Arak University of Medical Sciences, Arak, Iran.

1 Academic Member of Pediatrics Nursing Department, School of Nursing & Midwifery, Arak University of Medical Sciences, Arak, Iran.

2 Academic Member of Saveh University of Medical Sciences, Kaveh Industrial Estate Company, Saveh, Iran.

4 Academic Member of Traditional and Complementary Medicine Research Center, Department of Medical – Surgical, School of Nursing & Midwifery, Arak University of Medical Sciences, Arak, Iran.

This is an open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0), which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.

Abstract

Background: The most important responsibilities of an education system are to create self-directed learning opportunities and develop the required skills for taking the responsibility for change. The present study aimed at determining the impact of a learning contract on self-directed learning and satisfaction of nursing students.

Methods: A total of 59 nursing students participated in this experimental study. They were divided into six 10-member groups. To control the communications among the groups, the first 3 groups were trained using conventional learning methods and the second 3 groups using learning contract method. In the first session, a pretest was performed based on educational objectives. At the end of the training, the students in each group completed the questionnaires of self-directed learning and satisfaction. The results of descriptive and inferential statistical methods (dependent and independent t tests) were presented using SPSS.

Results: There were no significant differences between the 2 groups in gender, grade point average of previous years, and interest toward nursing. However, the results revealed a significant difference between the 2 groups in the total score of self-directed learning (p= 0.019). Although the mean satisfaction score was higher in the intervention group, the difference was not statistically significant.

Conclusion: This study suggested that the use of learning contract method in clinical settings enhances self-directed learning among nursing students. Because this model focuses on individual differences, the researcher highly recommends the application of this new method to educators.

Keywords: Clinical teaching, Learning contract, Self-directed learning, Learning Methods, Training, Autonomous learning, Education, Active learning, self-confidence, Training activity & support, Collaborative learning

↑ What is “already known” in this topic:

Use of new educational methods for improving competence and efficiency of learners is inevitable. The traditional approach in the field of education has numerous deficiencies and shortages and has not been designed according to the active learning involvement.

→ What this article adds:

The use of new learning styles such as LCs in a field setting may lead to SDL. This method nurtures in-depth learning and encourages students to learn independently. As this method focuses on individual differences, theoretical-based learning in adults, and strengthening SDL its implementation is highly recommended for nursing educators.

Introduction

Nursing education places an emphasis on achieving the ultimate goal of education, i.e. competence and efficiency in various aspects and meeting the clients’ care needs (1-3). Several studies have suggested that current nursing education has numerous deficiencies and shortages and might not meet the learning requirements of nursing students (4-7). Therefore, assessing and applying new educational approaches seem necessary (8, 9). During the past decades, educators and instructors have used various approaches to transform the learning procedure to self-directed learning (SDL) methods (10-12). Collaborative learning has been formed according to these efforts and made common in many countries (13). Collaborative learning adapts educational activities with the learners’ needs (14). Thus, students will be responsible for their own learning (15).

Some experts believe that the most important responsibility of the education system in this rapidly changing world and short half-life of knowledge in medical studies is to require educators to establish SDL opportunities in the safe environment of universities rather than provide a plethora of knowledge (16, 17). Moreover, they must provide the necessary facilities and requirements for developing the required skills and take responsibility for change (18, 19). Health care education, which has not been designed according to the active involvement of learning, will not persuade students to take responsibility for their own learning independent of educators and teachers (10). More traditional methods of education will also encounter shortages in preparing professional health team members (20).

The need to change from teacher-centered styles to student-centered styles was a valuable part of the education system for a long time, allowing students to participate in learning experiences. Encouraging the active role of the learner in learning fostered a deeper level of learning and enhanced the self-directed capacity and innovation that eventually increased the self-confidence and pervasive accomplishments of learners (21, 22).

One approach to SDL is a learning contract (LC) (21). Nowadays, in some developed countries, many educators encourage nursing students toward SDL by LCs (23). LCs have allowed much success among nurses in their professional development goals, distance education, and education-based services (24).

Most advocates of the contract learning method emphasize the benefits of individualizing the learning process, which promotes the learner’s independence, develops lifelong learning behaviors, and results in active participation of the learner (25).

LC is a method of learning and a reciprocal arrangement between the instructor and student to achieve educational goals (20). LC is a learner-centered activity that helps students relate what they learn in class with what they see in clinical practice, and this activity may lead to integration of theory and practice (26). Since then, there has been a considerable increase in supporting the benefits of using LCs in nursing education in the literature, many of which are about inducing self-confidence and pervasive possession. However, less literature exists on the reliability rating of LCs (21). LCs can foster the change of power and authority from the instructor to the leaner. Most of the accounted LCs described in various studies are concerned with a more traditional and conventional approach toward LCs, a process which begins with the learners writing down the learning objectives (10, 27). Researchers used many terms to describe LCs, terms, which concentrated on the participation of learners in the learning process. Some of these terms are learning programs, studying plans, learning agreements, and learning recommendations (28).

Various health care professions such as medicine, nursing, and radiology technologists have used LCs (29). Cross has proposed one of the rare studies in this field and suggested that contract learning is an efficient tool for facilitating learning and enhancing students’ clinical experience value (30).

Despite the positive features of LCs, Tsang et al. referred to several issues in running the LCs in the occupational therapy profession in Hong Kong. Many of their learners believed writing LCs were difficult and most of the learners wrote contracts with identical context and content. To pass the courses and ensure a high score, some students wrote objectives with fewer requirements than others (31).

According to Tsang, “negative scores may be due to perceived cultural differences between Western vs. Asian students toward educators.” Tsang found that providing sufficient education by supervisors or clinical seniors, appropriate counseling, and couching for learners might facilitate SDL by LCs and may be a positive experience for the process owners (31). Given the results of the literature review, the present study aimed at identifying the impact of a LC on SDL and the satisfaction of nursing students.

Methods

This study was conducted at Tehran University of Medical Sciences (TUMS) under the following ethical license: # 13895/12-02-90. The researchers used a 2-group experimental study design. The participants included all the nursing students of the same academic year, who have taken the pediatrics apprenticeship course. First, the students completed the demographic characteristic form, and they were then divided into six 10-member groups. All observed trainings and apprenticeship within the education department took place in 9 sessions from 7:30 a.m. to 1:00 p.m. To control any relationship between the groups, the first 3 groups were trained conventionally and the second 3 groups by LCs. The education processes and procedures, course objectives (course plans), scientific references, and literatures were described for the 2 groups. The educators of the 2 groups were comparable in their clinical and teaching experience and interest in the course.

1. Intervention group: The researchers performed a pretest to identify the students’ educational needs according to the educational objectives. A contract was signed between the educator and each of the students based on the test results. In each session, students chose a specific patient based on the educational objectives or lesson plans of that particular session and examined the patient accurately (eg, medical history and physical examinations). Then, the students addressed the test results, diagnostic tests, medications, and all actions made for the patient. Each student separately prepared a patient description in the form of a scenario based on the collected information. Meanwhile, the students accessed the library and the internet when faced with a problem. As this was the students’ first experience with this method, the educator reviewed the students’ achievement rate of daily objectives and tried to guide them accordingly. At the end of the day, the educator asked questions about the patient, induced the students to think, and provided them with the opportunity to solve the problem before the due date. In the second week, the contract could be changed according to the pervasive weaknesses and strengths, if necessary. Students completed 2 questionnaires at the end of the clinical practice.

2. Conventional education group: In this group, researchers provided the same traditional educational methods in a clinical setting such as patient care, nursing processes, and the bedside teaching. Each student was given a patient each day and examined his or her own patient. The educator solved the students’ problems and corrected their incomplete information and scientific issues. Then, a health care and educational plan was made for the patient according to the information collected through physical examinations, the patient’s history, test results, and diagnostic tests.

At the end of the training course, students in both groups completed self-directed and satisfactory inventories. The results were analyzed subsequently by descriptive and inferential statistical methods (dependent and independent t tests) using SPSS 20 for Windows software (SPSS, Inc., Chicago, IL, USA).

Results

The findings of this study revealed that the age range of most participants (78.6%) was 21 to 23, while the overall age range was from 21 to 25. All participants were single. Females comprised 87% (n= 51) of the participants, and 42.4% (n= 25) had an experience of working in a hospital during their undergraduate studies. All participants were single. From the 59 participants, researchers randomly assigned 24 participants to intervention and 35 to control groups.

This study revealed no significant differences between the 2 groups in grade point average (GPA); however, there was a significant difference between the 2 groups in age. Even though findings showed a significant difference between the 2 groups in age, the difference was less than a year and was not functionally significant ( Table 1 ).

Table 1