Queensland University of Technology

School of Nursing

Centre for Health Research

Improving Indonesian Nursing Students’ Self-

Directed Learning Readiness

Djenta Saha
BN, MHA

Submitted for the award of Doctor of Philosophy

May 2006
 KEYWORDS

Educational intervention program

Indonesia

Lifelong learning

Nursing education

Nursing students

Self-directed learning readiness

i
 ABSTRACT

Introduction

The purpose of this study was to improve Indonesian nursing students’ self-directed

learning readiness. An educational intervention program (EIP) was developed,

implemented and evaluated.

Background to the study

Many studies have documented the need for nursing students to be prepared for the

rapidly changing and complex health care environment. Lifelong, self-directed

learning (SDL) has been identified as an important ability for nursing graduates.

However, no study has documented the needs of, or preparation required for, nursing

students to function effectively in the rapidly changing health care system in

Indonesia. The Indonesian diploma nursing schools still use a teacher-centred

approach with little emphasis on a student-centred approach.

Method

The study used a mixed method involving both quantitative and qualitative design.

Simple random sampling was used to select an intervention school and control

school. The sample was 2nd year nursing students with 47 in the intervention group

and 54 in the control group. A pre-post test questionnaire, using the Self-Directed

Learning Readiness Scale (Guglielmino, 1978), was used to collect quantitative data

and focus group discussions (FGD) were used to collect qualitative data regarding

students’ perceptions of SDL prior to and at the completion of study. The

intervention group received an EIP. The Staged Self-Directed Learning Model

(Grow, 1991) and the Teacher Student Control Continuum (D’A Slevin & Lavery,

ii
1991) were used as the organising framework. A self-learning module and learning

plans were used as learning strategies to operationalise SDL concepts alongside

teacher-centred methods. The control group received the existing teacher-centred

methods. At the completion of the intervention, clinical instructors from both the

intervention and control groups participated in FGD to explore their perceptions of

students’ activities during the EIP.

Results

For the majority of students, readiness for SDL was ‘below average’. The mean for

the Indonesian nursing students was significantly lower than established norms

(Guglielmino, 1978). The introduction of SDL concepts through an EIP improved the

level of readiness for SDL in the intervention group from ‘below average’ to

‘average’ compared to the control group who remained in the ‘below average’ range.

Higher SDL readiness was reported by female students and students who completed

the educational intervention.

The FGD before the intervention revealed that students perceived SDL as a ‘self-

activity’. Perceptions of students in the intervention group changed during the EIP

compared to students in the control group. Students in the intervention group viewed

SDL as a ‘process of learning’. Increased self-confidence, incremental learning, and

having direction in learning were identified as benefits of SDL. Knowledge and skills

in SDL, learning materials and communication were identified as important issues

that needed to be improved. Clinical Instructors’ perceptions of students’ clinical

activities confirmed that students in the intervention group were ‘more active’

compared to the control group who were ‘still inactive’.

iii
Conclusion

The study confirmed the expected effect of the EIP on students’ SDL readiness. The

EIP improved nursing students’ readiness for SDL and had a positive impact on

students’ perceptions of SDL. Introducing the concept of SDL through the EIP was

found acceptable by the sample and was deemed feasible to implement within the

Indonesian nursing education system. The study has potential to make a significant

contribution to nursing education in Indonesia by promoting lifelong learning and

SDL in nursing students and in curricula through the development of innovative

curricula and teaching and learning practices. The study also has potential wider

benefit to nursing practice and global health practice.

iv
 TABLE OF CONTENTS

Keywords ............................................................................................................................ i
Abstract.............................................................................................................................. ii
Table of Contents .............................................................................................................. v
List of Tables .................................................................................................................... ix
List of Figures.................................................................................................................... x
Statement of original authorship .................................................................................... xi
Acknowledgements.......................................................................................................... xii
Chapter One ...................................................................................................................... 1
Introduction ....................................................................................................................... 1
1.0 Introduction........................................................................................................... 1
1.1 Background ...................................................................................................... 3
1.1.1 Nursing education in Indonesia..................................................... 3
1.1.2 Diploma Nursing Curriculum........................................................ 5
1.1.3. Nursing education in Central Kalimantan ..................................... 6
1.2 Significance of the study.................................................................................. 8
1.3 Purpose and objectives of the study ................................................................. 9
1.4 Research questions ........................................................................................... 9
1.5 Hypotheses ..................................................................................................... 10
1.6 Overview of methodology.............................................................................. 10
1.7 Definition of key terms .................................................................................. 12
1.8 Structure of the thesis..................................................................................... 13
Chapter Two .................................................................................................................... 15
Literature Review............................................................................................................ 15
2.0 Introduction......................................................................................................... 15
2.1 Overview of teaching and learning ..................................................................... 15
2.2 Students’ approaches to learning ........................................................................ 19
2.3 Self-directed learning.......................................................................................... 22
2.3.1 Definition .................................................................................................. 22
2.3.2 Conceptual model of self-directed learning .............................................. 27
2.3.3 Instructional methods to improve self-directed learning .......................... 36
2.3.3.1 Learning plans ............................................................................. 37
2.3.3.2 Learning module ......................................................................... 42
2.3.4 Measuring self-directed learning............................................................... 45
2.3.4.1 Oddi’s Continuing Learning Inventory (OCLI) .......................... 46
2.3.4.2 Self-Directed Learning Readiness Scale (SDLRS) ..................... 47
2.4 Summary ............................................................................................................. 52

v
Chapter Three ................................................................................................................. 53
Methodology .................................................................................................................... 53
3.0 Introduction......................................................................................................... 53
3.1 Research design .................................................................................................. 54
3.2 Population and sample ........................................................................................ 58
3.3 Sampling technique............................................................................................. 58
3.3.1 Quantitative sampling ............................................................................... 58
3.3.2 Qualitative sampling ................................................................................. 60
3.3.2.1 Student participants ..................................................................... 60
3.3.2.2 Clinical instructor participants .................................................... 61
3.4 Ethical considerations ......................................................................................... 61
3.5 Dependent and independent variables ................................................................ 62
3.6 Instrument ........................................................................................................... 63
3.6.1 Self-Directed Learning Readiness Scale (SDLRS)................................... 63
3.6.2 Demographic questionnaire ...................................................................... 67
3. 7 Procedure of data collection................................................................................ 67
3.8 Pilot study ........................................................................................................... 71
3.9 Educational intervention ..................................................................................... 71
3.10 Data analysis ....................................................................................................... 72
3.10.1 Quantitative data analysis ......................................................................... 72
3.10.2 Qualitative data analysis ........................................................................... 73
3.11 Summary ............................................................................................................. 75
Chapter Four ................................................................................................................... 76
Pilot study ........................................................................................................................ 76
4.0 Introduction......................................................................................................... 76
4.1 Design ................................................................................................................. 77
4.2 Sample................................................................................................................. 78
4.3 Instruments.......................................................................................................... 79
4.4 Procedure ............................................................................................................ 80
4.5 Data analysis ....................................................................................................... 81
4.6 Results................................................................................................................. 82
4.6.1 Demographic characteristics of the pilot sample ...................................... 82
4.6.2 Readiness for self-directed learning.......................................................... 83
4.6.3 Internal consistency................................................................................... 85
4.6.4 Temporal stability ..................................................................................... 86
4.6.5 General comment on the SDLRS.............................................................. 87
4.7 Discussion ........................................................................................................... 87
4.8 Summary ............................................................................................................. 90

vi
Chapter Five .................................................................................................................... 91
Educational Intervention Program ............................................................................... 91
5.0 Introduction......................................................................................................... 91
5.1 Conceptual framework of the Educational Intervention Program ...................... 93
5.2 Overview of traditional curriculum structure ..................................................... 99
5.3 Traditional teaching and learning activities........................................................ 99
5.4 Control group activities..................................................................................... 101
5.5 Overview of intervention group activities ........................................................ 103
5.6 Organisation of Educational Intervention Program .......................................... 105
5.6.1 Step 1: Preparation .................................................................................. 108
5.6.1.1 Workshops................................................................................. 108
5.6.1.2 Skills practice ............................................................................ 117
5.6.1. 3 Body fluid module..................................................................... 119
5.6.2 Step 2: Implementation ........................................................................... 120
5.7 Evaluation of Educational Intervention Program ............................................. 124
5.8 Summary ........................................................................................................... 124
Chapter Six .................................................................................................................... 125
Quantitative Results...................................................................................................... 125
6.0 Introduction....................................................................................................... 125
6.1 Demographic characteristics............................................................................. 126
6.2 Level of readiness for SDL ............................................................................... 129
6.3 Differences in pre-test scores............................................................................ 130
6.4 Impact of the educational intervention program............................................... 132
6.5 Influence of educational intervention and demographic variables ................... 134
6.6 Summary ........................................................................................................... 135
Chapter Seven ............................................................................................................... 136
Qualitative Findings...................................................................................................... 136
7.0 Introduction....................................................................................................... 136
7.1 Data collection .................................................................................................. 136
7.2 Data analysis ..................................................................................................... 139
7.3 Findings............................................................................................................. 142
7.3.1 Students’ perceptions of SDL before the intervention............................ 142
7.3.2 Students’ perceptions of SDL after the intervention............................... 147
7.4 Clinical instructors’ focus group discussions ................................................... 156
7.4.1 Clinical instructors from the control group............................................. 157
7.4.2 Clinical instructors from the intervention group..................................... 161
7.5 Summary ........................................................................................................... 167

vii
Chapter Eight ................................................................................................................ 168
Discussion and Recommendations............................................................................... 168
8.0 Introduction....................................................................................................... 168
8.1 Research Question One..................................................................................... 169
8.2 Research Question Two .................................................................................... 174
8.3 Research Question Three .................................................................................. 175
8.4 Research Question Four.................................................................................... 177
8.5 Research Question Five .................................................................................... 180
8.6 Research Question Six ...................................................................................... 183
8.7 Limitations of the study .................................................................................... 184
8.8 Implications....................................................................................................... 186
8.9 Recommendations............................................................................................. 188
8.10 Conclusion ........................................................................................................ 189
Appendix 1 SDLRS-A............................................................................................... 192
Appendix 2 Demographic questionnaire ................................................................ 197
Appendix 3 Fluid and Electrolyte Balance (Self-directed learning module)....... 198
Appendix 4 Information for participants (pilot study) ......................................... 212
Appendix 5 Information for participants (intervention group) ........................... 214
Appendix 6 Information for participants (control group) .................................... 216
Appendix 7 Consent form ........................................................................................ 218
References ...................................................................................................................... 223

viii
 LIST OF TABLES

Table 2.1 Different approaches to learning................................................... 20

Table 2.2: Staged Self-Directed Learning Model (SSDL) ............................. 33
Table 2. 3: Instruments identified as assessing self-directed learning ............ 45
Table 2.4: Levels of readiness for self-directed learning ............................... 48
Table 3.1: Modification of focus group protocol ........................................... 68
Table 3.2: Student focus group script before intervention ............................. 69
Table 3.3: Student focus group script after intervention ................................ 70
Table 3.4: Clinical instructor focus group script............................................ 71
Table 3.5: Modification of Stages of Thematic content Analysis.................. 74
Table 4.1: Demographic data of pilot sample ................................................ 82
Table 4.2: Means and standard deviations of SDLRS scores at Time 1 ........ 84
Table 4.3: Level of readiness for self-directed learning at Time 1 ................ 85
Table 5.1: Control group activities............................................................... 102
Table 5.2: Intervention group activities ....................................................... 105
Table 5.3: The workshop activities .............................................................. 110
Table 5.4: Stem/guided questions ................................................................ 115
Table 5.5: Skill activities in the nursing laboratory ..................................... 119
Table 5.6 Implementation of SDL concepts................................................ 122
Table 6.1: Frequency of demographic variables of sample.......................... 127
Table 6.2: Demographic differences between intervention and control
groups.......................................................................................... 128
Table 6.3: SDLRS scores at pre-test ............................................................ 130
Table 6.4: Different levels of readiness for SDL at pre-test......................... 131
Table 6.5: Mean and Standard Deviations of SDLRS by group .................. 132
Table 7.1: Themes developed from FGDs before the intervention .............. 143
Table 7.2: Category development from FGDs before intervention.............. 144
Table 7.3: Themes developed from the control group after the
intervention ................................................................................. 148
Table 7.4: The category development from the control group after the
intervention ................................................................................. 149
Table 7.5: Themes developed from the intervention group after the
intervention ................................................................................. 153
Table 7.6: Category development for intervention group after
intervention ................................................................................. 154
Table 7.7: Themes development from control group clinical instructors .... 158
Table 7.8: Category development from control group clinical instructors .. 159
Table 7.9: Themes development from clinical instructor in intervention
group ........................................................................................... 162
Table 7.10: Category development from intervention group clinical
instructors.................................................................................... 163

ix
 LIST OF FIGURES

Figure 2.1: Influence of cultural attitudes to knowledge on teaching and

learning strategies.......................................................................... 17
Figure 2.2: The teacher-student control continuum (TSCC) ........................... 35
Figure 3.1: Research design used in the study................................................. 55
Figure 4.1: Bland-Altman plot for reproducibility of SDLRS Scores............. 86
Figure 5.1: Conceptual framework integrating Staged Self-Directed
Learning (SSDL) and Teacher-Student Control Continuum
(TSCC) .......................................................................................... 94
Figure 5.2: The activities of the educational intervention program............... 107
Figure 5.3: Learning plan format used in this study...................................... 117
Figure 6.1: Graph of SDLRS scores for intervention and control groups at
pre- and post- test ........................................................................ 133

x
 STATEMENT OF ORIGINAL AUTHORSHIP

“The work contained in this thesis has not been previously submitted to meet

requirement for an award at this or any other higher education institution. To the best

of my knowledge and belief, the thesis contains no material previously published or

written by another person except where due reference is made”.

Signature _______________________

Date _______________________

xi
 ACKNOWLEDGEMENTS

The undertaking of this thesis was not a solitary effort. I appreciate all my

supervisors, colleagues, family and friends who helped me in so many ways; without

them this thesis would not have been completed. I wish to gratefully acknowledge

the support and kindness of the following individuals and organisations:

Firstly, I express my deep and sincere thanks to my supervisors Professor Helen

Edwards and Ms. Robyn Nash who encouraged me through the PhD journey. Their

continued guidance, support and critical comments were a source of great

encouragement. Thank you both.

I would like to thank the participants in the study, the nursing schools, staff, nursing

students and clinical instructors. Without their commitment this study would not

have been undertaken. It was a great pleasure and opportunity to work with them.

Thank you to all of you.

I would also like to recognise the financial support given to me by the World Bank

through the Health Professional Project V (HPV). This scholarship was invaluable

assistance to undertake this study.

I would also like to acknowledge and thank the Department of Health Central

Kalimantan Province and Palangkaraya Health Polytechnic for their financial

assistance. This financial assistance was invaluable support to finish my study.

I would like to thank Tina Thornton, Principal Academic Editorial Service for her

hard work towards the editing of this thesis.

xii
Finally, I would dedicate my thesis to my family: my husband E. J. Inso; and my

three loving daughters who were always waiting for their mum to come back home,

Florence Felicia (FF), Joanita Jalianery (JJ) and Maureen Marsenne (MM). Their

unending patience and unwavering belief in my ability to complete this thesis made

me realised how blessed I am.

Djenta Saha

xiii
 CHAPTER ONE

INTRODUCTION

1.0 Introduction

The rapid changes in the health care environment have many implications for nursing

education and nursing practice. Some of the significant changes facing nurses

include the expansion in technology, decreased length of stay in hospitals and the

ageing of the population. More changes are predicted in the coming decades—such

as increasing complexity of modern healthcare, technology prolonging an

individual’s life-span, and the increasing burden of healthcare expenditure

(Boychuck & Duchscher, 1999; Dexter et al., 1997). The rapidity of knowledge

changes have also resulted in knowledge becoming obsolete. Thus, nurses need to

keep learning in response to the rapidly changing healthcare environment so they can

keep abreast of technological changes, expectations of patients and the health care

system (Studdy, Nicol & Fox-Hiley, 1994).

Lifelong learning is important in rapid global changes (OECD, 2000). Self-directed

learning (SDL) is an essential strategy for lifelong learning (Glen, 1999; Harvey,

Rothman & Richards, 2003) and it can be used to prepare students to adapt with

rapidly changing knowledge and technology (Rossi, 2000). There is a growing

acceptance of the relationship between SDL and learners’ ability to cope with

changing knowledge and technology. Nursing educators in developed countries

including Australia, USA, Canada and United Kingdom have already adopted SDL

in their teaching and learning approaches, and have used a range of technologies in

learning, such as e-learning.

1
Many authors in nursing education state that nursing students today are not only

required to know more about a topic, but this information will change within the

period that they complete their formal learning. Nursing graduates will work in many

different situations and contexts during their professional careers. Furthermore, the

role of nurses increasingly requires that they are able to critically reflect and apply

their knowledge in different ways, in response to changing technology and healthcare

contexts (Fisher, King & Tague, 2001; Hewitt-Taylor, 2002; Iwasiw, 1987; Levett-

Jones, 2005; Lunyk-Child, et al., 2001; McAllister, 1996; Nicol & Glen, 1999,

O’Shea, 2003; Regan, 2003; Williams, 2004).

Rapid changes in the health care environment have forced the Indonesian

government to make changes in health care regulations—nursing is no exception.

The minimum standard for nursing entry to practice in the health care system in

Indonesia is diploma level. The Indonesian government is committed to increasing

the quality of nursing care through improvements in nursing education. The health

services need nurses with quality knowledge and skills who are able to cope with the

increasing complexity of health care (Health Professional Project V, 1998). Thus,

nursing education must provide students with a firm foundation for lifelong learning

on which nurses can continue to build throughout their professional careers.

However, at present there is a gap between nursing education and health care needs

because the improvement in the nursing educational level has not been followed by

improvement in the quality of teaching and learning. Although nursing education in

developed countries has adopted SDL in teaching and learning approaches, the

teaching and learning in nursing education in Indonesia has not adapted to changes

and developments. Traditional methods of teaching and learning are predominantly

2
used in all diplomas in nursing education in Indonesia. These methods of teaching

and learning do not prepare students to meet rapidly changing scientific and

technological advances in health care (Health Regional Office of Central

Kalimantan, 1998). Thus, the challenges for nursing education in Indonesia,

specifically in Central Kalimantan, are to prepare nursing students to be professional

nurses who can meet the increasing complexity of health care demands.

This chapter provides an overview of the background and significance of the study,

followed by the purpose and objectives of the study. Research questions and

hypotheses are then presented and an overview of the methodology is provided with

the definitions of key terms. The structure of the thesis is outlined at the end of the

chapter.

1.1 Background
1.1.1 Nursing education in Indonesia
Nurses comprise the largest health worker category in Indonesia, accounting for

roughly 44 per cent of health staff in government hospitals, 35 per cent in health

centres and sub health centres and 39 per cent in private hospitals. Approximately

113,000 nurses work in government hospitals, health centres and sub health centres

(World Bank, 1994). Around 50 per cent of Indonesia’s nurses graduate from

‘Sekolah Perawat Kesehatan’ (a three-year basic nursing course at senior high school

level), which they enter following completion of junior high school. This three-year

basic nursing program was initiated in 1975 as the successor to diverse training

activities that produced over 20 different types of nurses.

Until 1997 there were three types of nursing education in Indonesia, namely:

3
 • The Bachelor of Nursing (tertiary degree): this is a four-year nursing course

that students enter from senior high school and is offered at selected

government universities in Indonesia. Admission is based on a national

examination and all the bachelor programs use the same core curriculum. The

Bachelor of Nursing degrees were established in 1985 and they are

administered by the Department of Education and Culture. The graduates of

bachelor nursing courses account for 10 per cent of the nursing workforce

(Pusdiknakes, 1997).

• Diploma nursing program: this is a three-year nursing course that is conducted

in schools of nursing and students come from senior high schools. The

diploma nursing program was initiated in 1965 and most nursing schools are

in the large cities and regional capitals. Graduates from the diploma of nursing

are the second largest group of nurses and account for 40 per cent of all

nursing graduates. Diploma nurses are heavily concentrated in hospitals

throughout Indonesia, including private hospitals (Pusdiknakes, 1997).

• Secondary high school level school of nursing: this is a three-year nursing

course, which students enter from junior high school. Students from the course

account for 50 per cent of nurses in Indonesia (Pusdiknakes, 1997).

In 1997 minimum educational standard for nursing entry to practice was established

as the diploma of nursing. Consequently, all nursing schools offering below diploma

level education were upgraded to offer diploma level courses by 1997, so currently

only two types of basic nursing education exist in Indonesia. These are: Bachelor of

Nursing and Diploma of Nursing.

4
The education within the Diploma of Nursing aims to produce graduates who fulfil

the need for beginning professional nurses and who are able to have a rational,

professional and ethical attitude in the implementation of nursing care. Graduates of

the diploma of nursing are expected to be able to fulfil the demands and needs of the

community for qualified nursing care, to function as sources of information and to be

able to compete in the era of globalisation (Pusdiknakes, 2002, p.2). Thus, diploma

nursing education is now expected to produce nurses who can function effectively

and efficiently in health care settings. The nursing education that is discussed in this

chapter relates to the diploma level of nursing education.

1.1.2 Diploma Nursing Curriculum

All diploma nursing programs in Indonesia are based on a national nursing

curriculum for diploma nursing courses. The content of the diploma nursing

curriculum is 80 per cent of the national content, which means that all nursing

schools in Indonesia provide the same content and 20 per cent of local content so

each school can provide different content depending on local/regional needs. The

diploma nursing curriculum document states that the curriculum is guided by the

goal of national education, rules, norms and ethics of science, community needs, and

considerations of personal interest, capability and initiative (Sister School project,

2002). The diploma nursing curriculum is used for all nursing education in

Indonesia, including Central Kalimantan. The aim of the specification is to

standardise nursing education to a certain level throughout the country (Pusdiknakes,

2002, p.1).

The diploma nursing curriculum is a very specific document that describes the

number of credit points, subjects, objectives and structure of the courses. This

curriculum is six semesters in length and consists of 40 subjects. There are no

5
elective subjects and every semester has a different number of subjects. The first

semester comprises nine subjects, the second semester consists of nine subjects, the

third semester comprises five subjects, the fourth semester contains five subjects, the

fifth semester comprises seven subjects, and the last semester consists of five

subjects (Pusdiknakes, 2002). The subjects in the nursing curriculum can be divided

into three major areas: supporting theoretical science, professional nursing subjects,

and clinical nursing subjects (Sister School Project, 2002). Each nursing subject is

divided into a number of topics and skills to learn.

The semesters are 20 weeks in duration, including the examination period. The

semesters are structured such that the first two semesters have a higher theoretical

load than clinical load, with students spending about six to eight hours a week in

clinical learning. However, much of the clinical learning in these two semesters

occurs in the laboratory. In the third and fourth semester the clinical load begins to

increase (20 hours theory compared to 15 hours of clinical learning) and by the fifth

and sixth semester the majority of the student activity is clinical learning (25 hours a

week) compared to 10–12 hours of theory per week. Much of the theory is given

prior to the clinical component.

1.1.3. Nursing education in Central Kalimantan

There are four nursing schools in Central Kalimantan: Palangkaraya nursing school

(funded by the central government), Eka Harap nursing school (private nursing

school), Sampit nursing school (funded by the local government), and Kuala Kapuas

nursing school (funded by the local government). All these nursing schools offer a

diploma level program.

6
According to the Sister School Project (2002, p.15), the implementation of the

diploma curriculum at nursing schools in Central Kalimantan, Indonesia, appears to

have minimal emphasis on clinical judgment, self-directed learning and application

of theory to practice in individual subject descriptions. The teaching at schools of

nursing in Central Kalimantan also appears to be teacher-centred rather than student-

centred. Lectures as a method of teaching and learning are used almost exclusively in

all teaching and learning activities. Although self-directed learning (SDL)

approaches are used as a framework for the Indonesian diploma nursing curriculum,

this emphasis does not translate directly into particular curricula requirements. The

application of the general principles of SDL is not in actual practice. The

interpretation and application of SDL approaches is dependent on individual nursing

schools. However, most nursing schools in Indonesia, especially in Central

Kalimantan, are using traditional patterns of nursing education that is teacher-centred

approaches focusing on the transfer of knowledge.

It is assumed that the basis behind teachers and students in Central Kalimantan who

do not use SDL methods is that they have not been introduced to, or prepared for,

SDL. In Indonesia, most teachers in nursing education can communicate only in the

official language of the country and therefore to explore professional innovation in

nursing education beyond the country’s borders depends on translated information

being available. This influences the diploma nursing education courses to continue

applying traditional approaches. It relies on presenting factual information using a

rigid curriculum (developed at a national level). In Indonesia and in Central

Kalimantan students have only been exposed to teacher-directed learning in their past

and current studies, and the teachers have only used traditional teaching approaches

within curriculum constraints.

7
McAdams, Rankin, Love, and Paton (1989) state that this type of teaching may have

been justifiable in an era of limited technology gradual change and relative stability.

However, the times have already changed, and today students must possess skills to

achieve knowledge under rapidly changing conditions where knowledge quickly

becomes obsolete.

It seems that teachers take the responsibility for students’ learning and students only

achieve a superficial understanding; as a result students are passively waiting to be

taught (Health Regional Office of Central Kalimantan, 1998). It is likely that nursing

education in Central Kalimantan has failed to prepare students to become

professionals capable of working in a rapidly changing health care environment by

continuing to use predominantly traditional teaching approaches.

As Central Kalimantan nursing education wants their students prepared as

successfully as those within western nursing education systems, significant

improvements are needed in teaching and learning approaches. These are needed to

better prepare students to be professional nurses and to meet the needs of the

community for quality nursing. Introducing SDL approaches in nursing education in

Central Kalimantan has been chosen as the focus of this research as it has not yet

been applied in everyday teaching and learning activities in nursing courses.

1.2 Significance of the study

To date, no research has been done to improve nursing students’ self-directed

learning readiness in Indonesia. This study will be useful in two ways. The study is

significant for nursing students because an educational intervention program will

assist students to be more active in their learning. It is assumed the students will take

more responsibility for their own learning and that this will benefit their professional

8
and personal development. This study is significant also for nursing schools in

Central Kalimantan, as a cultural change is needed and will be introduced through

the study. The nursing school culture has been providing ‘factual knowledge’ and it

uses rote learning techniques. Clearly, a shift to more contemporary and life-long

learning strategies is required.

1.3 Purpose and objectives of the study

The primary purpose of the study is to improve readiness for self-directed learning in

nursing students in Central Kalimantan, Indonesia.

The objectives of the study are to:

1. Examine nursing students’ perceptions of self-directed learning;

2. Determine nursing students’ level of readiness for self-directed learning;

3. Identify factors affecting students’ readiness for self-directed learning;

4. Examine the impact of an educational self-directed learning program on

nursing students’ readiness for self-directed learning;

5. Examine clinical instructors’ perceptions of nursing students’ clinical

activities during the educational self-directed learning program.

1.4 Research questions

The research questions for the study were:

1. What were students’ levels of readiness for self-directed learning (SDL)

before the educational intervention, as measured by the Self-Directed
Learning Readiness Scale (SDLRS)?

2. Was there a difference in students’ readiness scores for SDL between the
intervention and control groups?

9
 3. Was there a difference in students’ readiness scores for SDL following the
educational intervention?

4. What factors contributed to students’ readiness for SDL?

5. What were the students’ perceptions of SDL before and after the educational
intervention?

6. What were clinical instructors’ perceptions of students’ clinical activities

during the educational intervention?

1.5 Hypotheses
In order to answer the research questions, the study set out to test the following

hypotheses that were developed from the first four research questions:

• Hypothesis 1: The students’ level of readiness for SDL as measured by

SDLRS would be lower than established group norms (Guglielmino, 1978).

• Hypothesis 2: There would be no significant difference between the

intervention and control group SDLRS scores at pre-test.

• Hypothesis 3: Self-directed learning readiness scores of students who

participated in the educational intervention program over fourteen weeks

would be significantly increased compared to scores of students who did not

participate.

• Hypothesis 4: Variables such as group (intervention-control), gender, birth

order, father’s educational background and mother’s educational background

would significantly contribute to students’ readiness for SDL.

1.6 Overview of methodology

A non-equivalent control group, pre-post test design was used in the study. The study

involved a pilot and the main study. The pilot study aimed to evaluate the Self

10
Directed Learning Readiness Scale (SDLRS) that was used in the main study. It was

piloted to test it in an Indonesian setting, to trial recruitment methods and to identify

students’ level of readiness for SDL. The length of time it took to administer the

SDLRS was noted. In addition, any issues such as ambiguity and misinterpretation of

the SDLRS were also noted. Participants for the pilot study came from a different

nursing school to the main study. There was 54 second-year students who

participated in the pilot study.

Participants for the main study were all students in the second year of a nursing

diploma course from two selected nursing schools in Central Kalimantan. One of

these nursing schools became the “intervention school” and the other was the

“control school”. There was 101 second-year students who participated in the main

study. Second-year students from the intervention school participated in an

educational intervention program designed for this study.

The educational intervention program (EIP) comprised four days of workshops, four

days of clinical skills’ practice in the nursing laboratory, and a 12-week

implementation period. Participants were asked to attend three tutorial meetings

during the implementation period at weeks three, six, and nine. Students from both

the intervention and control schools were asked to complete a pre-test prior to

commencement of the study and post-test questionnaires after the study finished.

Data were summarised using SPSS® version 12.

Focus group discussions (FGD) were conducted pre and post intervention for

students. Focus group discussion for clinical instructors was conducted after the

intervention for both groups. Qualitative data from FGD were content analysed using

11
Burnard’s guidelines (Burnard, 1991). The details of the methodology are presented

in Chapter Three.

1.7 Definition of key terms

For the purpose of this study, the following terms needed to be clearly defined, both

conceptually and operationally. They are: self-directed learning, educational

intervention program, and readiness for self-directed learning.

Self-directed learning:

Conceptual definition: “Self-directed learning is a process in which the learner takes

the initiative in diagnosing his/her learning needs, formulating goals, identifying

human and material resources, and evaluating learning outcomes. This may be done

with or without the help of others” (Knowles, 1975, p.18).

Operational definition: Self directed-learning was a process by which second-year

nursing students in Central Kalimantan who participated in the study took initiative

for their own learning, with or without the help of others, by identifying their

learning needs, formulating goals, resources and evaluating learning outcomes.

Readiness for self-directed learning

Conceptual definition: Readiness for self-directed learning is the degree (to which)

the individual possesses the attitudes, abilities and personal characteristics necessary

for self-directed learning (Wiley, 1983, p.182).

Operational definition: Readiness for self-directed learning was the degree (to

which) the second-year nursing students possessed the attributes of self-directed

learning as measured by the self-directed learning readiness scale (SDLRS).

12
Educational intervention program

Conceptual definition: an educational intervention program is a planned process to

modify attitudes, knowledge, skills or behaviour through a learning experience to

achieve effective performance in an activity or range of activities (Smith, 1992, p.2)

Operational definition: The educational intervention program was the planned

process to improve the knowledge, skills and attitudes for self-directed learning of

second-year nursing students in Central Kalimantan.

1.8 Structure of the thesis

Chapter One has given an overview of the teaching and learning approaches in

nursing education in Indonesia and Central Kalimantan. The diploma nursing

curriculum used in Central Kalimantan was outlined. The significance of the study to

nursing education has been outlined and the research questions, hypothesis, aim and

objectives of the study have been presented.

Chapter Two reviews the literature on self-directed learning. Teaching and learning

approaches relevant to SDL are presented and intervention studies in SDL in nursing

education are highlighted. Definitions of SDL are presented, as well as conceptual

models of SDL and teaching strategies. Instruments to measure SDL are also

presented.

Chapter Three outlines the methodology used in the quantitative and qualitative part

of the study. SDLRS and demographic questionnaires were used to collect

13
quantitative data. Chapter Three develops the conceptual framework grounded in the

Staged Self-Directed Learning model (SSDL) developed by Grow (1991) and

Teacher-Student Control Continuum model (TSCC) developed by D’A Slevin and

Lavery (1991) to operationalise the educational intervention. Focus group

discussions were used to provide qualitative data to improve understanding about

participants’ perceptions of self-directed learning.

Chapter Four presents the pilot study, which was conducted to determine relevant

information to ensure the feasibility and appropriateness of the method and tools for

the main study. Chapter Five describes the educational intervention program which

was developed to increase nursing students’ SDL readiness in Central Kalimantan,

Indonesia. Chapter Six presents the results from the quantitative data and Chapter

Seven presents the qualitative data—both of these results are discussed in Chapter

Eight. Limitations of the current study are also outlined in Chapter Eight as well as

recommendations from the study. It also highlights the implications for nursing

education, and future research.

14
 CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

Many authors state that culture has influenced teaching and learning approaches

(Ballard & Clanchy, 1997; Biggs, 1999a; Ramsden, 2003). Self-directed learning

(SDL) was the method of learning that was introduced into nursing education in

Central Kalimantan to improve nursing students’ readiness for self-directed learning.

The concept of self-directed learning was formulated in western culture and has been

widely used in English-speaking countries, where the educational system and cultural

background is different from that of Indonesia. It is, therefore, important to review

the concept of teaching and learning and to assess the perception of teaching and

learning within the Indonesian context. This chapter begins with an overview of

conceptions of teaching and learning followed by a description of student approaches

to learning. Definitions of self-directed learning are presented and a conceptual

model of self-directed learning is discussed. The literature review focuses on two

instructional strategies utilised to develop self-directed learning in nursing students

in Central Kalimantan. The characteristics of instruments most frequently used to

assess self-directed learning are also discussed. The chapter concludes with a

summary.

2.1 Overview of teaching and learning

The aim of teaching is simple—to enable students to learn—and teaching always

involves attempts to change students’ understandings (Ramsden, 2003). Ramsden

further states that learning occurs because of what the students do, and that skilled

15
teaching and the design of teaching and learning activities can encourage student

activity. According to Merriam (1993), learning includes concept knowledge and

behaviour changes. However, attitude to knowledge influences individual teachers

about what teaching is, and what learning is (Ballard & Clanchy, 1997). Assumptions

about what learning is, and how it occurs, will influence the selection of activities

teachers use to facilitate their students’ learning. According to Biggs (1999b),

teaching influences students’ approaches to learning.

Ballard and Clanchy (1997) state that knowledge and learning vary along a

continuum (Figure 2.1). At one end of the continuum, knowledge is seen as a

relatively fixed and circumscribed form of ‘wisdom’ and learning is about

conserving and transferring the wisdom. Teachers who perceive that knowledge is

fixed will view teaching as the transmission of information and skills. This form of

teaching encourages students to memorise and simply replicate the knowledge

provided by teachers. Both the students and the teachers perceive the teacher as the

exclusive or main source of knowledge. This certainly leads to a teacher-centred

approach.

At the other end of the continuum, knowledge is not bounded but is constantly being

created. Learning in this context is seen as an extension and applying of knowledge

in new and different ways. Ballard and Clancy (1997) make the point that those

teachers who place a greater emphasis on knowledge creation will perceive problem

solving, critical thinking and reflection to be of greater importance than simple

imitation and replication. Those teachers also perceive self-directed learning to be

essential and will encourage students to question and to seek out sources of

16
 information and knowledge for themselves. Teachers who adopt this approach are

more likely to encourage a student-centred approach.

. Attitude to knowledge Conserving Extending

Learning approaches Reproductive Analytical Speculative

Teaching Role of teacher Almost exclusive source of: Coordinator of learning More experienced colleague
strategies Knowledge recourses & collaborator
Direction/guidance Questioner, critical guide, Preliminary critic & adviser
Assessment gadfly patron
Principal source of assessment

This figure is not available online.

Please consult the hardcopy thesis
available from the QUT Library

.
Source: Ballard & Clanchy (1997, p. 12)

Figure 2.1: Influence of cultural attitudes to knowledge on teaching and learning

strategies

17
According to Ballard & Clanchy, many Asian cultures place greater emphasis on the

conserving attitude to knowledge than western culture. Indonesia has emphasis on

conserving attitude to knowledge.

Biggs (1999b) and Ramsden (2003) state that if learning is perceived to be a

qualitative change in students’ understanding of a subject that such students are able

to understand important concepts, and their related facts and procedures in the

subject. For the purpose of this study definition of learning was adopted from Biggs

and Ramsden that students are able to relate concepts, organise principles, integrate

information and skills, and apply this to new and different situations.

According to Nicol and Glen (1999) new nursing knowledge is being created at an

increasingly rapid pace. Long and Barnes (1995) stated that the emphasis in nursing

education internationally has changed from the simple transfer of knowledge to

students having the skills to extend and apply their knowledge, and to become

lifelong independent learners. These skills are necessary because of the rapid

innovations in health care and increased access to information. Teaching and

learning activities should encourage nursing students to problem solve, critically

analyse, make clinical decisions based on evidence and evaluate those decisions

(Nicol & Glen, 1999). Students should be encouraged to identify their own learning

needs and be able to find sources of information and knowledge. The teacher is not

the only source of information. Many other sources, such as written resources,

experts in the clinical field, patients, colleagues, the internet, and their own

experience should also be used (Sister School Project, 2002).

18
2.2 Students’ approaches to learning

Student factors such as attitude, motivation, and experience can influence their

approaches to learning (Ballard & Clanchy, 1997; Biggs, 1999b; Ramsden, 2003).

Learning research has identified two main types of approaches students adopt when

they attempt to learn new information and skills. These approaches have been

described as ‘deep’ and ‘surface’ According to Ramsden (2003), students are more

likely to take a surface approach to learning when they have an intention only to

achieve a minimal pass, have insufficient time to learn, are unclear about the

requirements of a course and think that rote learning will be enough to pass. In

contrast, students are more likely to take a deep approach to learning when they have

intention to engage meaningfully, have the necessary background knowledge about

subject materials, and have the ability to work conceptually and to make abstract

connections. Furthermore, Biggs (1999b) and Ramsden (2003) cite research that

indicates that students who look for deeper understanding and meaning and

connections in their methods for learning will have better learning outcomes, are

more able to understand scientific conceptions and get higher academic grades than

students who simply memorise and replicate the information with which they are

provided.

A student’s approach to learning is not only influenced by individual characteristics

but it can also be modified by curriculum and teaching/learning approaches in which

learning occurs. Research also indicates that course design can influence the

approach students have to learning (Ballard & Clanchy, 1997; Biggs, 1999a; Biggs,

1999b; Ramsden, 2003). For example, high course contact hours and excessive

amounts of course materials can mean the students lack the opportunity to pursue the

19
 subject in depth. By contrast, subjects whose coordinators have identified the need

and motivation for learning provide clear goals and have a well-linked and structured

knowledge base, give students choice and control over learning. It has also been

found that providing students with interaction with peers is a factor that can facilitate

a deep approach to learning (Ramsden, 2003).

Ramsden (2003) states that while the inherent ability of the student cannot be

changed; teachers can influence student motivation, expectation and experience to

encourage them to have a deep approach to learning. Teachers can facilitate students

to take deeper approaches to learning when they provide teaching and learning

activities that encourage students to take such an approach. The difference between

deep and surface approaches to learning is shown in Table 2.1.

Table 2.1 Different approaches to learning

.
Deep approach Surface approach
Intention to understand Intention only to complete task requirement
Student maintains structure of task Student distorts structure of task

This table is not available online. • Focus on ‘the signs’

• Focus on ‘what is signified’
Please consult the hardcopy thesis
• Relate previous knowledge to new knowledge • Focus on unrelated part of the task
available from the QUT Library
• Relate knowledge from different course
• Relate theoretical ideas to everyday
experience
• Relate and distinguish evidence and argument
• Organise and structure content into a coherent
whole
• Internal emphasis: ‘A window through which
aspects of reality become visible, and more
intelligible’ (Entwistle & Marton, 1984)
• Memorise information for assessments
• Associate facts and concepts
unreflectively
• Fail to distinguish principles from
examples
• Treat the task as an external imposition
• External emphasis: demands of
assessments, knowledge cut off from
everyday reality

Source: Ramsden (2003, p. 47)

According to Brown and Cooke (2002) the concept of teaching and learning, as

described in this chapter e.g. those of encouraging a deep approach, is implicit in the

20
Indonesian national nursing curricula objectives. For example, the documentation

objectives include (Pusdiknakes, 1997):

• Encourage active self-development in practicing by considering scientific

evidence;

• Continuously improve own professional competence;

• Function as a member of community who is creative, productive, and open to

any changes, has orientation to the future;

• Develop initiative and leadership.

However, the teaching program, institutional practices and cultural understandings of

teaching practice put teachers in the position of having the responsibility for

students’ learning. According to Brown and Cooke (2002), the focus of teaching and

learning activities in nursing schools in Central Kalimantan is the transfer of

knowledge. As part of this project, teachers identified and described their

assumptions about teaching and learning. The teachers believed learning was a

quantitative increase in knowledge, and they perceived that learning was about

memorising and storing information, and that students needed to acquire facts and

skills which can be used when required. The teachers also believed that if they used

the correct teaching techniques they could transfer the concepts and skills required

by students to the practice of nursing. Brown and Cooke (2002) further explained

that these conceptions of teaching and learning are teacher-centred and represent the

conserving/reproductive level of Ballard and Clancy’s model as presented in Figure

2.1. The focus is on what the teacher is doing, rather then what the student is doing,

and the outcomes are likely to be imitation or surface learning rather than the desired

critical thinking (Ballard & Clanchy, 1997).

21
Within the current curricula, nursing students in Central Kalimantan were more

likely to use surface approaches to learning than deep approaches. The students

memorised and reproduced only the information provided to them by teachers, and

they did not question the statements and ideas that teachers presented to them. They

also did not seek out additional information (Brown and Cooke, 2002). The course

design of the diploma nursing curriculum that is currently used may encourage

students to take a surface approach to learning. The curriculum appears to emphasise

a breadth of coverage rather than a depth of understanding as described by Ramsden

in Table 2.1. As Central Kalimantan nursing students desire to be as successful as

nurses educated in western systems, significant improvements are needed in teaching

and learning approaches to better prepare the students to be professional nurses. Self-

directed learning (SDL) is essential for lifelong learning and professional

development; however, it has not been emphasised in Indonesian nursing education.

SDL requires students to be more active in their learning; instructional methods to

improve SDL such as reflection, learning plans and asking critical questions can

encourage students to take a deep approach to learning. Therefore, deep learning is

more likely if students are more self-directed in learning. The next section presents a

review of self-directed learning as one strategy to be used to move nursing students

in Central Kalimantan away from their past style to a more self-directed approach.

2.3 Self-directed learning

2.3.1 Definition
Self-directed learning is not a new concept in adult learning (Grow, 1991). The

unique aspect of adult learning rests in its methods of delivery to accommodate the

characteristics of adult learners. Adults are different from children in learning.

22
Knowles (1984) emphasised that adults are self-directed and able to take

responsibility for their decisions. Adults have been found to learn more effectively

by doing or experiencing. Knowles (1984, p.9) further explained the characteristics

of adult learners as being (a) adults need to know why they need to learn something;

(b) adults approach learning as problem solving, and (c) adults learn best when a

topic is of immediate value.

An early writer, Houle (1961), first introduced the term of self-directed learning

when he described a study of adults who had engaged in learning activities without

support or assistance. The works of Knowles (1975) and Tough (1979), who

popularised the concept, have had a major influence on self-directed learning

practice.

The definition of self-directed learning varies throughout the literature. Self-directed

learning is generally defined in terms of either a personal attribute of a learner, or as

a process of learning (Brockett & Hiemstra, 1991; Caffarella & O’Donnell, 1989;

Candy, 1991; Fisher, King & Tague, 2001, Hiemstra, 1992). The most common

definition of self-directed learning is that described by Knowles (1975, p.18):

Self directed learning is a process in which the learner takes the

initiative in diagnosing his/her learning needs, formulating goals,
identifying human and material resources, and evaluating learning
outcomes. This may be done with or without the help of others.

Based on the work of Knowles (1975), Iwasiw (1987) considers self-directed

learning to be a form of study in which individuals have responsibility for planning,

implementing and evaluating their own work. Furthermore, Iwasiw (1987, p.222)

outlined five characteristics of self-directed learning and suggests students are

responsible for:

23
 • identifying their own learning needs;

• determining their learning objectives;

• deciding how to evaluate learning outcomes;

• identifying and pursuing learning resources and strategies; and

• evaluating the end product of learning.

Knowles’ definition of self-directed learning is cited by many authors to form the

basis of other self-directed learning definitions, such as that of Spencer and Jordan

(1999, p.1281) who define self-directed learning as: “when students take the

initiative for their own learning, designing needs, formulating goals, identifying

resources, implementing appropriate activities and evaluating outcomes”. Bonham

(1989) suggests that when a person chooses his/her own learning goal, his/her own

learning methods, the context and process, and the resource they will use, they are

being self-directed learners. According to Merriam (1993), what also appears

common to most definitions is the notion of some individual control by the learner

over the planning, implementing and evaluating of their own learning. It can be

assumed that no matter how self-directed learning is conceptualised, it has come to

be seen as an integral part of the adult learning process.

The literature indicates that self-directed learning can take multiple forms. The

synonyms found for self-directed learning include independent study, self-instruction

packages, guided study, group work, learning plans (learning contracts), computer-

assisted learning, distance study, teleconferencing, and e-learning (Hamilton &

Gregor, 1986; Iwasiw, 1987; O’Shea, 2003; Piskurich & Piskurich, 2003). Brockett

and Hiemstra (1985) emphasise three important keys of teaching strategies to

promote self-directed learning: using a variety of teaching and learning resources;

24
using a teaching role that is facilitative rather than didactic; and encouraging an

active role by students during the entire teaching and learning process.

All of the documented approaches to self-directed learning reflect the stages put

forward by Knowles (1975) in setting up a student-centred learning environment,

such as creating a climate for learning, identifying learning needs and learning

resources, carrying out the learning activities, evaluating learning and identifying

future needs. According to O’Shea (2003, p.16), these activities can be concluded

into a number of stages, as follows:

• Assessment: characteristics of participants such as: readiness for self-directed

learning, demographic data, learning needs and resources;

• Planning: explaining self-directed learning;

• Implementing self-directed learning; and

• Evaluating self-directed learning.

Grow (1991) also reports that a wide variety of learning activities and approaches are

used to encourage students to take personal responsibility for their own learning.

These include developing strategies for learning, goal setting, making learning plans

and practising these strategies until they are automatic. Through self-directed

learning the ability of students to acquire information retrieval skills, whether

individually or in a group, is enhanced.

According to Gibbons (1994, p.5) the practice of the self-directed learning method

requires three stages, including:

• Stage 1: ‘Learning how to learn from a teacher’. In this stage, course content

is carefully taught, and studies are carefully managed by the teacher. Students

25
 learn the assigned subject matter, how to identify what to learn, how to

organise content for learning, and how to recall what has been learnt.

• Stage 2: ‘Learning how to teach a course to oneself’. Students are guided

through the process of learning and how to learn course content by the teacher.

Students learn how to pursue course outcomes independently, how to develop

a personal learning style, how to plan and organise a unit, how to work with

others, how to take action, check progress, and get things done. The purpose

of this stage is to empower students to find the most interesting and successful

way to achieve the course goal.

• Stage 3: ‘Learning how to direct one’s own learning’. Students learn how to

decide what is important to learn, do or become, and how to pursue it. Each

student sets their own goals and explores how to pursue them. For example,

how to visualise future desires, how to set ambitious personal goals, and how

to organise time, effort and resources, how to evaluate and redirect progress.

The purpose of this stage is to empower students for a life of successful

learning, achievement and personal development.

According to Gibbons (1994, p.115) there are nine skills required to be self-directed

learners—self-awareness skills, planning skills, management skills, study skills,

practice skills, action skills, evaluation skills, interaction skills, and attitude skills.

These skills are similar to the set of competencies identified by Areglado, Bradley

and Lane (1996, p.18) as necessary for students to be self-directed learners:

• The ability to diagnose learning needs realistically with the help from others

such as teachers, peers and prescribed materials;

26
 • The ability to transform learning needs into learning behaviours and

objectives, and then to practice them;

• The ability to identify effective learning strategies, the ability to identify

material resources for information to help choose objectives, and

• The ability to use the appropriate skills and behaviours.

Despite the proposed advantages of self-directed learning, Brookfield (1986)

suggests self-directed learning might not be the best approach for all adults.

Darbyshire (1993) argued that self-direction is a motivational factor which people

exhibit to varying degrees, with some people being more self-directed than others.

Darbyshire (1993) also suggests that the differences between adults and children are

insufficient grounds for distinct educational approaches. A similar argument comes

from Burnard and Morrison (1992) who refute Knowles’s claim and suggest that not

all students may want or be able to be independent.

Knowles (1990) acknowledges that adults might not be familiar with self-directed

learning and require time to adapt to self-directed learning, and he also acknowledges

that andragogy and pedagogy need not be mutually exclusive.

2.3.2 Conceptual model of self-directed learning

Self-directed learning models can be categorised into three types: a linear model; an

interactive model, and an instructional model (Merriam & Caffarella, 1999, p.293).

The early model of self-directed learning was the linear model, similar to that

proposed by Tough (1971) and Knowles (1975). Learners move through a series of

steps to reach their goals in a self-directed manner. Tough (1971) outlined a

comprehensive description of self-directed learning, which he termed self-planned

learning. Tough found that learners used thirteen steps in self-planned learning

27
projects, representing key decision making about choosing what, where and how to

learn (Tough, 1971, p.94). Numerous research studies have used Tough’s model of

self-directed learning. A range of specific populations have been studied using

Tough’s original or modified interview schedule, such as: farmers (Bayha, 1983),

pharmacists (Johns, 1973), nurses (Kathrein, 1981), clergy (Morris, 1977), and

physicians (Richards, 1986).

Knowles (1975) proposed six steps for self-directed learning and the steps are

somewhat similar to those proposed by Tough (1979). Knowles’s (1975) description

of six steps of self-directed learning included: climate setting, diagnosing learning

needs, formulating learning goals, identifying human and material resources for

learning, choosing and implementing appropriate learning strategies, and evaluating

learning outcomes. Knowles included numerous resources for both learners and

teachers for completing each of these tasks, such as learning contracts (learning

plans). Although the work of Tough and Knowles has provided the concepts and,

more importantly, the descriptive terms for key elements and the process of self-

planned learning, other writers have conceptualised different models (Kasworm,

1992).

The interactive model is the second category. There are five interactive models

reported in the literature, namely: Spear’s model (Spear, 1988), Cavaliere’s model

(Cavaliere, 1992), Personal Responsibility Orientation (PRO) model (Brockett and

Hiemstra, 1991), Danis’s framework (Danis, 1992), and Garrison’s model (Garrison,

1997).

Spear’s model was based on three major elements—the opportunities people find in

their own environments, past or new knowledge, and chance occurrences. Spear

28
(1988, p.212) found that the process of self-directed learning could be reduced to

seven principal components—residual knowledge, acquired knowledge, directed

action, exploratory action, fortuitous action, consistent environment and fortuitous

environment. Spear concluded that self-directed learning projects do not generally

occur in a linear fashion. Only a few studies have been conducted using all or parts

of Spear’s framework, for example, those by Berger (1990) and Padberg (1994).

Cavaliere (1992) proposed elements and observations as a result of her case study of

how the Wright brothers learned to fly. Five specific stages of their learning project

were identified: inquiring (a need to solve a problem), modelling (observing similar

phenomena and developing a prototype model), experimenting and practicing

(continuous refinement and practice with the model), theorising and perfecting

(perfection of their skills and product), and actualising (receiving recognition for the

product of their learning efforts. According to Merriam and Caffarella (1999)

Cavaliere’s model is especially useful in that it describes both the stages of the

learning process and the cognitive processes used throughout a major learning

endeavour. No published studies have been found to test this model (Merriam &

Caffarella, 1999, p.298)

The Personal Responsibility Orientation (PRO) Model, developed by Brockett and

Hiemstra (1991), provides a framework for what they term self-direction in learning,

which comprises both instructional method processes and personality characteristics

of the individual learner (learner self-direction). In the instructional process

dimensions, learners assume primary responsibility for planning, implementing, and

evaluating their learning experiences. In this facilitation role, instructors must

possess skills in helping learners do need assessments, locate learning resources, and

29
choose instructional methods and evaluation strategies. The second dimension is

related to the personality characteristics of individual learners. Brockett and Hiemstra

(1991) have further described various aspects of using self-directed learning as an

instructional method; however, according to Merriam and Caffarella (1999, p.299)

no studies have tested the PRO model of self-direction.

Danis (1992) has proposed a ‘map of the territory’ that researchers could use to study

the major components of self-directed learning and explain how the various

components of the model interact. This model is grounded in the notion of what

Danis terms ‘self-regulated learning’, referring to the various process components of

the learning cycle and not to the internal cognitive aspects. No studies were found

using Danis’s model (Merriam & Caffarella, 1999, p.300).

Garrison’s model (1997) is the recent multi-dimensional and interactive model of

self-directed learning. His model, grounded in a collaborative constructive

perspective, integrates self-management (contextual control), self-monitoring

(cognitive responsibility) and motivational (entering task) dimensions to reflect a

meaningful and worthwhile approach to self-directed learning. The first dimension,

self-management, acknowledges the social milieu in which learners are interacting,

whether they are in formal or informal settings. It involves learners taking control of,

and shaping, the contextual conditions such that they can reach their stated goals and

objectives. The next two dimensions, self-monitoring and motivation, represent the

cognitive dimensions of self-directed learning. According to Garrison, self-

monitoring is synonymous with responsibility to construct meaning and the

motivational dimension involves what influences people to participate in a self-

directed learning activity and what keeps them participating in the activity.

30
Garrison’s model is not further explored in the literature (Merriam & Caffarella,

1999, p.302).

The third category of self-directed learning models represents frameworks that

instructors in formal settings use to integrate self-directed methods of learning into

their programs and activities. Three models are described in the literature that is

designed for educational settings. These were developed by Grow (1991), Hammond

and Collins (1991) and D’A Slevin and Lavery (1991). According to Merriam and

Caffarella (1999, p.304), Hammond and Collins’ (1991) model is the only model that

explicitly addresses the goal of promoting emancipatory learning and social action as

central tenets of SDL. In this model, learners take the initiative for building a

cooperative climate; analysing and critically reflecting on themselves and the social,

economic, and political contexts in which they are situated; generating competency

profiles for themselves; diagnosing their learning needs within the framework of both

the personal and social context; formulating socially and personally relevant learning

goals that result in learning agreements; implementing and managing their learning;

and reflecting on and evaluating their learning. According to Merriam and Caffarella

(1999), what makes this model different from the other process models is the

purposeful inclusion of the critical perspective through the examination of the social,

political, and environmental contexts that affect their learning, and the emphasis on

developing both personal and social learning goals. No research has been published

that has used Hammond and Collins’s model as their conceptual framework.

The Staged Self-Directed Learning (SSDL) model proposed by Grow (1991) and the

Teacher-Student Control Continuum (TSCC) model developed by D’A Slevin and

Lavery (1991) were used as the framework for the educational intervention in this

31
study. These two models were chosen as they propose how teachers can move

students through stages of increasing self-direction in a classroom setting; possible

roles for teachers and students and how they are related; and promoting students’

responsibility for their own learning in the time constraints dictated by curriculum.

These two models will be discussed in more detail below.

The Staged Self-Directed Learning (SSDL) model proposed by Grow (1991) outlines

how teachers can assist students to become more self-directed in their learning. The

self-directed learning in SSDL model is referring to “the degree of choice that

learners have within an instructional situation” (Grow, 1991, p.128). According to

Grow the SSDL model proposes a way teachers can be vigorously influential while

empowering students toward greater autonomy. The teacher’s purpose is to match

the learner’s stage of self-direction and prepare learner to advance to higher stage.

The model is grounded in the situational leadership model of Hersey and Blanchard

(1988), and describes four distinct stages that learners pass through (see Table 2.2).

• Stage 1: learners of low self-direction who need an authority figure (a teacher)

to tell them what to do;

• Stage 2: learners of moderate self-direction who are motivated and confident

but largely ignorant of the subject matter to be learned;

• Stage 3: learners of intermediate self-direction who have both the skill and the

basic knowledge and view themselves as being both ready and able to explore

a specific subject area with a good guide; and

• Stage 4: learners of high self-direction who are both willing and able to plan,

execute, and evaluate their own learning with or without the help of an expert.

32
Within each of these stages, Grow (1991) outlines a possible role for the teacher or

facilitator. However, Grow (1991) states that fully self-directed learning is not

possible in an institutional setting as it is constrained by curriculum. Rather, self-

directed, lifelong learning is the most important outcome of a formal education.

Table 2.2: Staged Self-Directed Learning Model (SSDL)

Stage Student Teacher Examples

Stage 1 Dependent learner Authority coach (teacher Informational lecture,

centred) Structured drill, intensive
individual tutorial.

Stage 2 Interested learner Motivator, guide Teacher-led discussion.

Demonstration and follow by
guided.

Stage 3 Involved learner Facilitator Seminar, learning contract,

evaluation check list

Stage 4 Self-directed learner Consultant, delegator Independent study, student

directed discussion

Adapted from Grow (1991)

Problems may arise when there is a mismatch between the role or style of the teacher

and the learning stage of the learners. Grow emphasises that the teacher should

individualise their teaching strategies to match the learner’s stage of self- direction

and allow the students to become more self-directed in their learning. Grow (1991)

also highlighted the weakness of the SSDL model, as the model does not contain any

method for reliably ascertaining the degree of students’ self-direction. However,

according to Grow (1991), some clues can be used when estimating a student’s

degree of self-direction, these include: signs of the student’s level of motivation,

such as coming to class on time, doing assignments, and participation in class

discussion.

33
Tennant (1992) has criticised Grow’s model and offered a number of observations

and questions about the utility and explanatory power of the model. For example,

who is the best person to judge which stage a student is at? How should this be done

if there is a mismatch between the learner’s ability and the willingness to use self-

directed methods? What, in the learning process, should teachers change from one

stage to another?

In response to Tennant’s comments about the staged self-directed learning model

(SSDL), Grow (1994) highlighted that the SSDL model is a concept where the

teachers lead students from being ‘less independent’ to ‘more independent’ in their

learning. According to Grow, the teacher’s task is first to work with the students

‘comfortable’ learning style and then introduce a creative mismatch that can promote

growth in self-directed learning. According to Merriam and Caffarella (1999),

Grow’s thoughts on integrating the notion of self-direction into formal instruction are

very similar to those of Pratt (1988), Long (1989) and Hiemstra and Sisco (1990).

The Teacher Student Control Continuum (TSCC) model was developed by D’A

Slevin and Lavery (1991). It identifies and focuses upon various levels of control

over the learning process. The TSCC model proposes to maximise SDL through a

sharing of control in learning between students and teacher. In the role relationships

there is an implied shift away from the traditional role in which the teacher is

superordinate and students subordinate, toward a more equal partnership. The TSCC

model comprises four types of interaction. The first type involves total teacher

direction and the teacher makes all program decisions and controls both planning and

evaluating. In the second type, partnership control is shared by the teacher and

students. The third type is when students have a high control of learning, and the

34
teacher enables but does not lead; and, the last type is student self-direction. There is

no teacher influence at all, students plan and control the program. The TSCC model

can be seen in Figure 2.2.

Total self-direction Facilitator Partnership Total teacher

direction

• Complete • Student- • Control is • Complete

student centred & shared teacher
control with high equally by control.
• No teacher control student & • The teacher
influence at • Teacher teacher makes all
all enables but • Essentially a program
• Student plans not does transactional decisions.
and controls lead. model. • The student is
the program • Student still • Student & not
• Self- makes teacher consulted
assessment decision on agree • Teacher
only program program assessment
• Always plan & plan & only
individualise content content. • Almost
d. • Self- • Learning always
assessment contract is a group of.
with Teacher common students.
advice on feature.
request. • Self-
• Usually assessment
individualise & teacher
d assessment.
• May be
individualise
d or in a
group.

Source: Adapted from D’A Slevin and Lavery (1991)

Figure 2.2: The teacher-student control continuum (TSCC)

According to D’A Slevin and Lavery, the TSCC model requires students to be

proactive in organising and undertaking the required study. The teacher has an

important role in terms of providing direction, support and advice, as required, and

monitoring their progress. The importance of promoting students’ responsibility for

35
their own learning should be balanced with the teacher’s responsibility for ensuring

that specified outcomes have been achieved. The TSCC model was incorporated into

the intervention within this study by using the first two types of teacher-direction on

the learning process, and then gradually moving to partnership and shared control for

learning by students and teachers. These two types were applied across the

educational intervention with the partnership approach being applied gradually as the

program progressed.

2.3.3 Instructional methods to improve self-directed learning

A variety of teaching and learning strategies can be vehicles to achieve self-directed

learning, and a number of tools can be used to facilitate the self-directed learning

process (Atkins & Murphy, 1993; Garrison, 1987; Knowles, 1990; Margetson, 1994;

O’Shea, 2003; Parker, 1995; Taylor, 1997). Knowles (1986) cites learning plans

(learning contracts) as an ideal method to facilitate self-directed learning. Reflection

has also been suggested as a way to achieve self-directed learning as it requires

individuals to learn throughout the experience (Parker et al., 1995), with the outcome

a changed perspective of self and the world (Atkins and Murphy, 1993). Crooks et al.

(2001) state that reflection is integral to SDL. It helps students to attribute meaning

to the learning experience and the outcome of reflection is to explore learning

experiences and develop deeper understandings.

Problem-based learning has also been linked to self-directed learning, with

Margetson (1994) illustrating problem identification followed by students engaging

in self-directed learning to solve the problem. Taylor (1997) also linked problem-

based learning and self-directed learning in so far as students can set their objectives

based on a relevant scenario, access material and receives feedback on their learning.

36
Garrison (1987) describes written materials or modules that can also be used to

promote self-directed learning.

Learning plans (learning contracts) and modules are seen as appropriate tools to

facilitate self-directed learning in this research study. The reason for choosing these

tools is based on the feasibility and applicability of these tools in the Central

Kalimantan setting. The limited human resources, funding, teaching and learning

materials, and access to contemporary information technology influenced the

decision to choose these tools. It can be assumed that through the combination of

these tools to fit the local conditions, participants in this study would get maximum

benefit to increase their readiness for self-directed learning. These two tools, learning

plans and modules, are further discussed below.

2.3.3.1 Learning plans

The use of learning plans (Learning contracts) has become increasingly widespread

in recent years to operationalise SDL. According to Knowles (1986) one of the

predominant methods teachers have used to assist adult learners to be more self-

directed in formal instructional situations is the learning plan. Knowles (1986, p. 38),

defines a learning plan as “a written plan in which the individual documents in

varying detail, what and how she/he intends to learn in a given learning experience”.

The learning plan has several benefits (Knowles, 1990, p. 139), including:

• Being a tool for communication between learner and facilitator;

• Guiding learners in planning the learning experience;

• Solving the problem of the wide range of backgrounds in education,

experience, interest, motivation and ability that is characteristic of most adult

groups;

37
 • Providing a way for individuals or sub-groups to tailor their own learning

plans;

• Providing the learner with a sense of ownership of the objectives he or she

will pursue;

• Identifying a wide variety of resources so that different learners can go to

different resources for similar learning content;

• Providing each learner with a visible structure for systematising their

learning, and

• Providing a systematic procedure for involving the learner in evaluating the

learning outcomes.

According to McAllister (1996), many authors believe that learning plans

individualise the learning process and assist students to develop habits related to

lifelong learning. These habits include independence, self-direction, and active

engagement with the subject matter (Dart & Clarke, 1991; de Tornyay & Thompson,

1987; Richardson, 1987). According to de Tornyay and Thompson (1987) the use of

learning plans can promote problem-solving skills, foster a desire for lifelong

learning, and enhance creative and critical thinking. The learning plans (learning

contracts) develop autonomy because they increase student’s internal locus of control

(Knowles, 1984; Tompkins & McGraw, 1988). This is based on the assumption that

to achieve objectives, students must rely on their own learning skills and not on

teachers to give them knowledge.

Dart and Clarke (1991) state that learning plans help students achieve greater self-

direction in their learning by allowing them to control their learning experiences, to

meet their own learning needs, and develop skills to educate themselves. Moreover,

38
Dart and Clarke (1991) indicate that learning plans can promote deep learning and

deep learning always involves gaining understanding through strategies such as wide

reading, use of a variety of resources, discussion, as well as reflection. Learning

plans also have benefits for teachers because they are free to use creative approaches

and students tend to be more self-motivated requiring less external motivation from

teachers (Dart & Clarke, 1991).

Several studies have demonstrated that learning plans have a positive correlation

with self-directed learning (Chan & Chien, 2000; Dyck, 1986; Hamilton & Gregor,

1986; Mazhindu, 1990; McAllister, 1996; Richardson, 1987; Waddell & Stephens,

2000). The assumption has been made that learning plans enable learners to achieve

competency in all the areas required for self-directed learning.

McAllister’s (1996) study used learning plans in a Bachelor of Nursing course in an

Australian university for a unit titled “Preparation for professional practice”. This

course was offered in the final semester of a three-year course. By the third week of

semester all students were proceeding to learn through their learning plans and by the

15th week the learning plans were competed. The findings of this study identified

several benefits, including:

• Students commented upon a greater sense of control in using learning plans;

• Learning plans also appeared to promote deeper learning; and

• Creativity also appeared to be promoted in the use of learning plans.

Another study conducted by Waddell and Stephens (2000) used learning plans in a

Registered Nurse (RN) leadership course. The diversity of RN students was the

reason for using learning plans in this study. Nominal group process was used as a

strategy during the first class session to determine content for the course. Waddell

39
and Stephens (2000) found that learning plans were favourably rated as an effective

strategy for the leadership course in the RN program.

Chan and Chien (2000) conducted a study using learning plans as a learning tool in

students’ clinical placement in mental health nursing. Students had 42 hours of

theory input and 18 days of clinical placements during the course in mental health

nursing. The sample for this study comprised 47 third-year students. The action

research cycle consisted of three phases: planning and learning plan making;

implementing learning plans, and evaluating the effectiveness of learning plans. A

questionnaire ‘Perceived benefit of Contract Learning’ was used to obtain students’

views on the benefits of the learning plans. Results of the study showed that there

was an increase in students’ autonomy and motivation in learning, as well as sharing

between students and clinical instructors. However, the study found the lack of

experience in using learning plans and limited time in clinical areas created

difficulties for both students and clinical instructors.

Contrary to other studies that learning plans have a positive correlation with self-

directed learning, is the work of Clark (1990). Clark (1990) conducted a study

comparing a traditionally taught and learning plan taught, course for nursing

students. The aims of the study were to see the impact of teaching method on self-

directed learning skills and clinical performance. The sample for the study comprised

86 junior and senior nursing students. At the end of the semester, students’ clinical

performance scores and post self-directed learning readiness scores were obtained.

The study found there was a significant relationship between teaching method and

dependent variables. The traditionally taught groups had better self-directed learning

and clinical skills. However, data contamination may have affected the result.

40
Caffarella and Caffarella (1986) also found that the use of learning plans in formal

education had little effect on students developing readiness for self-directed learning

within formal settings. This view is supported by Caffarella and O’Donnell (1989),

who note that there is little research or other evidence to support the use of learning

plans to facilitate self-directed learning. Other factors that limit the usefulness of

learning plans include:

• Discomfort by learners who use the learning plans, since it is often a new

experience;

• The quality of the learning may be questionable/problematic, since it is

directed by the learner rather than the teacher;

• Time pressures of using this method over more traditional forms of class

organisation, and

• Unsuitability of the plan form of learning for certain content areas. (Caffarella

& O’Donnell, 1989, p.17 )

In her study, McAlister (1996) found that despite the benefit of learning plans there

were also limitations, including the format of learning plans being confusing for

students. Some students did not know what their learning needs were. Another issue

about learning plans was their ability to trigger student anxiety. Some students were

uncertain about using learning plans and made too many learning objectives that they

could not accomplish in the time constraints of the study. Based on these findings

McAllister (1996) suggested future studies should prepare teachers, simplify the

format, help students to set realistic goals, and share ideas on quality learning.

In conclusion, learning plans can be a challenging, effective way for students to

learn, and can foster deep learning. In addition, use of learning plans promotes the

41
concept of becoming a self-directed, independent, lifelong learner. Therefore

effective use of learning plans can help students learn content that is context-specific,

relevant and applied. Moreover, by promoting independent learning the students are

better prepared to be independent learners. However, since the learning plans may be

only partially useful in developing the skills or competencies required for self-

directed learning many researchers (Caffarella & O’Donnell, 1989; McAllister,

1996) suggest that learning plans should be used in conjunction with other methods

to promote self-directed learning and to get maximum benefit from learning plans.

2.3.3.2 Learning module

Learning modules are frequently identified as an essential resource for self-directed

learning. Learning modules are one type of written material widely used in education

specifically for distance learning. The use of modules as resources for pro-active

learning in self-directed modes has very important implications for adult learning,

continuing professional education and programs in rural and isolated settings

(Brockett & Hiemstra, 1985: 35). Many authors have previously demonstrated that

learning modules can promote self-directed learning (Brunt & Scott, 1986; Davis &

Pearson, 1996; Donaldson, 1992; Huckabay, 1981; Jones & Jones, 1996; Kang,

2002; Pedley & Arber, 1997; Willock, 1998).

Jones and Jones (1996) conducted a study using a self-learning package compared to

a conventional lecture. The study aim was to investigate students’ preference for

conventional lecture or self-learning package. The sample of this study was 66 first

year students divided into a conventional lecture group and self-learning package

group, followed by a six-week implementation. Two questionnaires were used in the

study; “Study Process Questionnaire” (SPQ) and “Attitude Questionnaire” (AQ) to

examine their level of understanding. The result of the study that was there was no

42
correlation between students’ study approach and their preference for different

teaching methods when measured by test performance. Jones and Jones (1996)

suggested a need to review independent study packages to better match students’

needs.

Another study conducted by Davis and Pearson (1996) used a self-learning module

in a primary health care course. The sample was 103 nursing students who enrolled

in the Primary Health Care course, 69% generic students and 31% registered nurses

(RN). Age of the sample ranged from 21–56 years, modal age 22 years. Two

instruments were used in the study, Guglielmino’s SDLRS (1978) and Affective

Measure (Huckabay, 1981). The results of the study revealed significant differences

in course evaluation related to self-directed learning readiness. However, the results

of the study cannot be generalised due to the particular nature of the sample who

reported a high degree of self-directed learning readiness scores, which may be

atypical.

Pedley and Arber (1997) conducted an exploratory qualitative study using Jarvis’

(1992) experiential framework to evaluate student-centred module learning.

Following a nine-month module of study, a convenience sample of 135 students

completed a questionnaire with fixed choice and open-ended questions. The nine-

month implementation of the self-learning module was supplemented by group

discussion and feedback. A key theme that emerged was the beneficial learning

experience. The reported benefits included more choice, autonomy and taking

responsibility. However, no pilot test was conducted for the questionnaire and

questions remain regarding its reliability and validity, therefore the finding cannot be

transferred to other settings.

43
A study conducted by Willock (1998) compared performance outcomes of entry-

level nursing students who were taught selected psychomotor skills by traditional

lecture method versus self-learning modules. Students were divided into two groups:

self-learning module group for urine catheterisation and lecture/discussion for sterile

dressing change; self-learning module group for sterile dressing change and

lecture/discussion for urine catheterisation. The performance outcomes were a

paper/pencil test and skill demonstration. The finding of the study revealed no

significant difference in the performance outcomes. Data contamination is suspected

to have influenced the results.

A recent study conducted by Kang (2002) used a self-learning module to teach

nurses caring for hospitalised children with tracheostomies, with a sample of 85

nurses—74 RNs and 11 Licensed Practical Nurses (LPN). Pre- and post- tests using a

self-developed questionnaire contained eight questions about current practice

regarding tracheostomy care including skills, knowledge, and critical thinking. The

results of the study revealed a statistical difference on post-test scores compared to

pre-test scores after four months implementation of the program. Furthermore, Kang

(2002) suggested improvements to self-learning modules by adding other teaching

methods to increase learning and retention, such as, educators discussing the topic

and demonstrating the skills, as well as using video.

Brunt and Scott (1986) suggested that many factors need to be considered when

developing and implementing self-learning module, including appropriate planning

and assessment, which can provide a mechanism to assist in the development and

implementation of quality self-learning modules. It is suggested by many authors that

modules, together with other self-directed learning tools, can improve self-directed.

44
2.3.4 Measuring self-directed learning
The need for instruments to effectively evaluate readiness for self-directed learning

has been a recurring theme throughout the literature. In reviewing the literature,

Cormick (1995) identified 17 instruments used to measure readiness for self-directed

learning; one instrument is found in the literature developed by Fisher, King and

Tague in 2001 giving a total 18 instruments used to measure SDL readiness. Of

these, 13 require the student to respond to questions or statements, two assess

teachers’ self-directed learning behaviour, two study students’ behaviour from an

educator’s viewpoint, and one rates programs for self-direction. These instruments

are displayed in Table 2.3.

Table 2. 3: Instruments identified as assessing self-directed learning

.

This table is not available online.

Please consult the hardcopy thesis
available from the QUT Library

Source: Cormick (1995, p.51)

45
According to Walker and Long (1997), two of these instruments are widely used—

the Guglielmino’s Self Directed Learning Readiness Scale (SDLRS) and Oddi’s

Continuing Learning Inventory (OCLI).These two instruments are presented below.

2.3.4.1 Oddi’s Continuing Learning Inventory (OCLI)

The Oddi Continuing Learning Inventory was developed to measure the personality

dimensions that characterise self-directed adult learners. These items were developed

after reviewing the literature on the type of personality characteristics that adult self-

directed learners possess (Oddi, 1986, p.98). The OCLI is a 24-item self-report scale

in which an individual records the extent of agreement along a seven point Likert

Scale. The response categories on the scale are arranged as follows: 1 = strongly

disagree, 2 = moderate disagree, 3 = slightly disagree, 4 = undecided, 5 = slightly

agree, 6 = moderately agree, 7 = strongly agree. The 24 items are summed to obtain a

score reflecting the extent to which an individual’s personality characteristics lead

him or her to initiate and persist in learning through various modes (Oddi, 1986,

p.105). An internal consistency coefficient of 0.85 (Oddi, 1984); 0.77 (Six, 1989),

and 0.79 (McCoy & Langenbach, 1989) was estimated for Oddi’s Continuing

Learning Inventory.

Oddi (1986) found the instrument to have both convergent and discriminant validity

and described moderate relationships with several psychological outcome measures.

Furthermore, Six (1989) found that the three factors identified by Oddi remained

consistent across study samples. However, McCoy and Langenbach (1989, p.84)

failed to find any difference in OCLI scores between those who felt they were

required to participate in self-directed learning activities and those who did not.

McCoy and Langenbach (1989) recommended additional items be added to the OCLI

in order to provide a more thorough understanding of the characteristics of self-

46
directed learners. Few studies used OCLI compared to Self-Directed Learning

Readiness Scale (SDLRS).

2.3.4.2 Self-Directed Learning Readiness Scale (SDLRS)

This instrument is a self-report questionnaire designed to measure the degree to

which an individual perceives his or her willingness and capacity to engage in self-

directed learning (Guglielmino, 1978). The SDLRS instrument scores an individual

on eight factors, namely:

• Openness to learning opportunities;

• Self-concept as an effective learner;

• Initiative and independence in learning;

• Informed acceptance of responsibility for one’s own learning;

• Love of learning;

• Creativity;

• Positive orientation to the future; and

• Ability to use basic study and problem solving skills.

According to Guglielmino (1978), these factors define attitudes, values, and abilities

associated with the preparedness or readiness of learners for self-directed learning.

The SDLRS is used to collect information about students’ level of readiness for self-

directed learning. More than 40,000 adults and 5,000 children have taken the

SDLRS. The instrument has been translated into more than 17 languages including

Indonesian and has a 27-year history of usage (Guglielmino & Guglielmino, 2005).

To design the SDLRS, Guglielmino (1978) obtained a pool of items for the inventory

from the literature and submitted them to a panel of experts in self-directed learning.

47
A final set of items was confirmed using a Delphi technique, the purpose of which

was to reach a consensus on the characteristics essential and distinct to self-directed

learning. The set of items was then tested with a sample of college students and later

revised to form the version in common usage since 1978.

The SDLRS is a 58-item Likert scale designed to assess the degree to which

individuals perceive themselves to possess skills and attitudes frequently associated

with self-directed learning. Individuals respond to each item on the scale as follows:

1 = Almost never true of me; I hardly ever feel this way; 2 = Not often true of me; I

feel this way about half the time; 3 = Sometimes true of me; I feel this way more

than half time; 4 = usually true of me; I feel this way more than half time; 5 =

Almost always true of me; there are very few times when I don’t feel this way. The

possible scores range therefore from 58 to 290. The total scores obtained by each

individual were used to indicate his/her level of readiness for self-directed learning in

relation to Guglielmino and Guglielmino’s (1991) norms. A high score indicates a

high readiness for self-directed learning. The scores and corresponding levels are

shown in Table 2.4.

Table 2.4: Levels of readiness for self-directed learning

Scores Level of readiness for self-directed learning
58 – 176 Low
177 – 201 Below average
202 – 226 Average
227 – 251 Above average
252 – 290 High

Source: The learning preferences assessment (Guglielmino & Guglielmino, 1991, p.8)

The original study by Guglielmino found a mean score for the adults completing the

SDLRS in Canada of 214, and a standard deviation of 25.6 (Guglielmino &

48
Guglielmino, 1991). A Cronbach’s alpha reliability coefficient of 0.87 was estimated

for the self-directed learning readiness scale; the split half reliability was estimated to

be 0.94 (Guglielmino, 1989a).

Supporting evidence from previous research has identified that the SDLRS is a

reliable instrument. This evidence is provided by many authors in early studies

(Brockett; 1985; Graeve, 1987; Hall-Johnsen, 1985; Skaggs, 1981; Wiley, 1983).

Other supportive studies acknowledge the validity of the instrument (Adenuga, 1991;

Bonham, 1989; Crook, 1985; Curry, 1983; Darmayanti, 1994; Delahaye & Choy,

2000; Finestone, 1984; Hassan, 1981; Long & Agyekum, 1988; Savoi, 1980).

The reliability of the SDLRS was measured by Delahaye and Smith (1995) with an

Australian sample. They obtained an alpha coefficient of 0.67 for the SDLRS scores

for a sample of 200 Technical and Further Education (TAFE) and university

students, aged below 49 years, pursuing business administration courses. When those

aged below 20 years were excluded from the analysis, Delahaye and Smith (1995)

found that the alpha coefficient rose to 0.72. They suggest that students under the age

of 20 years appear not to have settled into a preferred learning style, cautioning that

the use of the SDLRS with students under the age of 20 years may not be

appropriate. Delahaye and Smith (1995) recommended further investigations into the

use of the instrument with that age group. However, Warner, Christie and Choy

(1998) studied the level of readiness for self-directed learning of 524 Vocational

Education and Training (VET) learners using the SDLRS and found no significant

difference between level of readiness for self-directed learning of those age groups

15 to 20 years and 21 to 25 years. They found that there was a difference between the

49
levels of readiness for self-directed learning of those aged below 25 years and those

over 25 years.

In their review, Delahaye and Choy (2000) concluded that the SDLRS can be used

with acceptable confidence to provide an accurate measurement of readiness for self-

directed learning for Australian students. However, as indicated by other users, they

also suggest that caution must be exercised when interpreting the results of the

SDLRS.

The SDLRS has also been used in an Indonesian study (Darmayanti, 1994).

Darmayanti found a mean score for 391 Indonesian Open University students of

215.5, and a standard deviation of 21.9. The mean score of the sample in

Darmayanti’s study was one and half points higher than the mean score of the

normative population of Guglielmino’s study. The mean score of Darmayanti’s study

also shows that students of the Indonesian Open University have an average

readiness for SDL, which is similar to that in Guglielmino’s study (1978). A

Cronbach’s alpha reliability coefficient of .87 was estimated for the SDLRS in the

pilot study, and in the main study reliability was estimated at .91 (Darmayanti, 1994).

While the SDLRS has received support as a reliable and valid means for measuring

readiness for self-directed learning, Brookfield (1985) cautioned against capricious

use of this instrument. He argued that the construction of the instrument favours

those who are relatively educationally advantaged and it may not be suitable for

measuring levels of readiness for self-directed learning for working class adults. His

view is also shared by Brockett (1985). Likewise, Field (1989) has argued that the

SDLRS is better suited to measure the love and enthusiasm for learning and may not

be suitable to measure the level of readiness for self-directed learning. Field (1989)

50
claimed that a high score on positively phrased items and a low score on negative

items do not necessarily correspond to readiness for self-directed learning.

The instrument has also been criticised, Candy (1991) and West and Bentley (1991)

have also questioned the basic structure of the SDLRS. The SDLRS has weaknesses

that have been identified by other researchers (Brockett, 1985; Leeb, 1985; Long &

Walsh, 1992). Brockett and Field found that 12 of the 58 items did not significantly

correlate to the total score, while Lebb found 11 items did not. Long and Walsh

found that the 17 reverse-scored items displayed a lower correlation with the total

score data than their positively scored counterparts. For that reason, Caffarella and

O’Donnell (1989) called for additional verification studies using subjects from

different economic, ethnic, and cultural backgrounds. This view was vigorously

debated by a number of researchers with no resolution.

In defending her instrument, Guglielmino (1989b) responded that it measures the

level of readiness to engage in self-directed learning at the time that it is answered,

suggesting that the level could change. The SDLRS contains both positively and

negatively phrased items, where 17 items (out of 58) are reverse-scored. Guglielmino

(1989b) highlighted that a high score on some negatively phrased items such as item

14: “Difficult study doesn’t bother me if I’m interested in something” and item 33:

“I don’t have any problem with basic study skills” indicates a high level of self-

direction. Similarly, a low score on some positively phrased items such as item 7: “In

a classroom, I expect the teacher to tell all class members exactly what to do at all

times” also indicates a high level of self-direction. Guglielmino (1978) included

negatively scoring items (reverse items) in the SDLRS to avoid the subjects from

developing a response set. A response is developed if the rating is similar on all

51
questions; the subjects then develop a tendency not to read the items carefully.

Guglielmino’s (1989b) study showed that all of the reverse items, except one, had

item correlation of 0.30 or higher. Despite the debate around the questionnaire,

according to Walker and Long (1997), Guglielmino’s self-directed learning readiness

scale (SDLRS) remains the most widely used instrument to assess readiness for self-

directed learning in education at this time.

2.4 Summary

This chapter outlined the literature on self-directed learning. An overview of

conceptions of teaching and learning and student approaches to learning were

provided. The definition of self-directed learning was presented as well as a

conceptual model of self-directed learning. The two teaching strategies utilised to

improve self-directed learning in nursing students in Central Kalimantan and the

characteristics of the instrument used in assessing self-directed learning completed

the chapter. The next chapter outlines the methodology used in this study.

52
 CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter describes the methodology used to address the research questions for

the study. The research questions were:

1. What were students’ levels of readiness for self-directed learning (SDL)

before the educational intervention as measured by the Self Directed Learning
Readiness Scale (SDLRS)?

2. Was there a difference in students’ readiness scores for SDL between the
intervention and control groups at pre-test?

3. Was there a difference in students’ readiness scores for SDL following the
educational intervention?

4. What factors contributed to students’ readiness for SDL?

5. What were the students’ perceptions of SDL before and after the educational
intervention?

6. What were clinical instructors’ perceptions of students’ clinical activities

during the educational intervention period?

This chapter begins by presenting the research design. This is followed by the

population and sample, sampling technique, ethical considerations associated with

the study, and independent and dependent variables. Data collection tools are

explained with justification for their inclusion. This is followed by procedures for

data collection, a brief explanation of the pilot study, and the educational

intervention program (EIP). Analytical plans for quantitative data are outlined in

53
relation to each hypothesis, as well as the data analysis for qualitative data; these are

presented at the end of the chapter. The chapter then concludes with a summary.

3.1 Research design

A mixed or multi-method approach that included quantitative and qualitative

methods was used to address the research questions for this study. Brewer and

Hunter (1989) state that the benefits of a mixed method approach allow the

exploitation of the potential strengths of each paradigm to better inform the focus of

the study.

The quantitative component of the study was used to evaluate the impact of the

educational intervention on students’ readiness for SDL using the SDLRS. Two

collection points, before and after the introduction of the intervention, allowed the

researcher to examine the impact of the intervention (Polit & Hungler, 1999)—in this

case the structured educational intervention.

To gain the fullest understanding of the participants’ experiences of using SDL a

qualitative method was also used for the study. Students’ perceptions of SDL and

clinical instructors’ perceptions of students’ clinical activities regarding SDL were

explored. To gather qualitative data, focus group discussions (FGD) were employed.

By using focus groups, quantitative research findings were expanded and enhanced.

The research design is outlined in Figure 3.1.

54
 Educational program Post test
4-day workshop SDLRS
Pre-test
Intervention
4-day skill practice at FGD:
SDLRS & Demographic
nursing lab students
questionnaire Focus
12-week implementation and clinical
group
3 tutorial meetings instructors
discussion(students)
Self-directed learning
module & Learning plans

Pre-test Post test:

SDLRS & Demographic SDLRS
Educational program as
questionnaire
Control

usual FGD:
Focus group discussion students
(students) and clinical
instructors
Figure 3.1: Research design used in the study

The quantitative aspect of the study used a non-equivalent control group design with

pre- and post- tests of an intervention and control group, which evaluated the impact

of a structured educational intervention on students’ readiness for SDL in a diploma

nursing program in Central Kalimantan, Indonesia. The quantitative aspect of the

study also involved the collection of data that potentially contributed to students’

readiness for SDL.

A structured educational intervention was developed and used for nursing education

in Central Kalimantan to introduce SDL concepts, followed by implementation of

SDL into the learning situation. The SDL concepts were implemented as part of one

nursing subject for second year students. The structured educational intervention

aimed to improve students’ self-directed learning abilities by increasing their

participation in their own learning.

The intervention group participated in four days of workshops which introduced SDL

concepts followed by four days of practice in the nursing school laboratory for

selected nursing skills. A self-directed module and learning plan was used in the

study to operationalise principles of SDL. Students received the self-directed module

55
at the beginning of the program. To support students’ efforts to implement SDL

concepts for twelve weeks, three tutorial meetings were held in weeks 3, 6, and 9 of

their program.

Maas, Buckwalter, Reed, and Specht (1998) note that when the non-equivalent

control group design is employed, the control group may also receive a treatment.

The control group received the teaching approaches normally used in the nursing

school that had agreed to participate as the control condition for this study. The usual

practices were teacher-centred rather than student-centred. Students in the control

group received the self-directed learning module after the post- test data were

collected.

The quantitative aspect of the study evaluated the impact of the educational

intervention for SDL by using the Self-Directed Learning Readiness Scale (SDLRS)

developed by Guglielmino (1978). The analyses of the quantitative data addressed

hypotheses that were developed from the first four research questions:

• Hypothesis 1: The students’ level of readiness for SDL as measured by

SDLRS would be lower than established group norms (Guglielmino, 1978)

• Hypothesis 2: There would be no significant difference between the

intervention and control group SDLRS scores at pre-test

• Hypothesis 3: Self-directed learning readiness scores of students who

participated in the educational intervention program over fourteen weeks

would be significantly increased compared to the scores of students who did

not participate

56
 • Hypothesis 4: Variables such as group (intervention-control), gender, birth

order, father’s educational background and mother’s educational background

would significantly contribute to students’ readiness for SDL.

The qualitative part of the study used focus group discussions (FGD) to collect

qualitative data from students and clinical instructors. A focus group is defined by

Krueger (1994, p.18) as “a carefully planned (group) discussion designed to obtain

perceptions on a defined area of interest in a permissive, non-threatening

environment”. The purpose of students’ FGD in this study was to explore students’

perceptions of SDL and general factors that may influence their readiness for SDL.

The aim of conducting FGD for clinical instructors was to explore their perceptions

of students’ clinical activities regarding SDL. The qualitative data from the clinical

instructors provided a holistic view of the factors that were thought to contribute to

students’ activities in clinical practice. FGD with students and clinical instructors

extended the knowledge about students’ SDL approaches. Collectively, the focus

group discussions explored factors that contribute to readiness for SDL from the

perspective of students and their clinical instructors. Students were asked their

perceptions of SDL before and after intervention to address research question five:

5. What were the students’ perceptions of SDL before and after the educational
intervention?

Clinical instructors were asked their perceptions of students’ clinical activities to

address research question six:

6. What were clinical instructors’ perceptions of students’ clinical activities

during the educational intervention period?

57
3.2 Population and sample

The target population for this study was all second-year nursing students who were

enrolled in a nursing school in Central Kalimantan at the time of the study

(September 2003 to March 2004). The population of this research study therefore

consisted of all nursing students from four nursing schools in Central Kalimantan,

Indonesia. There was total of approximately 560 students in these schools at the time

of the study.

The sample for the study was nursing students in the second year of their studies.

This was justified on the basis that students in their first semester of first year do not

study nursing-specific subjects, as prescribed by the Indonesian nursing curriculum.

Students commence their nursing subjects in the second semester of the first year of

their course. There were approximately 60 second-year students at each school. To

be eligible for the study the students had to meet the following criteria: be in their

second year of nursing study at the time of the research study and be willing to be

involved in the research study.

3.3 Sampling technique

3.3.1 Quantitative sampling

A random sampling procedure is generally recommended and argued to be the most

rigorous in allowing for generalisability (Bowling, 2002; Buckwalter, Maas &

Wakefield, 1998; Polit & Hungler, 1999; Punch, 1999). However, important

considerations such as costs, time and convenience for determining sampling designs

are also raised as critical issues (Neuman, 2000).

58
Randomisation of individuals to groups within this sample was not possible because

of the nature of the study design and educational system in nursing schools in

Indonesia. If the researcher had randomly allocated students to either control or

experimental groups from the same school or the same area, there would have been

the opportunity for discussion of the intervention between members of both research

groups, as students would have time together in clinics or in the class. The time

together would provide opportunities to discuss aspects of the intervention, which

may have caused contamination of the data collected from the control group and

experimental group. The control group may have inadvertently adopted some aspects

of the intervention in their method of study.

Random selection of schools was possible, however, as they were located in different

districts. Of the four nursing schools in Central Kalimantan, two of these were

similar in funding, size, human resources, and curricula. Based on those similarities,

these two schools were selected to be in the study. Following a letter of agreement

from the nursing schools, both heads of the nursing schools were invited to attend a

meeting. Information about the study was given to them, including the purpose and

procedures of the study. They were told that students’ participation in the study was

voluntary and that the students could withdraw at any time. One of these two schools

was randomly allocated to become the ‘intervention school’, and the other became

the ‘control school’. Simple random sampling using a coin toss, ‘heads’ as

intervention and ‘tails’ as control, was used to draw which school became the

intervention school or control school.

One of the major outcome variables in this study was the SDLRS scores. The sample

size for the study was estimated from mean scores for SDLRS, with 50 participants

59
in each group, assuming a baseline average SDLRS score of 190 points (SD = 18).

With this sample size it was possible to detect mean changes over time of 10 units or

more with 80% power at 95% significant level (one-tailed). Therefore, the power is

considered to be adequate with a sample of this size. To allow for eligible students

who may refuse to participate and a further 10% of respondents who could withdraw

or be excluded during the study, the sample needed to be inflated by 20% (to n = 60

per group). Thus, 120 eligible second-year nursing students were needed to be

approached to retain 50 participants in each group by the end of the study.

Students from second year classes were asked to volunteer to participate in the study.

A total of 101 students participated in the study. Forty-seven of fifty students in the

intervention school volunteered to participate, and forty-four of sixty students in the

control school volunteered to participate in the research study. Gay (2003) cautions

about generalising results obtained from volunteers to the population being studied,

suggesting that samples could be biased. This study among nursing students is the

first of its kind in Indonesia and therefore exploratory in nature. It will need to be

repeated to verify any variances before generalising to the larger population of

nursing students.

3.3.2 Qualitative sampling

3.3.2.1 Student participants
Participant students were also invited to participate in focus group discussion (FGD).

Twenty-four second-year students from each school, giving a total of forty-eight

students, volunteered to participate in FGD. Each school had two groups for FGD

pre- intervention and one group post- intervention. The FGD were undertaken in two

nursing schools in Central Kalimantan. Each group consisted of eight participants

and a total of six focus groups were conducted across the two schools.

60
 3.3.2.2 Clinical instructor participants
Clinical instructors from the intervention school and control school were invited to

participate in focus groups. The FGD for clinical instructors was held at the end of

the study. Twelve clinical instructors volunteered and consented to participate in the

two focus group discussions. The clinical instructor groups comprised six nurses

from the intervention and six nurses from the control group.

3.4 Ethical considerations

The study was granted ethical approval from the University Human and Research

Ethics Committee, Queensland University of Technology, and permission from the

Regional Body Research and Development (Balitbangda), Central Kalimantan

Province. All potential student participants in this study were given verbal

information and written information sheets about the study and informed of their

rights. They were informed that participation in the study was voluntary and that they

could withdraw at any time without explanation, and that withdrawal would have no

effect on their current or future study. The participants were assured that their

academic progress or future study would not be affected by their decision to

participate, or not participate, in the research study.

In anticipating that some students may feel unable to refuse due to their cultural

background in Indonesia, the researcher made it very clear to all potential

participants that she was not an employee of their schools or affiliated with them in

anyway, and had no capacity to intervene in their academic progress or future study.

The researcher provided ongoing support during the educational intervention

program. Opportunities were provided for participants to ask questions at any time,

and the researcher was freely available to answer all participant questions related to

61
the study. If required, students could also talk freely with the head of the nursing

school if they had any concerns about the study. All students were assured about the

confidentiality of their responses. All information collected was confidential and was

not disclosed to anyone other than the researcher. No names appeared on any results

and a coding system known only to the researcher was developed and used.

It was considered that the risks for students from this research study were minimal.

However, a potential risk existed if students perceived a threat to their academic

progress if they did not participate, or a heightened expectation of their performance

if they did participate. The intervention group could also believe that the educational

intervention program increased their study load. The control group could think that

they were treated unfairly because they did not participate in the educational

intervention program. In order to reduce the risk for students, it was explained to the

students during a group presentation how they could benefit from this study. The

intervention group could increase their knowledge and basic skills in SDL. The

control group got the same module as the experimental group at the end of the study.

An information sheet (Appendix 5 and 6) and written consent form (Appendix 7) was

given to each student.

3.5 Dependent and independent variables

The dependent variable or outcome variable in this study was students’ readiness for

SDL scores at post- test. This variable is a continuous variable. The students’

readiness for SDL was measured by the SDLRS (Guglielmino, 1978). The main

independent variable or explanatory variable was the group (intervention or control

group). Additional independent variables were selected in response to the literature

62
in the area of SDL, which suggests these factors may influence SDL, and included

age and gender.

As there were no previous published studies in SDL in nursing education in

Indonesia, the following variables were considered by the researcher to potentially

affect the students’ readiness for SDL and hence the following data also were

collected: first born order (yes/no; dichotomous variable), father’s educational

background (categorical), and mother’s educational background (categorical

variable). The pre-test SDL scores were used as a covariate.

3.6 Instrument

Two questionnaires were used to collect the quantitative data in the study—the

SDLRS and a demographic questionnaire.

3.6.1 Self-Directed Learning Readiness Scale (SDLRS)

The SDLRS is a self-report questionnaire that uses a 58-item Likert scale.

Individuals respond by indicating whether each item on the scale is: 1 = Almost

never true of me; I hardly ever feel this way; 2 = Not often true of me; I feel this

ways about half the time; 3 = Sometimes true of me; I feel this way more than half

time; 4 = Usually true of me; I feel this way more than half the time; 5 = Almost true

of me; there are very few times when I don’t feel this way. The SDLRS contains both

positively and negatively phrased items, where 41 of the items are positively phrased

and 17 negatively phrased. The questionnaire is designed to measure the attitudes,

values and abilities of an individual relating to his/her readiness to engage in self-

directed learning at the time of response. According to Guglielmino and Guglielmino

(1991), the SDLRS collects data on the following aspects: openness to learning

63
opportunities, self-concept as an effective learner, initiative and independence in

learning, informed acceptance of responsibility for one’s own learning, love of

learning, creativity, positive orientation on the future, ability to use basic study, and

problem solving skills.

The readiness is assessed as a total score with possible scores ranging from 58 to

290. A high score indicates a high readiness for self-directed learning. These scores

are then converted into bands of readiness: low [58 to 176], below average [177 to

201], average [202 to 226], above average [227 to 251], and high [252 to 290]

(Guglielmino & Guglielmino, 1991).

The original study by Guglielmino was undertaken in the USA with college students.

The mean score was obtained in Guglielmino’s study of 214, with a standard

deviation of 25.6. This mean score has been used for comparison purposes in many

studies (Bulik & Romero, 2000; Delahaye & Choy, 2000; Jones, 1992; McCauley &

McClelland, 2004). According to Guglielmino and Guglielmino (2005) more than

500 major organisations from around the world have used the SDLRS, and more than

100,000 adults and 100,000 children have completed the SDLRS. The majority of the

studies have been conducted in western and developed countries. The instrument has

been translated into more than 17 languages, including French, Spanish, German,

Italian; Finnish; Japanese; Chinese; Korean; Greek; Portuguese, Arabic, Russian,

Indonesia and has a 27 year history of usage (Guglielmino & Guglielmino, 2005).

It takes about 30 minutes to complete the SDLRS (Guglielmino & Guglielmino,

1991). The total scores obtained by each individual are used to indicate his/her level

of readiness for SDL in relation to SDL norms. The scores and corresponding levels

(see Table 2.4), and the nursing students’ SDLRS scores in the current study could

64
therefore be compared to the normative data provided by Guglielmino and

Guglielmino (1991).

The SDLRS was developed and has been widely used in English speaking countries,

where the educational system and cultural background is different from that of

Indonesia. Therefore, accurate translation of the instrument (SDLRS) for use with an

Indonesian population was important. Prieto (1992) argued that the goal of the

translator is to produce a translation which will be equivalent to the source and

understood by the audience for whom it is translated. The SDLRS had been used in a

previous Indonesian study (Darmayanti, 1994). For the purpose of the study the

SDLRS was translated into Indonesian in 1992 and has been piloted and used to

collect data on students’ readiness for SDL with Indonesian Open University

students. The procedure for translation in Darmayanti’s study combined methods

suggested by Brislin (1980) and Prieto (1992): a committee approach, a back

translation, and a pre-test procedure or a pilot testing of the translated instrument.

The Indonesian version of SDLRS in Darmayanti’s study was piloted on 37

Indonesian Open University students and was then administered to 391 Indonesian

Open University students in the main study. Based on the procedure of translation

outlined in Darmayanti’s study the translated SDLRS was regarded as a sufficiently

reliable and accurate translation. Darmayanti found that the outcome of the pilot and

main study showed that Indonesian Open University students were familiar with

SDL concepts and the instrument was easy to comprehend. Therefore, she concluded

it to be suitable for Indonesian Open University students.

However, Indonesia is diverse in ethnicity and language as there are approximately

3000 ethnic groups and 250 languages and dialects. Despite “Bahasa Indonesia”

65
being the national language, the majority of Indonesians have a language other than

Indonesian as their “first” language. Sechrest, Fay and Zaidi (1988) identified that

dialect differences and regional differences in colloquial speech and idiom all

contribute to potential sub cultural research problems. As a result, it was thought

appropriate for the present study to check the Indonesian SDLRS for language and

dialect influences.

In order to use the SDLRS it was necessary to purchase the instrument from the

author. The SDLRS was translated into Indonesian contemporary language based on

suggestions from Darmayanti (1994). She suggested adding further explanations for

students in parentheses for items in number 33 and 53 to ensure that the students

would understand the items clearly. The original Indonesian translation of SDLRS is

11 years old and tended to have a ‘Javanese influence’. For example, the word ‘ajeg’

(constant) in parentheses for item number 33 is not common to non-Javanese so the

word ‘ajeg’ was not added in parentheses for the current translation.

Five bilingual Indonesian undergraduate students studying in Brisbane were asked to

complete the translated SDLRS and they were also asked to give feedback on the

items that were not clear enough from their point of view. No changes were made to

the translated SDLRS draft. The draft of the translated SDLRS was then sent to a

registered translator to check for accuracy and appropriateness of translation. After it

was checked by the registered translator, the translated SDLRS was considered as a

second draft. The second draft of the SDLRS was pilot tested before administration

to participants in the main study. The SDLRS is provided in Appendix 1.

66
3.6.2 Demographic questionnaire
A demographic questionnaire (see Appendix 2) was developed by the researcher

based on literature related to SDL. Personal characteristics that were likely to

influence readiness and ability for SDL were identified from the literature. The

demographic questionnaire therefore included the following participants’

characteristics: gender; age; birth order (First born: yes-no); father’s educational

background (≤Junior High School or ≥Senior High School), and mother’s

educational background (≤Junior High School or ≥Senior High School).

3. 7 Procedure of data collection

Letters were sent to the head of each nursing school expressing a request to conduct

the research study at the nursing schools and seeking permission to do so. Letters of

agreement from the schools were provided before conducting the research study.

Subsequent to ethical approval being obtained, the eligible students were identified

from administration records and they were invited to participate in the research study

through invitations on notice boards and through teaching staff.

Prospective participants then attended a meeting where the researcher made it very

clear to students that their participation was voluntary and they were free to withdraw

anytime. Information sheets and consent forms were distributed to the participants

and they were asked to read and sign the consent form and return their consent form

to the researcher. After informed consent was obtained, the prospective participants

from the intervention school and the control school completed the pre-test

questionnaires. Both the intervention group and the control group were post- tested

for SDL after 14 weeks. During the 14-week period, students from the intervention

school participated in the educational intervention program.

67
 Following the pre-test, the prospective participants in both intervention and control

groups were invited to attend an initial focus group discussion (FGD). The FGD

were held to collect qualitative data on students’ perceptions of SDL and used

modified guidelines by Myers (1999). The guidelines outline each step of the process

for the researcher and the assistant; from before participants arrive to when they

leave. The same guidelines were used to conduct all FGD. Table 3.1 shows the

modified focus group protocol used in the study.

Table 3.1: Modification of focus group protocol

. No Phase Specifics

This table is not available online.

Please consult the hardcopy thesis
available from the QUT Library

Source: Myers (1999 p.105)

68
Each group was asked a generic set of questions about their perceptions and practice

of SDL. In doing this, the researcher used a FGD interview script; it was a plan for

covering topics so the desired information was obtained. The FGD interview scripts

provide a series of questions framed together to answer the research questions. The

scripts began with an ice-breaker question which required little reflection and worked

up to more penetrating questions (key questions). This allowed participants to warm

to the context and subject matter before being asked to explore the subject which

took more thought or was more difficult to discuss. The length of each group

interview varied between 90 to 120 minutes and was audio taped for transcription.

Table 3.2 show the FGD script for students before the educational intervention

program (EIP).

Table 3.2: Student focus group script before intervention

1. Thank you for participating in this program

2. Introduce purpose of focus group
3. Ice-breaker question: Have you heard about self-directed learning?
4. 4. Key questions
• What does self-directed learning mean to you?
• What do you think self-directed learning involves?
• What teaching and learning issues will arise if self-directed learning was
implemented?
5. Summary question: these are the main point raised today
• Do you agree?
• Is there anything you would like to add?
Thank you very much for your participation in this focus group and good bye.

The script was used for the intervention and control groups before the EIP and was

also used for control group FGD after EIP. The following table presents the FGD

script for students in intervention group after the intervention program was

69
completed (Table 3.3). This interview script was only used for the intervention

group, as only this group could talk about the SDL activities.

Table 3.3: Student focus group script after intervention

1. Thank you for participating in this FGD

2. Introduce purpose of FGD
3. Ice-breaker question:
• Did you enjoy the program?
• What did you learn?
4. Key questions
a. What does self-directed learning mean to you?
b. Generally, describe your SDL activities
c. What do you think are the benefits of self-directed learning?
d. What teaching and learning issues will arise if self-directed learning was
implemented?
5. Summary question: these are the main point raised today……
• Do you agree?
• Is there anything you would like to add?
Thank you very much for your participation in this focus group and good bye.

Clinical instructors’ perceptions of students’ clinical activities in clinical settings

during the implementation period were explored through FGD at the end of the

study.

The FGD interview script was used for clinical instructors from both groups and is

presented in Table 3.4.

70
Table 3.4: Clinical instructor focus group script
1. Thank you for participating in this program;
2. Introduce purpose of focus group;
3. Ice-breaker questions
• Can you tell me, what did students do in clinical practice?
• What did you think about the clinical practice?
4. Key questions
a. Do you think the 2nd year students were “more active” in clinical practice compared
to 3 months before? (If “yes”, continue to question b, if “no”, skip to question 5)
b. Can you give some examples of students being “more active”?
c. What do you think the implication of students being “more active” to your
workload?
d. What issues will arise relevant to your professional development if students are
more active?
5. Summary question: these are the main point raised today……………
• Do you agree?
• Is there anything you would like to add?
Thank you very much for your participation in this focus group and good bye.

3.8 Pilot study

Polit and Hungler (1999) state that the main focus of a pilot study is to assess the

adequacy of the data collection plan. Although the SDLRS had already been used

with Indonesian Open University students and has good reported reliability and

validity (Cronbach’s alpha = 0.91), a pilot study was conducted using the SDLRS

with the diploma nursing students to ascertain if the instrument was appropriate for

use with them. The pilot study is discussed in detail in Chapter Four.

3.9 Educational intervention

Intervention activities took the form of a structured educational intervention

program. The activities of the intervention in this study included introducing and

implementing the concepts of SDL, and evaluating the impact of the intervention on

71
students’ readiness for SDL. The main objective of the intervention was to improve

students’ self-directedness in learning.

Rombothan (1995) pointed out that the first steps undertaken to improve a learner’s

self-directed ability are to assess the current level of readiness for SDL that the

individual is able to exhibit. One of the ways to justify the level of SDL is to use an

assessment tool known as SDLRS (Guglielmino, 1978). The level of students’

readiness for SDL in the current study was assessed before and after the intervention

using the SDLRS.

The educational intervention program comprised a four-day workshop, a four-day

skills practice in a nursing laboratory and three days a week for 12 weeks of clinical

practice in hospital settings to apply SDL concepts. A self-directed module and

learning plans were used to operationalise the SDL concepts. Piskurich and Piskurich

(2003) state that support systems are needed to assist students’ efforts to become

self-directed learners. In order to provide support for students, three tutorial meetings

were held in weeks 3, 6, and 9 during the implementation period. The educational

intervention program is discussed in more detail in Chapter Five.

3.10 Data analysis

3.10.1 Quantitative data analysis

The data obtained from the questionnaire were analysed using the SPSS statistical

software package version 12. Each response was coded and entered into the software

database to conduct statistical procedures such as descriptive statistics, one sample t-

test, independent-samples t-test, analysis of covariance and multiple regression

analysis. The level of significance was set at .05.

72
Descriptive statistics were used to explain demographic data. A one sample t-test was

conducted to examine differences on SDLRS scores between sample study scores

and the norm group scores (Guglielmino, 1978). The difference on SDLRS scores

between intervention and control groups at pre-test was examined using an

independent sample t-test. Analysis of Covariance (ANCOVA) was conducted to

explore differences between groups (intervention and control groups) on post test

SDLRS. Multiple regression was employed in this study to explore the relationship

between scores on post test SDLRS and independent variables—including group

(intervention and control), gender, birth order (first born and non first born), father’s

educational background (less than or equal to Junior high school and more than or

equal to Senior high school), and mother’ educational (background: less than or

equal to Junior high school and more than or equal to Senior high school).

3.10.2 Qualitative data analysis

The aim of the qualitative component of the study was to ascertain and analyse

nursing students’ perceptions about SDL and their clinical instructors’ perceptions

about students’ activities in clinical practice before and after the introduction and

implementation of an educational intervention.

The transcripts from the FGD were analysed by thematic content analysis using

guidelines proposed by Burnard to identify emerging themes (Burnard, 1991).

Burnard’s original guidelines comprised 14 steps. The guidelines were adapted from

Glaser and Strauss’ grounded theory approach (Glaser & Strauss, 1967), work on

content analysis (Babbie, 1979; Couchman & Dawson, 1990; Fox, 1982), and from

other sources concerned with analysis of qualitative data (Bryman, 1988; Field &

Morse, 1985). The method employs a step-by-step approach to coding and

73
categorising focus group transcripts. For the purpose of this study, Burnard’s

guidelines were modified from 14 stages to 17 steps. All focus groups were analysed

using the same processes. The modification of Burnard’s guidelines is summarised in

Table 3.5 and outlined in more detail in the results section of this thesis (see Chapter

6).

Table 3.5: Modification of Stages of Thematic content Analysis

1 Transcription of taped interviews into original language (Indonesian)
2. Transcriptions read and notes made about general themes
3 Transcriptions were translated from original language (Indonesian) into English
4 The transcriptions were then checked by a registered translator for accuracy of
translation and quality of data
5 Open coding–Re-read transcripts and developing descriptive categories
6 Independent preliminary themes by two researchers–three lists of themes were
developed
7 Transcribed the three lists into separate document
8 Reviewed the three lists for commonalities/link between any of them and grouped
together into categories
9 Each group was explored for subcategories. Repetitious or very similar categories were
removed to produce a final list
10 The two researchers were asked to verify the accuracy of categorisation system
11 Modifications were made to produce final list
12 Re-read transcripts to check a true representation of the interview had been captured
13 Section transcripts were identified and coded under corresponding categories
14 “Cut” and “pasted” the section of transcripts in step 13
15 Results from step 14 were translated back to original language while keeping the
English categorisation for further analysis*
16 Returned the thematic content analysis results (original language) to the focus group
participants to check for “truth value”
17 Write up the findings alongside relevant literature and research, using direct quotes
from the transcripts to further illustrate the point under discussion
*Maintain copies of complete transcript for future reference.

Source: Adapted from Burnard (1991)

74
3.11 Summary

This chapter outlined the rationale for the study design. Population and sample,

sampling technique, and independent and dependent variables were also presented.

Instrument and data collection methods were explained and reliability coefficients

reported. Ethical considerations and potential risks were described. Data analysis

plans completed the chapter. The following chapter outlines the pilot study.

75
 CHAPTER FOUR

PILOT STUDY

4.0 Introduction

Many authors have confirmed that the importance of a pilot study is to provide

information for a main study (Lakey & Wingate, 1998; Polit & Hungler, 1999).

Buckwalter, Maas, and Wakefield (1998) make the point that a pilot study is strongly

recommended before conducting any major experimental study. According to Polit

and Hungler (1999) the main focus of a pilot study is to assess the adequacy of the

data collection plan. The proposed data collection and analysis procedure can then be

evaluated and changed as needed. Polit and Hungler (1999) make further comment

on the importance of pilot studies, even when the data collection plan involves the

use of existing standardised instruments.

The main study was to use the SDLRS, which had already been used with Indonesian

Distance Learning students (Darmayanti, 1994), and had good reported reliability

and validity (Cronbach’s alpha = 0.91). However, for the current research, a pilot

study was conducted using the SDLRS with nursing students in Central Kalimantan

to ascertain if the instrument was appropriate for use with them. Testing of the

educational intervention was not possible due to time constraints associated with

fully pilot testing a 14-week intervention, but data from the pilot study could be used

to test the recruitment method. In addition, the pilot study would provide insights

into the students’ levels of SDL readiness, which could help to inform the content of

the educational intervention program.

76
There were two purposes for conducting the pilot study:

• To examine the internal reliability and test-retest reliability of the Indonesian

version of SDLRS;

• To trial the recruitment method.

Two questions were used to guide the pilot study:

• What was the reliability of the Indonesian version of the Self-Directed

Learning Readiness Scale (SDLRS) when used among student nurses from

Central Kalimantan, Indonesia?

• Did the recruitment method achieve the required sample?

This chapter begins by presenting a description of the design, sample, instrument,

and procedures for the collection of data. Analytical approaches to the data are then

presented, followed by results and discussion. The chapter concludes with a

summary.

4.1 Design

A descriptive exploratory design was used for the pilot study. A survey was

administered at two time points. Data were collected using the SDLRS and a

demographic questionnaire. At Time 1, participants were asked to complete the

SDLRS and the demographic questionnaire, and at Time 2 they were asked to

complete the SDLRS. The period of time between Time 1 and Time 2 was two

weeks.

77
4.2 Sample

Participants selected for the pilot study came from the same population that was to be

used for the main study. The population for the main study was to be all second-year

nursing students from four nursing schools in Central Kalimantan at the time of the

study (September 2003 to March 2004). These schools had approximately 560

second-year students. The sample for the pilot study was chosen to ensure they had

similar characteristics to those of the main study. The pilot study was therefore

carried out in a school of nursing in Central Kalimantan, Indonesia, which was a

different school to those involved in the main study.

Nieswiadomy (1993) indicates there is no set number of participants needed for a

pilot study. The sample size for the pilot must be large enough to detect flaws or

weaknesses in the methodology and will depend on the overall size of the population.

Treece and Treece (1986) recommend that a pilot study sample be one-tenth the size

of the sample proposed for the main study. This pilot study used the Treece and

Treece (1986) suggestion on the sample size. The desired sample size for the main

study was at least 100 participants so the minimal sample size of the pilot study was

10 participants. A total of 54 second-year students from a total of 520 students in the

pilot school volunteered to participate in the study. It was decided to include all

voluntary participants in the pilot to ensure a large enough sample size. The larger

than required sample size would provide a good description of SDL for nursing

students in Central Kalimantan. This information would be very useful for designing

and planning the educational intervention.

78
4.3 Instruments

Two questionnaires were used in the pilot study. Guglielmino’s Self-Directed

Learning Readiness Scale (SDLRS) was used to collect data on students’ readiness

for SDL and a demographic questionnaire was used to collect data on gender, age,

birth order, father’s educational background, and mother’s educational background.

The Self-Directed Learning Readiness Scale (SDLRS), a commercially available

self-report instrument (see Appendix 1), was developed by Guglielmino (1978). It

has become the most widely used and well-respected instrument for the assessment

of readiness for SDL (Guglielmino & Klatt, 1993; Harvey & Harvey, 1995; Walker

& Long, 1997; McCune, 1988).

The SDLRS is reported to have a Cronbach’s alpha reliability coefficient of .87

(Guglielmino, 1978). As described by McCune, Guglielmino, and Garcia (1990), the

latest reliability estimate based on a varied sample of 3,151 adults, was 0.94. Wiley

(1983), in a study of 104 undergraduate nursing students, used a test-retest of SDLRS

and reported a Cronbach’s alpha coefficient of .91 (pre-test) and .79 (post-test). It is

important to note that the time between the administrations of the two tests was nine

weeks. This may have affected the reliability coefficient at the post-test. Another

study reported on the test-retest reliability of SDLRS (Finestones, 1984). This study

reported a reliability coefficient of .92 (Time 1) and .82 (Time 2). However, the time

between the two tests was not reported. Studies in Indonesia that used the SDLRS

have reported Cronbach’s alpha coefficients of .87 at pilot study and .91 at main

study (Darmayanti, 1994).

79
A demographic questionnaire (Appendix 2) was developed by the researcher based

on literature related to SDL. Personal characteristics that were likely to influence

readiness and ability for SDL were identified from the literature. The demographic

questionnaire therefore sought information regarding the following characteristics of

participants: gender; age; birth order (First born: yes-no); father’s educational

background (≤Junior High School or ≥ Senior High School), and mother’s

educational background (≤Junior High School or ≥ Senior High School).

4.4 Procedure

A letter was sent to the head of the pilot school expressing an intention to conduct

the pilot study and seeking permission to do so. A letter of agreement from the pilot

school was provided before conducting the pilot study. Subsequent to ethical

approval from Queensland University of Technology (QUT) and from the Regional

Body Research and Development Office (Balitbangda), all eligible students were

identified from the pilot school administration records. The students were invited to

participate in the pilot study through an invitation on notice boards and through

teaching staff who informed students about the study during scheduled classes. Prior

to commencement of the pilot study, an information meeting was held with second

year students. An information sheet was given to those who attended the meeting to

explain the purpose and procedure of the study. Students were told their participation

was voluntary and that they could withdraw at any time, and that non-participation

would not affect their academic results or future study. They were told that all

information would be treated confidentially.

Students who agreed to participate in the pilot study were asked to sign a consent

form (Appendix 7). Fifty-four second year students from a total of 300 second-year

80
students in the pilot school agreed to participate in the pilot study for Time 1 and

Time 2, and they also signed the consent form. The questionnaires were then

distributed to participants after the meeting and they were asked to complete the

questionnaires at the same time in one room.

The length of time it took to administer the SDLRS for students in the pilot study

was noted. It took approximately twenty-five minutes for the students to complete

the SDLRS at Time 1 (range between 24 and 32 minutes) compared to thirty minutes

as noted in the literature (Guglielmino & Guglielmino, 1991). To identify issues such

as ambiguity and misinterpretation of the question, students were asked to comment

on the SDLRS.

After two weeks, participants were asked to come back together to complete the

SDLRS again and to give their comments. The time to administer the SDLRS for

Time 2 was also noted. The range of time to complete the SDLRS for Time 2 was

between 20 and 35 minutes.

4.5 Data analysis

Quantitative analysis was undertaken using the Statistical Package for the Social

Sciences version 12 (SPSS version 12). The main purpose of data analysis in the

pilot study was to assess the reliability of the instrument for the Indonesian nursing

students and to trial data analysis techniques.

The data analysis included univariate analysis of key variables using frequency

distribution, measures of central tendencies and normality, and bivariate analysis

using χ². Independent sample t-tests were used to evaluate the difference in mean

scores between groups based on the demographic data—including gender, age, birth

81
order, father’s educational background, and mother’s educational background.

Internal consistency and temporal stability of the SDLRS were examined with inter-

item correlation (Cronbach’s alpha), Pearson’s correlation, and Bland Altman scatter

plot (1986). Statistical significance was set at alpha .05.

4.6 Results

This section describes the demographic characteristics of the pilot sample,

descriptive statistics for SDLRS and analysis of internal consistency and temporal

stability of SDLRS. It concludes with some general comment about SDLRS.

4.6.1 Demographic characteristics of the pilot sample

Demographic data relating to the pilot sample are presented in Table 4.1.

Table 4.1: Demographic data of pilot sample

Variables Total (n=54) Chi-square test
n (%)
χ² P value
Gender
Male 20 (37) 3.630 0.06
Female 34 (63)
Age
0.296
≤ 20 years 29 (54) 0.59
≥ 21 years 25 (46)
Birth order: First born
0.296
Yes 25 (46) 0.59
No 29 (54)
Father’s educational
background 16 (30) 8.96 0.003
≤ JHS1 38 (70)
≥ SHS2

Mother’s educational
background 23 (43) 1.185 0.276
≤ JHS1 31 (57)
≥ SHS2
1
JHS = Junior High School
2
SHS = Senior High School

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Overall, the sample consisted mainly of females (63%) with 37% of males.

Participants’ ages ranged from 18 to 24 years (M = 20.48 and SD = 1.15). More

participants were within the age group ≤ 20 years (54%) compared to the age group ≥

21 years (46%). Similarly, just over half of the participants were not first-born

children (54%). There were more participants whose fathers (70%) and mothers

(57%) had completed at least senior high school, compared to parents who had just

completed junior high school.

A one-sample chi-square test was conducted to assess whether the proportions of

participants were equal for the selected demographic variables. The result indicated

that there were no significant differences between demographic variables, except for

father’s educational background. There was a significant difference in father’s

educational background. Significantly, more students in the pilot study had fathers

who had completed at least senior high school χ² (1, N= 54) = 8.96, p= .003.

The sample characteristics indicated that the pilot sample demographics were

consistent with those of nursing students in Central Kalimantan or in Indonesia.

4.6.2 Readiness for self-directed learning

The mean and standard deviation of Time 1 and Time 2 SDLRS scores were

calculated. The overall mean and standard deviation for the sample at Time 1 was

188.59 and 17.33, respectively. The mean and standard deviation for the sample at

Time 2 was 189.30 (SD = 16.88). Table 4.2 presents the mean and standard deviation

for the SDLRS scores at Time 1 for each of the demographic variables. Those data

indicate that the pilot sample had mean SDLRS scores lower than those reported in

the literature.

83
Table 4.2: Means and standard deviations of SDLRS scores at Time 1
Demographic variables Mean (SD) t p
Gender
Male 185.45 (16.62) - 1.02 .31
Female 190.44 (17.72)
Age
≤ 20 year 187.34 (15.82) -.56 .57
≥ 21 year 190.04 (19.17)
Birth order: First born
Yes 188.44 (20.47) -.06 .95
No 188.72 (14.47)
Father’s educational background
≤JHS1 188.75 (17.89) .043 .97
≥ SHS2 188.53 (17.34)
Mother’s educational background
≤JHS1 185.91 (17.09) -.98 .33
≥SHS2 190.58 (17.52)
1JHS = Junior High School
2SHS = Senior High School

The data suggest that female nursing students, older nursing students and nursing

students whose mother had completed at least senior high school had higher SDLRS

scores than male nursing students, young nursing students, and nursing students

whose mother had completed junior high school education. However, an independent

sample t-test was used to examine the mean differences between the two groups for

each variable. The results showed that there were no significant differences for any

of the demographic variables (see Table 4. 2). The distribution of the sample within

the five levels of readiness as suggested by Guglielmino and Guglielmino (1991)

were examined. The distribution of the sample is shown in Table 4.3.

84
Table 4.3: Level of readiness for self-directed learning at Time 1
Level of readiness Score Time 1 n (%)

Low 50–176 16 (30)

Below average 177–201 26 (48)

Average 202–226 11 (20)

Above average 227–251 1 (2)

High 252–290 0 0

Of the total number of 54 participants at Time 1, 30% had a low level of readiness,

48% were below average, 20% were average, and only 2% were above average. Not

one participant had a high level of readiness. This result clearly showed that the

majority of participants (78%) had below average and low levels of readiness for

SDL.

4.6.3 Internal consistency

Cronbach’s alpha was used to assess internal consistency for the SDLRS in the

current pilot study. Based on sample data of 54 students, the Cronbach’s alpha was

0.85 (Time 1) and 0.84 (Time 2). These data indicate that for the current sample of

nursing students in Central Kalimantan, the internal consistency was good. These

data are consistent with other reported studies. The SDLRS has good internal

consistency with a Cronbach’s alpha coefficient reported of 0.87 in the initial study

(Guglielmino & Guglielmino, 1991). As described by McCune, Guglielmino, and

Garcia (1990), the latest reliability estimate, based on a varied sample of 3,151

adults, was 0.94. The SDLRS has been used to assess readiness for self-directed

learning in Indonesian Open University students. In a pilot study (Darmayanti,

1994), a Cronbach’s alpha was reported for Indonesian Open University students

85
(n=37) of 0.87, and in a main study (N= 391), the Cronbach’s alpha was reported as

0.91.

4.6.4 Temporal stability

A Pearson’s correlation coefficient was calculated to determine the strength of

relationship between responses (n=54) to the SDLRS over time, with two weeks

between Time 1 and Time 2. The result was r = 0.985 (p<0.001). Figure 4.1 shows

the agreement of the measurement at Time 1 and Time 2.

Bland-Altman plot for reproducibility

of test

6
Difference in test scores (time2-

2
time1)

-2

-4

-6

140 160 180 200 220 240

Average of two measurements
Comparing test two weeks apart

Figure 4.1: Bland-Altman plot for reproducibility of SDLRS Scores

The level of agreement between responses at both administrations was plotted using

a method described by Bland and Altman (1986). The level of agreement for each

participant was within 95% confidence estimates (- 5.22 and 6.62), indicating that the

SDLRS was stable over time. The mean difference was 0.70 and standard deviation

was 3.02.

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4.6.5 General comment on the SDLRS
Following completion of the SDLRS, students were asked for their comments, if they

were able to understand the entire questions and if the questions were clear and easy

to understand. All responded that it was clear and easy to follow the meaning of the

questions. Their comments were supported by the time taken to complete the

SDLRS. The shortest time was 24 minutes at Time 1 and 20 minutes at Time 2. The

longest time to complete the SDLRS at Time 1 was 32 minutes and at Time 2 was 35

minutes. The times are very similar to the times reported in the literature

(Guglielmino & Guglielmino, 1991), and indicated that the students did not find the

questions difficult or time consuming. Other supporting evidence came from the

questionnaires, as all the questions were answered and there were no missing data

from the questionnaires.

4.7 Discussion

The findings of the pilot study show that the age and demographics are consistent

with second year nursing students in Central Kalimantan and in Indonesia. The pilot

study showed that the instrument for the study—the Indonesian version of the

SDLRS—could be used effectively in the Indonesian setting. It is effectiveness was

shown by:

• the internal consistency estimated by Cronbach’s alpha coefficients of 0.84

(Time 1) and 0.85 (Time 2)

• the reproducibility shown by the Bland and Altman plot

• the temporal stability estimated by the Pearson’s coefficient (.98)

• the lack of difficulty the students reported understanding and responding to

the questions

87
 • the relatively short time to complete the SDLRS.

The descriptive results of the pilot study showed that the mean SDLRS score of Time

1 was 188.59 (SD= 17.33). The Time 2 mean was 189.30 (SD = 16.88). Compared to

the data from the Guglielmino study (1978) where the mean of SDLRS was 214

(SD= 25.6), the pilot study scores are lower. Darmayanti’s study (1994) of

Indonesian students reported a mean SDLRS of 215.5 (SD= 21.9). Both of these

studies reported higher SDLRS means compared to the current pilot study.

Seventy-eight per cent of students in the pilot study had SDLRS scores that placed

them in the “below average” and “low” level of readiness for SDL group. Compared

to the finding of Darmayanti’s study (1994), which found that approximately 25.5%

of the sample had above average level of readiness for self-directed learning, the

finding of the pilot study showed a lower percentage of students (2%) with above

average levels. One fifth of the overall percentage of students (20%) in the pilot

study had average scores.

The different results of the pilot study from Darmayanti’s study (1994) might be

explained by the characteristics of students involved in Darmayanti’s study. The

students were likely to have had a high self-directed learning readiness before they

enrolled in the university program. Their motivation to enrol in distance learning at

the Indonesian Open University suggests that they may have had high levels of SDL

before commencing their university studies. A second explanation could be that the

Indonesian Open University already uses SDL concepts in their educational system.

As a distance learning institution, Indonesian Open University students require a

different approach from the passive engagement approach mainly used by

conventional education institutions such as the pilot school. A third explanation

88
could relate to the differences between cohorts. Approximately 70% of Darmayanti’s

(1994) samples were mature students (working students) compared to the pilot

sample of high school graduate students. Furthermore, 79% of Darmayanti’s samples

came from big cities in Indonesia (Java), whereas the pilot sample came from a

relatively remote area, in Central Kalimantan.

The pilot data confirm that the nursing students in Central Kalimantan were likely to

have low levels of SDL readiness. Confessore (1991) says that some people have a

low level of readiness because they have consistently been exposed to “other-

directed” instruction (teacher-centred approaches). The pilot study finding seems to

support Confessore’s views, as the educational system that is used in all nursing

schools in Indonesia involves “other-directed” instruction. Furthermore, the nursing

students had graduated from high school within two years and high schools in

Indonesia also use teacher-centred approaches.

Given the level of SDLRS scores reported in the pilot study, nursing students in

Central Kalimantan are likely to experience difficulties as the education system

moves away from teacher-centred approaches and introduces a student focus. The

data from the pilot study clearly demonstrates the need to assist students to develop

knowledge and skills in SDL.

No significant differences of readiness for SDL were found for gender, age, birth

order, father’s educational background and mother’s educational background.

Therefore, in the pilot study the difference between these variables did not affect the

students’ readiness for SDL.

A total of 54 participants from a total of 520 students in the pilot school volunteered

to participate in the pilot study. The desired sample size for the pilot study was at

89
least 10 participants. The invitation on notice boards and through teaching staff, and

the information meeting prior to the study successfully attracted students to

participate in the pilot study. Thus, the recruitment method was appropriate to

achieve the required sample in the pilot study and there were no difficulties with the

recruitment process.

4.8 Summary

The pilot study used the SDLRS to collect data on students’ readiness for SDL and,

based on the data obtained for this pilot study and the results of the statistical

analysis, the following conclusions were drawn:

• The SDLRS could be used effectively in Indonesia in a culture which is

different from the original culture in which the instrument was developed;

• The majority of students in the pilot school had below average and low levels

of readiness for SDL;

• There were no significant differences in students’ readiness for SDL for the

selected demographic variables;

• The recruitment method was appropriate to achieve the required sample.

The following chapter outlines the educational intervention program that was

developed to assist the students to improve their knowledge and skills related to

SDL.

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 CHAPTER FIVE

EDUCATIONAL INTERVENTION PROGRAM

5.0 Introduction

In Central Kalimantan, the majority of nursing education is conducted through a

traditional lecturing approach that focuses on the transfer of knowledge from teacher

to students. It places a greater value on didactic and non-student-centred methods,

with students seen as the receivers and teachers the transmitters of knowledge.

Central Kalimantan nursing students desire to be as successful as nurses educated in

western systems. However, significant improvements are needed in teaching and

learning approaches to better prepare students to be professional nurses. Nursing

education in Central Kalimantan needs to prepare students as lifelong learners, and

the students need to develop self-directed learning skills so they can continue to

provide effective nursing care throughout their nursing careers in a rapidly changing

healthcare environment (Health Professional Project V, 1998).

Successful implementation of self-directed learning (SDL) concepts is dependent not

only upon the students’ readiness to participate in SDL but also upon the nursing

education institution’s ability to facilitate SDL. Becoming self-directed learners is

not an easy process for either students or teachers. According to D’A Slevin and

Lavery, (1991) teachers who have operated in a traditional mode within curriculum

constraints of the past may find it difficult to adjust to a more student-centred

curriculum. Similarly, students in all types of curricula require some degree of

ongoing support from their teachers, especially students who have experienced

traditional modes of learning in their previous study and have never been faced with

self-directed learning. Therefore, students need to be introduced to SDL concepts,

91
experience the SDL process, and be supported in their efforts to improve their self-

directed learning abilities. Thus, nursing education should provide support for

students to become self-directed learners. The Educational Intervention Program

(EIP) outlined in the following section was developed in response to this need in

Central Kalimantan.

Results from the pilot study indicated that 78% of diploma nursing students had a

low or below average ability to self-direct their learning, encompassing quite a

dominant percentage of the pilot sample. It was assumed that the level of readiness

for SDL for the majority of nursing students in Central Kalimantan was similar to

that of the pilot sample, as they came from the same population. Time constraints of

the project and many limitations in nursing education in Central Kalimantan—for

instance human resources, teaching/learning materials (e.g. library, laboratory

equipment) as well as funding—had to be considered in developing the intervention.

The educational intervention program was developed as a planned classroom

approach to prepare students for SDL. It was designed to enhance the students’ self-

direction by creating planned experiences of SDL in the classroom setting.

This chapter presents the educational intervention program (EIP) that was used in

this study. The chapter begins by presenting the conceptual framework for the EIP.

This is followed by an overview of traditional diploma nursing curriculum structure

in Indonesia, specifically in Central Kalimantan; and activities of teaching and

learning in nursing education in Central Kalimantan. Control group learning

activities and intervention group activities are provided in the next section. The final

sections present the organisation of the EIP and evaluation of the EIP. The chapter

concludes with a summary.

92
5.1 Conceptual framework of the Educational Intervention

Program

Self-directed learning (SDL) is an important component in lifelong learning skills,

but to date there has been little emphasis on SDL in Indonesian nursing curricula

(Sister School Project, 2002). It would seem that there is a need to address this issue

and to investigate how best to facilitate SDL in the Indonesian nursing curriculum.

Introducing and providing students with the opportunities to experience SDL has

been suggested as one strategy for improving quality of teaching and learning in

nursing education in Central Kalimantan (Sister School Project, 2002). It has also

been assumed that introducing SDL approaches and improving students’ self-

learning abilities will assist students to become more “active” in, and to take more

responsibility for, their own learning.

A conceptual framework was constructed to guide teaching and learning of SDL in

this research study. The conceptual framework for the study is adapted from the

work of Grow’s (1991) staged self-directed learning (SSDL) model and the teacher-

student control continuum (TSCC) model developed by D’A Slevin and Lavery

(1991). This conceptual framework formed the basis for the educational intervention

program.

The conceptual framework comprises the stages of SDL, teacher and student roles in

every stage as proposed by Grow (1991), and the role relationship between teacher

and student as proposed by D’A Slevin and Lavery (1991). This conceptual

framework facilitated and guided the development of SDL knowledge and skills in

nursing students in Central Kalimantan, and appears as Figure 5. 1.

93
 Stage SDL Stage 1# Stage 2# Stage 3 Stage 4

Teacher role
Authority/expert
(SSDL) Motivator/guide Facilitator Consultant
content

Student role
Involved
(SSDL) Dependent learner Interested learner Self-directed
learner

Teacher-
student Students
Teacher direction Partnership Facilitation
Interaction direction
(TSCC)
#Shaded area denotes stages being addressed in the current study

Source: Adapted from Grow, 1991, and D’A Slevin and Lavery, 1991

Figure 5.1: Conceptual framework integrating Staged Self-Directed Learning (SSDL) and
Teacher-Student Control Continuum (TSCC)

According to Cresswell (1994, p.97) “[a] conceptual framework explains either

graphically or in narrative form, the main dimensions to be studied–the key factors or

variables—and the presumed relationship among them”. Sarantakos (1993, p.93)

explains “[i]n this sense frameworks guide research and coordinate researchers’

activities”. Similarly, Burns and Grove (2005, p.131) state: “[a] framework is the

abstract, logical structure of meaning that guides the development of the study and

enables the researcher to link the finding to body of knowledge”. The conceptual

framework for the educational intervention program was developed from its relevant

literature and was intended to guide the teaching and learning of SDL knowledge and

skills in order to enhance this ability in Central Kalimantan nurses. The educational

intervention used in this study focused on two stages of self-directed learning (SDL).

The SSDL model was developed by Grow (1991) and proposes that students advance

through stages of increasing self-direction in classroom settings. The model is

94
grounded in the situational leadership model of Hersey and Blanchard (1988), and

describes four distinct stages of learners. The SSDL model outlines how teachers can

assist students to become more self-directed in their learning. Within each of these

stages, Grow (1991) outlines a possible role for the teacher and students and how

they are related.

The SSDL model comprises four stages, with students as dependent learners who

need an authority figure (teacher) to tell them what to do in Stage 1; while in Stage 2,

students are interested learners who are motivated and confident but largely need

teacher-direction of the subject matter to be learned. Within Stage 3, students are

involved learners who have intermediate self-direction with both basic skills and

knowledge and view themselves as being ready and able to explore a specific subject

with a good guide. The final stage, Stage 4, sees students as learners of high self-

direction who are willing and able to plan, execute, and evaluate their own learning

with or without the help of others.

Results from the pilot study indicated that 78% of diploma nursing students were low

and below average in their ability to self-direct their learning. Based on this

assumption, this study was designed to focus only on two stages of SDL: Stage 1 and

Stage 2. The reason not to include Stage 3 and Stage 4 of Grow’s SSDL model was

because in Stage 3 students are involved learners (learners of intermediate self-

direction), and in Stage 4 they are learners of high self-direction with the capability

to plan, to complete and evaluate their own learning with or without the help of an

expert/teacher. Because of time constraints and cost for this study as well as many

constraints in nursing education, such as limited teaching and learning materials and

limited books in the library, it was reasonable to aim for Stage 2 as an optimal goal

95
for students in the study. Stage 2 of the SSDL model is the stage in which students

have moderate self-direction.

However, as the pilot study result has shown, the students in their second year of

study at nursing schools in Central Kalimantan contained a mixture of different

abilities and stages of readiness for SDL (low and below average levels), it would be

difficult to match teaching styles to student stages, as suggested by the SSDL model.

Therefore it was decided to begin the intervention by teaching towards dependent

learners (Stage 1), as the majority of the students’ SDL readiness was below average.

It was planned to gradually change the teacher’s role to “guide” and “motivator” to

introduce a mismatch between teaching style and students’ stage as the SSDL

suggests, so that students can move to becoming “interested” learners (Stage 2).

The model presented by Grow (1991) is worthy of note, particularly with regard to

teacher accountability in terms of introducing SDL However, in the context of

supervision of students throughout the course, in regard to individualised learning in

the classroom setting, the model is rather limited. There is a particular issue in

diploma nursing education in Central Kalimantan, where the class size comprises 50

to 60 students, and there are time restrictions and a statutory curriculum. It is

therefore unrealistic to match teaching style to address individual students’ stages as

suggested by SSDL (Grow, 1991). Students are treated as if they have similar

abilities and levels of readiness for SDL, when in fact students have a mixture of

different abilities and stages of readiness for SDL.

In the time constraints dictated by the curriculum, specific learning outcomes are

being met and there are statutory responsibilities to confirm the achievement of

learning outcomes. The SSDL model does not give sufficient emphasis to the need to

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build the students’ responsibility for their own learning. Nor does it put enough stress

on assisting teachers to facilitate learning. Meeting students’ needs is important in

developing skills for SDL. The Teacher-Student Control Continuum (TSCC) model

offers a partnership model that can be applied in this situation, so the TSCC model

was integrated into the design to fill the gap in conducting the Educational

Intervention Program (EIP).

The Teacher Student Control Continuum (TSCC) model was developed by D’A

Slevin and Lavery (1991). It identifies and focuses upon various levels of control

over the learning process. The TSCC model proposes to maximise SDL through a

sharing of control in learning between students and teacher. In the role relationships

there is an implied shift away from the traditional role in which the teacher is

superordinate and students subordinate, toward a more equal partnership. The TSCC

model comprises four levels of interaction: the first involves total teacher direction at

this level and the teacher makes all program decisions, and controls both planning

and evaluating. In the second level, partnership control is shared by the teacher and

students. The third level is when students have a high control of learning, and the

teacher enables but does not lead; and, the last level is student self-direction. There is

no teacher influence at all, students plan and control the program.

According to D’A Slevin and Lavery the TSCC model requires students to be

proactive in organising and undertaking the required study. The teacher has an

important role in terms of providing direction, support and advice, as required, and

monitoring their progress. The importance of promoting students’ responsibility for

their own learning should be balanced with the teacher’s responsibility for ensuring

that specified outcomes have been achieved.

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The TSCC model was incorporated into the intervention by using this technique of

teacher-direction on the learning process, then gradually moving to partnership and

shared control for learning by students and teachers. The teacher direction and the

partnership stages were applied to sessions in the workshop and skill practice in the

nursing laboratory. The partnership teaching approach was applied gradually in

tutorial sessions.

The focus of the study was to move students from Stage 1 to Stage 2 as proposed by

Grow (1991). Teachers and students are connected at each stage by different

processes of interaction as proposed by D’A Slevin and Lavery (1991). More details

for Stage 1 and Stage 2 are discussed in the following section.

Within Stage 1, students are seen as dependent learners (learners of low self-

direction), and teachers as experts or authorities. The interaction between teacher and

students is hierarchical, with expert content transmitted to the dependent learner. The

nursing students in Central Kalimantan are at this stage and teaching and learning

takes place using a teacher-centred approach. Students in Stage 1 are dependent

learners or low in self-direction. They respond to directional techniques and they

expect direction or demonstration from their teachers, especially when learners are

new to a subject or unfamiliar with the content of the learning. Furthermore, when

students have not had any experience in taking responsibility for their own learning,

they need explicit direction (Cranton, 1992).

At Stage 2, students are interested learners who have moderate self-direction and

teachers act as motivators or guides. The interaction is still hierarchical in nature,

however, the role of the teacher changes from content expert to motivator of

learning, as students move to a moderate level of self-direction. This stage was used

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to guide teaching and learning approaches in the educational intervention program.

Teachers wish to move their students from Stage 1 to Stage 2 by changing their

approach from expert content provider to motivator. To achieve this, different modes

of teaching will be used, such as, discussion, and demonstration followed by guided

practice. Students should be trained in basic skills, such as developing goal setting so

they will later be able to use them without high levels of supervision.

The expected outcomes are that students will advance to Stage 2 with increased

abilities for self-directed learning, and increased scores of readiness for self-directed

learning. Another expected outcome is positive perceptions toward self-directed

learning.

5.2 Overview of traditional curriculum structure

The Indonesian diploma nursing curriculum is used for all nursing education in

Indonesia, including Central Kalimantan. This curriculum is six semesters in length

and consists of 40 subjects. Every semester has a different number of subjects. The

subjects in the nursing curriculum can be divided into three major areas: supporting

theoretical science, professional nursing subjects, and clinical nursing subjects. Each

nursing subject is divided into a number of topics and skills to learn (See Chapter

One). According to the Sister School Project (2002), the Indonesian diploma nursing

curriculum provides more emphasis on teacher-centred approaches.

5.3 Traditional teaching and learning activities

In diploma nursing education in Central Kalimantan the semester length is 20 weeks,

including the examination period; this is divided into 16 weeks of teaching and

learning activities, and four weeks for the mid test and final tests. According to the

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Indonesian nursing curriculum for second-year students, throughout each of the 16

weeks, the students have three days of classroom teaching and three days of clinical

practice. The classroom teaching includes lectures and practical sessions in the

nursing laboratory.

The subjects in the third semester (year 2), when the intervention was introduced,

are: Medical Surgical Nursing 1 (MSN1), Medical Surgical Nursing 2 (MSN2),

Health Education, Nursing Documentation, and Nursing Profession. Traditionally,

each subject is managed in a team (three to five lecturers), with one lecturer being

the subject coordinator to ensure that all topics are implemented, with a lesser

emphasis on “how” topics are implemented. The majority of information is provided

via lectures. Students memorise and reproduce only the information provided to them

by teachers. Seminars and group discussions are also used, however, the way the

seminar and group discussions are organised primarily facilitates only the transfer of

information. In essence, students provide a mini lecture to other students.

Practical sessions involve the transfer of specific skills. Students are perceived to

have learnt the skill when they can copy or reproduce it. In the nursing laboratory,

students follow sets of rules or procedures by imitating or copying examples. In the

practical sessions, one lecturer demonstrates a nursing skill to the class followed by

one group of 10 to 12 students re-demonstrating the nursing skill to the rest of the

class. Two or three students from this group role model the skill and one student

verbally describes what is happening. The rest of the presenting group is involved in

answering audience questions. After the question and answer session, the lecturer

gives feedback both to the presenters and audience.

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For the clinical placement component, students are divided into groups and the

number of groups depends on how many clinical placements are available.

Traditionally, second-year students are divided into five groups (with 10–12 students

per group) for their hospital clinical placement, including the emergency unit, two

general wards, the paediatric ward, and the maternity ward. During their clinical

placement, students are supervised by clinical instructors, and sometimes by clinical

teachers. The clinical instructor is a ward nurse who is expected to teach students in

the clinical setting, and the clinical teacher is the coordinator of the nursing subject.

However, effective monitoring is intermittent because only one clinical instructor per

ward is appointed to supervise students in the clinical practice. Moreover, the clinical

instructors are committed to their primary tasks of caring for patients. Patients-per-

nurse ratios in the hospital are typically in the range of six to eight patients per nurse.

However, most of the patients who come to the hospitals are acutely ill and they have

high dependent care needs. The nurses are very busy looking after very sick and

acutely ill patients. When clinical instructors are absent from duty the students rely

on their own efforts to practice the skills.

The clinical teachers’ contact has traditionally been at two points, the beginning and

the end of the clinical placement. Between these times the students usually work

alone without direction, and the development of clinical skills is dependent on what a

particular placement has to offer.

5.4 Control group activities

To evaluate the educational intervention program (EIP), the program was

implemented with an intervention group and results were compared to those of a

control group. This section outlines the activities of the control group as they

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continued to use traditional teaching and learning activities. This is followed by the

description of intervention group activities in the next section.

The students in the assigned control group (N=54) undertook the traditional

curriculum as described previously. There was no change to the teaching team or the

usual lecture format for the control school. The majority of teaching was provided

via lectures, and the skill practice involved teachers demonstrating a skill followed

by one group re-demonstrating the skill to the rest of the class. Therefore, only the

presenting group experienced “hands-on” practice.

The students in the control group completed the same questionnaires, pre- and post-

test, as the intervention group. These were the demographic questionnaire, and

SDLRS. The activities of the control group for the third semester are displayed in

Table 5.1.

Table 5.1: Control group activities

Week Activities
0 Pre-test and Focus group discussion (FGD)
1–10 Regular activities 3 days class & 3 days clinical practice
11–12 Mid test
13–17 Regular activities 3 days class & 3 days clinical practice
18 Post test and FGD
19–20 Final test

The week before classes began, 54 students completed the pre-test questionnaire and

focus group discussions (FGD) were held with 16 students. In Weeks 1 to 10,

students’ regular activities comprised three days in the classroom to learn five

subjects and three days of clinical practice in a hospital setting as a component of

Medical Surgical Nursing 1 (MSN1) and Medical Surgical Nursing 2 (MSN2). At

weeks 11 to 12 students undertook mid tests. In weeks 13 to 17 they continued the

regular activities of three days in the classroom and three days of clinical practice. At

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week 18 students completed the post- test questionnaire and focus group discussion

(FGD). In weeks 19 and 20 they undertook final tests for all the subjects in the third

semester.

5.5 Overview of intervention group activities

The students assigned to the intervention group (N = 47) undertook the educational

intervention program (EIP) designed to introduce and implement SDL concepts in

their learning. Given the low level of SDL readiness in the pilot study, it was

assumed that not all students would be ready for SDL approaches and that there may

be difficulties in adapting to SDL. The students had never been faced with SDL in

their previous study and the SDL concept was new to them. Therefore, the

introduction of SDL concepts and skills using a familiar teaching approach was

considered to be one way to reduce this concern.

The introduction of the SDL concepts was given in workshops across four days. The

workshops included lectures, and practice in small groups. The aim was to use a

teaching strategy that was familiar to students and then move them gradually towards

the desired teaching and learning strategy. Learning plans and a self-directed module

were used to operationalise SDL concepts and they were introduced in the

workshops. As the workshops were conducted over four consecutive days, and the

skill practice (also over four consecutive days), the other four subjects for the third

semester were reorganised by changing their order of presentation. Teaching the

other four subjects commenced in week three, after the eight days of workshops and

skill practice.

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In Week 1, the students participated in the four days of workshops to introduce the

SDL concepts and skills related to SDL. A two-day clinical practice in a hospital

setting was also scheduled for the first week. In Week 2, students participated in four

days of skill practice in a nursing laboratory for body fluid skills and two days

clinical practice in a hospital. For Weeks 3 to 10 students did the regular activities of

three days of classes doing other MSN1 topics and the other four subjects, and three

days of clinical practice. During these eight weeks the students worked through the

SDL module and did their learning plans. The first tutorial was held in Week 5,

followed by the second tutorial in Week 8. In Weeks 9 and 10 students undertook

their mid test. For Weeks 13 to 16 students went back to their regular activities of

three days of classes and three days of clinical practice as suggested by the

Indonesian nursing curriculum for second-year students. They continued to work

through their SDL module and did their learning plans, as well as the other MSN1

topics and the four subjects for the third semester. The third tutorial was held in

Week 13. At Week 16 the implementation of SDL finished. The students completed

the post- test for SDLRS and FGD in Week 17. For Weeks 17 and 18 students went

back to three days in the classroom and three days on clinical practice. In Weeks 19

and 20 students completed their final tests that marked the end of the semester. The

intervention group activity is shown in Table 5.2.

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Table 5.2: Intervention group activities
Week Regular activities Intervention activities
0 Pre-test and Focus group discussion (FGD)
1 Clinical practice 4 day SDL workshops
2 Clinical practice 4 days skill practice at nursing laboratory
3–4 Class & clinical practice Commenced SDL module & learning plans
5 Class & clinical practice 1st SDL tutorial
6–7 Class & clinical practice SDL module & learning plans
8 Class & clinical practice 2nd SDL tutorial
9–10 Class & clinical practice SDL module & learning plans
11–12 Mid test -
13 Class & clinical practice 3rd SDL tutorial
14–16 Class & clinical practice SDL module & learning plans
17 Class & clinical practice Post test and FGD
18 Class & clinical practice
19–20 Final test

5.6 Organisation of Educational Intervention Program

The aim of the Educational Intervention Program (EIP) for the intervention group

was to increase students’ knowledge of, basic skills in, and attitudes towards, self-

directed learning (SDL) and to motivate students to become less passive and more

active in their learning. At the end of the EIP, it was expected that students would

have developed:

• capabilities to demonstrate an understanding of the key concepts and

principles of self-directed learning;

• competence in applying the basic skills of self-directed learning.

As the diploma nursing curriculum is produced at a national level, self-directed

learning (SDL) could not be fully implemented for all topics in a nursing subject.

Therefore SDL was introduced in one topic—in the subject Medical Surgical

Nursing 1 (MSN1). MSN1 is the first in a series of five medical surgical nursing

subjects focusing on medical and surgical health issues that impact on children,

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adults and older people. There are four topics in MSN1: immune disorders, body

fluid disorders, neurological disorders, and endocrine disorders. Traditionally, the

immune disorders topic is covered in three weeks, and followed by the body fluid

disorders topic (also three weeks). The neurological disorders topic is covered in five

weeks, and the endocrine disorders topic is covered in the last five weeks.

MSN1 focuses on the issues of acute and/or chronic illness in the context of immune

disorders, body fluid disorders, neurological disorders, and endocrine disorders. The

content of this subject covers nursing assessment, care planning and care evaluation

for people in hospital settings with health problems related to immune disorders,

body fluid disorders, neurological disorders, and endocrine disorders. The skills

introduced in Medical Surgical Nursing 1 (MSN1) include physical assessment,

administration of insulin, wound care, parenteral therapy, insertion of urinary

catheters, and insertion of nasogastric tubes.

To facilitate the introduction of self-directed learning for the intervention group the

MSN1 subject was reorganised by changing the topic order, and replacing face-to-

face teaching hours with preparatory SDL activities in one topic. The educational

intervention (EIP) was introduced and applied to the body fluid topic. The body fluid

topic was chosen as the topic for the self-directed learning educational intervention

because cases of body fluid disorders are very common in Indonesia and Central

Kalimantan. Infectious diseases such as malaria, typhoid, and haemorrhagic fever are

major causes of body fluid disorders, so it is beneficial for students to prepare well

for such cases. The other three topics, immune disorders, neurological disorders, and

endocrine disorders, were taught in traditional lecture format.

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The original place in the content sequence for the body fluid topic was second, and

the session format for the body fluid topic included 12 hours of lectures, and 10

hours of skill practice in the nursing laboratory. The body fluid topic order was

changed to the beginning of the semester and the 12 hours of lectures were changed

to a self-directed format with ongoing tutorials. The 10 hours of skills practice at the

nursing laboratory remained. This topic was therefore not completed in three weeks

but carried out over 14 weeks. The time that would have been used for body fluid

topic lectures was used as workshops to introduce SDL concept and skills.

The EIP was carried out by the researcher and three faculty staff who usually taught

MSN1 from the nursing school, these included the subject coordinator, nursing

laboratory coordinator, and a lecturer responsible for the body fluid topic. During the

EIP, the researcher’s role was to run the workshops and teach and guide students in

the tutorials, and the three staff assisted in the skill development in the laboratory and

supervised clinical practice.

To enhance self-direction for the students in the intervention group there were two

steps—preparation and implementation. The organisation of the EIP can be seen in

Figure 5.2.

Step 1: Preparation Step 2: Implementation

4 days workshops 12 week implementation:

4 days skills practice in nursing SDL module
laboratory Learning plans
Self-directed learning module 3 tutorial meetings
(SDL module)
Figure 5.2: The activities of the educational intervention program

Step 1, preparation, included four days of workshops and four days of skills practice

in the nursing laboratory and introduction of the SDL module. Step 2,

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implementation, included 12 weeks implementation of the SDL module and learning

plans, and three tutorial support meetings. Details of the workshops, modules and

skill practice are presented in the next section.

5.6.1 Step 1: Preparation

Three sessions comprised the preparation step. These includied four days of

workshops, four days of skills practice in the nursing laboratory, and the introduction

to the SDL module. The workshops, skills practice and SDL module are discussed in

more detail in the following section.

5.6.1.1 Workshops
The purpose of the workshops was to introduce the concepts and skills related to

SDL and to make sure that every student received the same concepts. The workshops

introduced and explored the following topics: self-directed learning, time

management, generating questions and learning plans. The workshops were

conducted in a classroom using a lecture format followed by practice in small

groups. The formal objectives of the workshops were that, at the end of the workshop

sessions, students will have developed:

• an understanding of key concepts/principles of SDL;

• an understanding of how to manage time related to learning activities;

• an understanding of how to generate different types of questions;

• skills to carry out a learning plan.

The workshop was opened by the head of the nursing school and was attended by

faculty staff and students. The head of the nursing school highlighted the importance

of the EIP for the students. He also motivated the students to participate actively in

all EIP activities, and asked students to raise questions with the researcher. The four

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days of workshop were conducted from 8 am to 3 pm except on Friday, where 11 am

to 1 pm was granted as prayer time for Muslim students. The time included five

hours for interactive learning, and two hours for lunch, two breaks and prayer time.

Students needed to complete an attendance record to check their attendance for the

day sessions. All students’ attendance was 100%. The researcher acted as a teacher

and a tutor in the workshop. All topics were presented by the researcher. Each of the

content areas was dealt with in a similar fashion. This involved a didactic overview

providing essential information. Details about the workshop activities can be seen in

Table 5.3.

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Table 5.3: The workshop activities
No Activities Content Method Time SDL
stage
Day 1 Opening SDL topics: Didactic 30 mins Stage 1
workshop Introduction of SDL: Lecture format 120 mins
Interactive Definition of SDL
Lecture
Benefits of SDL
Competencies for SDL
Tools for SDL

Distribute SDL Body fluid module Explanation of 60 mins

module task
Interactive Time management Didactic 60 mins
Lecture Lecture format
Practice time Working group 60 mins Stage 2
management in
small group (3
students)
Day 2 Interactive Generating questions Lecture format 60 mins Stage 1
Lecture

Practice asking Working group 60 mins Stage 2

questions in
group (3 students)

Library tour 60 mins

Interactive Introduction Learning Lecture format 120 mins Stage 1

Lecture plans: Give example of
Definition of Learning learning plans
plans
Benefit of learning plans
Component of learning
plans
Format of learning plans
Day 3 Practice learning Assessing learning need Coaching with 180 mins Stage 1
plans: Formulate learning goals immediate
Develop group Identifying learning feedback
learning plans resources
Evaluating learning Guided practice Stage 2
outcomes Working in
small group
Day 4 Practice learning Assessing learning need Coaching with 240 mins Stage 1
plans: Formulate learning goals immediate
Develop Identifying learning feedback
individual resources
learning plans Evaluating learning Guided practice Stage2
outcomes Working in
small group
Closing 30 mins
workshops

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Two models guided the changes to the teacher-directed design: the Staged Self-

Directed Learning (SSDL) model (Grow, 1991), and the Teacher Student Control

Continuum (TSCC) model (D’A Slevin & Lavery, 1991). These two models provide

direction on how classroom settings can promote SDL, and assumptions about the

ways teachers and students relate to each other (these two models were discussed in

detail of the beginning of this chapter). Stages 1 and 2 of the SSDL (Grow, 1991)

were used in the process of teaching and learning in the workshop, and teacher

direction and partnership of TSCC (D’A Slevin & Lavery, 1991) were used in the

teaching and learning in the tutorials.

In Stage 1, the students’ role is that of dependent learners. They learn the assigned

topic matter, and how to identify what to learn, how to organise content for learning,

and how to recall what has been learnt. According to Gibbons (1994, p.5), in this

stage students are “learning how to learn from a teacher”. The teacher’s role is one of

expert and authority. According to Cranton (1992), students expect direction or

demonstration from their teacher, especially when they have not had any experience

in taking responsibility for their own learning. The researcher acted as an expert

providing information via lectures. Strategies for teaching and learning included

lectures, teacher direction and individual tutorials. Topic content was carefully

taught, and learning was carefully managed by the researcher. Students received a

copy of the overheads so that they could more fully participate in the interactive

lecture, rather than be busy writing notes. Students were given explicit directions on

what to do.

In Stage 2, teachers helped to move students from stage 1 to stage 2 by changing

teaching approaches from expert content provider to motivator. To achieve this,

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different teaching approaches were used. At this stage, students are “learning how to

teach a topic to oneself” (Gibbons, 1994, p.5). Students, as interested learners, were

guided through the process of learning, and how to learn the topic content, by the

researcher acting as teacher. The students learned how to plan and organise the

topics, how to work with others, how to take action, check progress and get things

done. To achieve this, the teaching and learning strategies included discussion and

demonstration followed by guided practice and close supervision. The lectures were

followed by practice in small groups with the researcher encouraging students to

work through their tasks by themselves. The students then did some group work on

their task with the researcher moving between groups and giving individual

feedback.

As the workshop topics introduced to students were new, more time was spent on

these areas. Each of the four topics (Self-directed learning, Time management,

Generating different types of questions, and Learning plans) presented in the

workshops is briefly discussed below:

1. Self-directed learning (SDL)

The aim of the SDL topic was to provide students with knowledge of SDL.

At the end of this session it was intended that students would be able to:

• define the concept of SDL;

• describe the benefits of SDL;

• discuss the purpose of SDL;

• describe competencies for SDL;

• describe tools for SDL.

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The SDL topic covered the importance of SDL, the definition of SDL that was used

in this study, the benefits of SDL, competencies for SDL, and tools for SDL.

2. Time management

Time is an unrenewable resource. No one can manage time but self-management is

possible. The aim of the time management topic was to provide students with the

basic knowledge and skills on how to manage their time for learning. On completion

of this session it was intended that students would be able to:

• demonstrate an understanding of time management in learning activities;

• explain the benefits of time management in learning activities;

• plan and document learning activities effectively;

• understand the time management of learning activities skills as a tool for SDL.

The time management topic covered the purposes for time-management in learning

activities, along with the benefits and format of time management. Skills addressed

in this session included systematic planning and documenting of learning activities.

In the time management session, students learnt how to analyse their daily routine in

order to identify the areas where time was wasted, to plan the day for learning

activities and decide what was achieved.

3. Generating different types of questions

According to King (1994), teaching students to ask their own questions can help

students become more independent in their learning and assume more responsibility

for meeting their learning needs. King (1990, 1992) indicates that previous research

has shown that when students are asked to generate their own questions they usually

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produce questions that require only the recall of factual materials, rather than critical

questions.

King (1994) has developed an instructional procedure for teaching students to pose

their own thought-provoking questions. The instructional procedure uses generic

questions to guide students in formulating their own questions related to materials to

be discussed. According to King (1994), these generic question stems are based on

the higher levels of Bloom’s taxonomy of thinking—including application, analysis

and evaluation. The questions serve as a stimulus to induce high level thinking

(King, 1994). King states further that students need to be trained to produce critical

questions because they do not spontaneously generate such questions.

The aim of the generating questions session was to provide students with a guide to

questioning to enable them to create different types of questions.

At the end of this session it was intended that students would have:

• understood the importance of asking critical questions;

• gained competence to develop their own critical questions;

• understood about asking questions as a tool for SDL.

The generating question topic covered the importance of asking questions,

instructions about how to generate questions (King, 1994) and Bloom’s levels of

thinking (Anderson & Sosniak, 1994). The skill addressed in the session was how to

develop different types of questions. This session used stem/guided questions

developed by King (1994) and these are shown in Table 5.4.

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 Table 5.4: Stem/guided questions
. Generic Questions Specific Thinking Skill Induced

This table is not available online.

Please consult the hardcopy thesis
available from the QUT Library

Source: King (1994, p. 14)

4. Learning plan

According to Knowles (1990), teaching students to use a learning plan is the most

effective way to help students structure their learning. Learning plans are also

considered potentially useful in nursing education for individualising learning,

promoting independence and instilling habits of lifelong learning (Chan & Chien,

2000). The aim of the learning plan session was to provide students with the basic

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knowledge and skills of learning plans. At the end of the learning plan session it was

intended that students would have:

• a basic understanding of learning plans;

• basic skills to carry out a learning plan;

• an understanding about assessing learning needs;

• an understanding of developing learning goals;

• an understanding of identifying learning resources;

• an understanding of evaluating learning outcomes;

• an understanding about learning plans as tools for SDL.

The learning plan topic covered the definition of learning plans used in this study, the

benefits of learning plans, assessing learning needs, formulating learning goals,

identifying resources, evaluating outcomes, and learning format used in the study.

Skills addressed in these sessions included assessing learning needs, formulating

learning goals, identifying resources, evaluating outcomes, and using learning

formats. The students were guided to make their own learning plans and, as part of

their learning plans, to develop objectives to undertake during their clinical practice.

This study used the learning plan format developed by McAllister (1996). The

learning plan format can be seen in Figure 5.3.

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 Learning Plans

This figure is not available online.

Please consult the hardcopy thesis
available from the QUT Library

Source: McAllister (1996)

Figure 5.3: Learning plan format used in this study

5.6.1.2 Skills practice

The purpose of skills practice in the nursing laboratory was for students to develop

competencies related to the body fluid topic prior to their experience in the practice

placement area. The skills practice is an integral part of body fluid topic. Nicol and

Bavin (1999) state that practice in a nursing laboratory enables students to develop

nursing skills at their own speed, in a safe environment before exposure to real

clients or patients. The laboratory also provides a suitable environment for

developing dexterity, and learning opportunities can be structured and predictable.

Clinical skills can be controlled according to students’ level of skill and learning

needs, lowering the anxiety of both students and teachers.

Lesson plans for laboratory sessions were provided to encourage active practice by

all students in order to achieve mastery and clinical competence. Biggs (1999b)

states when clear objectives are provided to students they are more likely to use deep

learning approaches. The nursing skills practised in the laboratory related to the body

fluid topic and included physical assessment, insertion of intravenous therapy,

insertion of nasogastric tube and insertion of urinary catheter.

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The formal objectives of skill practice in the laboratory are stated below:

At the end of skill practice sessions it was proposed that students will be able to:

• demonstrate basic skills for physical assessment;

• demonstrate basic skills for insertion of intravenous therapy;

• demonstrate basic skills for insertion of nasogastric tube;

• demonstrate basic skills for insertion of urinary catheter.

The nursing laboratory facilities could only accommodate a maximum of 20

students. The students were divided into three groups with 16 students in each group.

Three teaching staff taught the skills in the laboratory and the researcher was there to

provide help if needed. Skill demonstration and coaching were used as teaching

approaches in the nursing laboratory. Each group was supervised by a member of the

teaching staff. In these sessions, students had a 2.5 hour session devoted to skills

practice.

The skills were demonstrated by teaching staff and then practised by students to

ensure that they had some notion of how to perform a range of basic procedures

before contact with real clients or patients. All non-invasive skills were practised by

students on each other, with the advantage that students not only learn how to

perform the skills but also how it feels to be a patient. It also encouraged them to

focus on normal physiology before progressing to potentially abnormal signs with

real patients. Invasive skills were practised using a mannequin and students practised

in pairs. The skill activities are shown in Table 5.5.

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Table 5.5: Skill activities in the nursing laboratory
Day Activities Content Method Time SDL
stage
Day 1 Skills practice Physical assessment Demonstration 150 mins Stage 1
Students divided into Intravenous therapy
3 groups, each group Insertion nasogastric
coached by a teacher. tube
Insertion urinary
catheter

Day 2 Skills practice Physical assessment Coaching with 150 mins Stage 1
Students divided into Intravenous therapy immediate Stage 2
3 groups, each group Insertion nasogastric feedback
coached by a teacher. tube Working in pairs
Insertion urinary
catheter

Day 3 Skills practice Physical assessment Coaching with 150 mins Stage 1
Students divided into Intravenous therapy immediate Stage 2
3 groups, each group Insertion nasogastric feedback
coached by a teacher. tube Working in pairs
Insertion urinary
catheter

Day 4 Skills practice Physical assessment Coaching with 150 mins Stage 1
Students divided into Intravenous therapy immediate Stage 2
3 groups, each group Insertion nasogastric feedback
coached by a teacher. tube Working with
Insertion urinary peers
catheter

On day 1, students divided into three groups and each group was supervised by a

member of the teaching staff. The skills were then demonstrated by a member of

teaching staff. Teacher-centeredness was used as a method of teaching, the teacher

was actively doing the demonstration and the students were passively watching the

skills demonstration. On Day 2 to Day 4, students did skill practice and the teachers

coached them with immediate feedback.

5.6.1. 3 Body fluid module

To provide activities and a structure for the students to develop their learning plans,

an SDL module was developed by the researcher based on the body fluid topic in the

Indonesian nursing curriculum. This module was only used with the intervention

group. The SDL module was given to students and they were provided with an

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explanation about how to use the SDL module (body fluid content) and how to work

through it for 14 weeks. The objectives of the body fluid module were:

At the end of the EIP it was indented that students will have:

• knowledge and understanding about body fluids;

• knowledge and understanding about caring for patients with a fluid imbalance;

• basic skills to use SDL in the body fluid topic;

• an understanding about self-directed modules as a tool for SDL.

Students were expected to carry out activities in the module throughout the 14 weeks

either by themselves or in a group. The body fluid module was provided for students

in Indonesian as well as the reading from textbooks such as Fundamental of Nursing

and Medical Surgical Nursing which is available in Indonesian translation. For the

purpose of this study copy of the body fluid module in English is provided in

Appendix 3.

5.6.2 Step 2: Implementation

The objective of the 12 weeks implementation was to encourage students to take time

to self-direct their learning and to practise skills of SDL continuously within the

support structure of a classroom. Another objective was to move students from being

dependent learners (Stage 1) toward becoming interested learners (Stage 2) through a

change in the teaching strategy and a move towards sharing more control over

learning. It was generally accepted that students would assume a “degree” of control

over their learning process. The researcher was acting as a tutor to encourage

students to use the knowledge that they had obtained from the workshop. The 12-

week implementation period was conducted at the hospital and in the classroom

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setting. In the clinical setting, the students were supervised by clinical instructors and

had more clinical teachers (three clinical teachers) compared to the control group

(one clinical teacher) and they had more contact. In their learning plans students had

developed the objectives to undertake during clinical practice. The learning plan was

used to guide their regular clinical practice to encourage integration of theory with

practice. During the implementation period there were three tutorials to support

students’ efforts to apply SDL concepts.

All students’ learning plans related to completing the self-directed module and the

nursing skills related to body fluids. The content focus on the learning plans was

knowledge about body fluids from the SDL module and nursing skills related to the

body fluid topic including: physical assessment, intravenous therapy, insertion of

nasogastric tube, and insertion of urinary catheter. Despite the content of the learning

plans being the same for all students (knowledge about body fluid and skills related

to body fluid), each student had a different focus and a different pace in completing

the module and acquiring the nursing skills. Some students paid more attention to

physical assessment, while others concentrated on nursing procedures in intravenous

therapy, insertion of urinary catheter, or insertion of nasogastric tube.

Piskurich and Piskurich (2003) state that support systems are needed to assist

students’ efforts to become self-directed learners. In this study, support was provided

through tutorial sessions. The implementation activities are shown in Table 5.6.

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Table 5.6 Implementation of SDL concepts
Week Activities Contents Methods Setting Stage

1—2 Individual clinical Individual learning Self-direction Clinical Stage 2 SSDL

practice plans and self- setting
directed module
3 Individual clinical Individual learning Self-direction Clinical Stage 2 SSDL
practice plans and self- setting
directed module
Tutorial 1 Discussion Classroom TSCC: teacher
(Individual) setting direction

4—5 Individual clinical Individual learning Self-direction Clinical Stage 2 SSDL

practice plans and self- setting
directed module

6 Individual clinical Individual learning Self-direction Clinical Stage 2 SSDL

practice plans and self- setting
directed module

Tutorial 2 Discussion Classroom TSCC:

(Small group of 4) setting partnership

7–8 Individual clinical Individual learning Self-direction Clinical Stage 2 SSDL

practice plans and self- setting
directed module
9 Individual clinical Individual learning Self-direction Clinical Stage 2 SSDL
practice plans and self- setting
directed module
Tutorial 3 Discussion Classroom TSCC:
(Larger group 9 or setting partnership
10)
10—12 Individual clinical Individual learning Self-direction Clinical Stage 2 SSDL
practice plans and self- setting
directed module

Three tutorial sessions were held during the implementation period to assist students

in their efforts to adopt self-directed learning attitudes and techniques. The

researcher acted as a teacher and motivator in tutorial sessions. From weeks 1 to 12

students did clinical practice using learning plans to guide their activities. They were

supervised by clinical instructors and clinical teachers. Tutorials were held in weeks

3, 6, and 9. Each tutorial is discussed in more detail in the following section.

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The first tutorial session was conducted to meet individual needs. The researcher and

individual students discussed issues relating to the students’ learning plans and the

self-directed module. The researcher encouraged students to ask questions, raise

issues on applying learning plans and using the self-directed module. In this tutorial

the researcher took an active role to give the students direction. In accordance with

the first type of TSCC (D’A Slevin & Lavery, 1991), teacher direction was used to

interact with students. Students were given feedback on their learning plans, which

allowed them to review and improve their learning plans, hopefully strengthening

their learning plans for the next tutorial. Every student was reminded to take more

control over their learning for the next tutorial by asking questions and raising issues

relating to problems. Ten students per day were self-scheduled for an individual

tutorial day and each student received 30 minutes of feedback and discussion.

For the second tutorial students were divided into 12 groups. There were four

students self-scheduled in each group. In line with the second type of TSCC (D’A

Slevin & Lavery, 1991), a partnership was used to interact with students and control

of learning was shared by the teacher and student. The researcher changed the role

from “give more direction and less listening” to “give more listening and less

direction”. The researcher and students discussed group problems and individual

problems in applying learning plans and using the self-directed module. In the group

tutorial sessions the researcher used the students’ contribution as the basis for

discussions and guided them to find solutions for their problems. Two hours were

provided for each group and three groups were scheduled for group tutorials per day.

For the third tutorial students were divided into five groups according to their clinical

placement. Group tutorials were scheduled for two and half hours to discuss

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problems in applying learning plans and the self-directed module. Two groups were

self-scheduled for group tutorials per day. The strategy for interaction was similar to

that of the second tutorial. Students’ contributions were used as the basis for

discussion and the researcher guided the group to provide the answers.

5.7 Evaluation of Educational Intervention Program

Pre-testing was conducted prior to commencement of the study using Guglielmino’s

Self-directed Learning Readiness Scale (SDLRS) and focus group discussion (FGD)

was used to collect qualitative data relating to students’ perceptions of SDL before

EIP. Post-testing was conducted using the SDLRS after completing the twelve weeks

of implementation. In addition, focus group discussions were held to collect

qualitative data. The FGD elicited students’ perceptions of SDL, the effectiveness of

the EIP, and clinical instructors’ perceptions of the students’ clinical activities.

Evaluation for the body fluid topic was included in the MSN1 mid test and final test.

5.8 Summary

This chapter outlined the educational intervention program (EIP) that was used in

this study. The conceptual framework was presented. An overview of traditional

diploma nursing curriculum structure in Indonesia, specifically in Central

Kalimantan was provided. The activities of the control group and intervention group

were outlined as well as the organisation of the EIP. Evaluation of the EIP completed

the chapter. The following chapter describes the results of the study.

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 CHAPTER SIX

QUANTITATIVE RESULTS

6.0 Introduction

This chapter describes the results from quantitative data collected prior to, and

following, the educational intervention program. Students’ readiness for SDL data

was collected using the SDLRS (Guglielmino, 1978). A demographic questionnaire

was used to collect selected demographic variables that related to SDL. The chapter

begins by presenting descriptive statistics of demographic variables for the whole

sample, and the intervention and control groups. The results include frequencies and

percentages. This is then followed by descriptive statistics of readiness for SDL. The

results include mean (M), standard deviation (SD) and range. Such analysis was

considered important in the initial stage of data analysis to summarise and

understand the data (Punch, 1999).

A one-sample t-test was conducted to evaluate differences between SDLRS scores of

the current study and group norm scores (Guglielmino, 1978). The result was used to

address Hypothesis 1: The students’ level of readiness for SDL as measured by

SDLRS would be lower than the established group norm (Guglielmino, 1978).

An independent sample t-test was conducted to examine differences on SDLRS

scores between intervention and control groups at pre-test. A level of readiness for

SDL as suggested by Guglielmino and Guglielmino (1991) was calculated. The

result was used to address Hypothesis 2: There would be no significant difference

between the intervention and control group SDLRS scores at pre-test.

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Results from post-test were analysed using analysis of covariance (ANCOVA) to

address Hypothesis 3: Self-directed learning readiness scores of students who

participated in the educational intervention program (EIP) over fourteen weeks

would be significantly increased compared to the average scores of students who did

not participate. This test determined the relationship between the educational

intervention and students’ readiness for SDL, while controlling for pre-test scores.

Multiple regression was employed to find out the predictors of readiness for SDL,

including the demographic and educational intervention variables. The multiple

regression was undertaken to address Hypothesis 4: Variables such as group

(intervention-control), gender, birth order, father’s educational background and

mother’s educational background would significantly contribute to students’

readiness for SDL.

The Statistical Package for the Social Science (SPSS) version 12 was used to analyse

the quantitative data and statistical significance was set at alpha .05.

6.1 Demographic characteristics

One hundred and one second-year students participated in the study. The number

represented approximately 10% of total students enrolled in four nursing schools in

Central Kalimantan. Table 6. 1 shows the demographic data of the sample.

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Table 6.1: Frequency of demographic variables of sample
Variables N Percentages (%)

Group
Intervention 47 46.5
Control 54 53.5

Gender
Male 37 36.6
Female 64 63.4

Age:
≤20 year 57 56.4
≥21 year 44 43.6

Birth order: First-born

Yes 43 42.6
No 58 57.4

Father’s educational background

≤ JHS 1 36 35.6
≥ SHS 2 65 64.4

Mother’s educational background

≤ JHS 53 52.5
≥ SHS 48 47.5

1
JHS = Junior High School
2
SHS = Senior High School

Of the sample of 101, forty-seven participants were in the intervention group and

fifty-four were in the control group. Overall, the sample consisted mainly of female

students (63%), with approximately a third (37%) being male students. The age of

the participants ranged from 19 to 25 years (M = 20.59, SD = 1.22), with 56% of

participants aged ≤ 20 years and 44% aged ≥ 21 years. Nearly half (43%) of the

participants were first-born, and 64% of the students’ fathers had graduated from

high school or university. However, only 47% of the participants’ mothers had

graduated from high school or university. Generally, in Indonesia, men are more

highly educated than women are. The students’ characteristics in this sample were

similar to other nursing students at diploma level in Central Kalimantan or Indonesia.

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To check for any differences in demographic variables between groups at pre-test the

chi-square test for independence was conducted. Table 6.2 shows differences

between intervention and control groups at the pre-test. No significant differences for

gender, age group, birth order, father’s educational background and mother’s

educational background were identified.

Table 6.2: Demographic differences between intervention and control groups

Variables intervention control Chi-square test
n (%) n (%)
X² P- value

Gender
Male 17 (36) 20 (37) 0.00 1.000
Female 30 (64) 34 (63)
Age:
≤ 20 year 31 (66) 26 (48) 2.56 .11
≥ 21 year 16 (34) 28 (52)

Birth order: First born

Yes 25 (53) 18 (33) 3.28 .07
No 22 (47) 36 (67)
Father’s educational background
≤ JHS 1 14 (30) 22 (41) 0.88 .35
≥ SHS 2 33 (70) 32 (59)

Mother’s educational background

≤ JHS 22 (47) 31 (57) 0.75 .39
≥ SHS 25 (53) 23 (43)

1
JHS = Junior High School
2
SHS = Senior High School

Of the total second-year students from intervention and control schools, the

percentage who participated in the study at pre-test and post-test was high (92%).

There was no attrition throughout the study. The lack of attrition may relate to the

use of intact groups for intervention or control conditions; additionally, the cultural

background features such as respect for authority (teachers) may have resulted in

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students continuing to participate until the end of the study. The next section of this

chapter presents the results for the SDLRS to address the hypotheses.

6.2 Level of readiness for SDL

Hypothesis 1: The students’ level of readiness for SDL as measured by SDLRS

would be lower than established group norms (Guglielmino, 1978).

Within a possible range of 58–290, the pre-test scores ranged from 143 to 235. The

mean and standard deviation of the SDLRS scores for the whole sample was 196.48

and 16.63 respectively. As expected, the mean readiness scores reported by the

nursing students in Central Kalimantan were lower than those reported for USA

students, M = 214, SD = 25.59 (Guglielmino, 1978). This mean has been used as a

norm for comparison purposes in various studies (Bulik & Romero, 2000;

Darmayanti, 1994; Delahaye & Choy, 2000; Jones, 1992; McCauley & McClelland,

2004).

A one sample t-test was conducted on the study sample’s SDLRS scores to evaluate

whether the mean was significantly different from the normative mean (M = 214),

the accepted mean for adult learners in general (Guglielmino, 1978). The sample’s

mean of 196.48 (SD = 16.67) was significantly different from 214, t (100) = −10.59,

p = .000. The 95% confidence interval for the sample’s mean ranged from 175.67 to

182.24.

The mean score for Australian undergraduate students is reported as 203, SD = 21.6

(Delahaye & Choy, 2000). In Irish undergraduate students the SDLRS scores are

reported as 215.80, SD = 22.99 (McCauley & McClelland, 2004). The SDLRS mean

for Indonesian Open University students in Indonesia (N = 369) is reported as 215.5,

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SD = 21.9 (Darmayanti, 1994). The lowest score in the current study (143) was also

lower than that noted in Darmayanti’s (1994) study. The range of SDLRS scores in

Darmayanti’s study was 148–268. In addition to having significantly lower SDLRS

scores than normative data (based on the US students), the students in the current

study have lower scores than students in Australia, Ireland and Indonesia. This data

confirms the hypothesis about students’ readiness for SDL.

6.3 Differences in pre-test scores

Hypothesis 2: There would be no significant difference between the intervention and

control group SDLRS scores at pre-test

The intervention and control groups’ means for SDLRS scores at pre-test were

calculated. The scores are presented in Table 6. 3.

Table 6.3: SDLRS scores at pre-test

SDLRS scores Intervention (n = 47) Control (n = 54)

Mean 190.72 201.48

SD 18.57 12.95

Range 143–235 170–229

An independent sample t-test to analyse the difference between the two group means

was performed. The assumptions for t-test were met. The scores for both intervention

and control groups were normally distributed. The Levene’s test indicated that the

samples had equal variances (p = .87). The hypothesis was not confirmed, in fact the

analysis showed that there was a significant difference in scores t (99) = −3.42, p =

0.001. The mean SDLRS score was higher in the control group than in the

intervention group.

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Students’ level of readiness at pre-test was also examined according to the five levels

as suggested by Guglielmino and Guglielmino (1991)—low, below average, average,

above average, and high. The distribution of the intervention and control group

within the five levels of readiness is shown in Table 6. 4.

Table 6.4: Different levels of readiness for SDL at pre-test

Scores Level of readiness Intervention group Control group
n (%) n (%)
50–176 Low 9 (19) 2 (4)

177–201 Below average 27 (57) 27 (50)

202–226 Average 8 (17) 24 (44)

227–251 Above average 3 (7) 1 (2)

252–290 High 0 0

At the pre-test, 76% of the intervention group and 54% of the control group were in

the “low” and “below average” ranges. Only 7% and 2% of the intervention and

control groups, respectively, were in the “above average” range. No students were in

the “high” range for SDL readiness in the pre-test. More students in the control group

scored in the average range and above average than in the intervention group (46%

vs. 24%).

Despite the randomisation of the two schools to intervention or control group, the

students in the control group had high SDLRS scores. These data do not support the

hypothesis that pre-test scores between the groups would not differ. The different

SDLRS scores between intervention and control groups might be explained by

external factors of readiness for SDL in the control group. The library, in terms of

number of books and longer hours of services, was better in the control group than

intervention group. Another explanation could be that the “home-work”, the

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traditional method of SDL in Indonesia, was more often used in the control group

than in the intervention group.

6.4 Impact of the educational intervention program

Hypothesis 3: Self-directed learning readiness scores of students who participated in

the educational intervention program (EIP) over fourteen weeks would be

significantly increased compared to the scores of students who did not participate.

To examine changes in SDL readiness following the introduction of the educational

intervention program (EIP), differences between the intervention and control groups’

pre- and post- test scores were calculated. Means and standard deviations for pre-

and post- test SDLRS scores for intervention and control groups are shown in Table

6.5.

Table 6.5: Mean and Standard Deviations of SDLRS by group

Group SDLRS (pre-test) SDLRS (post test)
Mean (SD) Mean (SD)

Intervention 190.72 (18.57) 203.04 (18.51)

Control 201.48 (12.95) 193.18 (17.36)

Because the SDLRS scores of the two groups were significantly different at pre-test,

it was considered necessary to control for pre-test SDLRS scores. The pre-test scores

for each participant were therefore used as a co-variate. A one-way between group

analyses of covariance was conducted to compare differences between the groups

(Pallant, 2001). The independent variable was group—intervention or control—and

the dependent variable was post-test SDLRS scores. A preliminary check was

conducted to ensure that there were no violations of the assumptions of normality,

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linearity, homogeneity of variance of regression slopes. The assumptions were all

met.

After adjusting for pre-intervention scores, there was a significant difference between

the two groups on post-test scores for the SDLRS, F (1, 98) = 63.25, p = .000, Partial

Eta Square = .39. This result indicated that the intervention group improved their

readiness for SDL after the educational intervention program. It is interesting to note

that despite having higher SDLRS scores at pre-test, the control group scores

decreased following the intervention. As expected, Hypothesis 3 is confirmed. The

SDLRS scores for intervention and control groups at pre- and post- test shown in

Figure 6.1.

230
Intervention
220 control

210

200

190

180

170
Pre-test Post test

Figure 6.1: Graph of SDLRS scores for intervention and control groups at pre- and post- test

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6.5 Influence of educational intervention and demographic

variables

Hypothesis 4: Variables such as group (intervention-control), gender, birth order,

father’s educational background and mother’s educational background would

significantly contribute to students’ readiness for SDL.

A standard multiple regression was performed with SDLR post-test scores as the

dependent variable and intervention-control group, gender, birth order and parents’

educational level as independent variables. Analysis was performed using SPSS

regression and SPSS frequencies for evaluation of assumptions. A preliminary check

was conducted to evaluate the assumption of sample size, outliers, multicollinearity,

normality, linearity, homocedasticity, and independence of residual. The result of

evaluation of assumptions led to transformation of the dependent variable to reduce

the number of outliers, reduce skewness, and improve the normality,

homocedasticity, and linearity. No cases had missing data (n = 101). Logarithmic

transformation was used on SDL readiness post-test scores.

Overall, the five variables explained 15% of the variation in readiness for SDL

scores (R2= .148, p = .009). Two of the independent variables contributed

significantly to the prediction of readiness for SDL scores as logarithmically

transformed. Results showed that intervention–control group had the strongest

unique contribution (β = −. 243, p = .01) with the intervention group having higher

SDL readiness scores compared to the control group. The beta value for gender was

slightly less (β = .240, p = .01) with females reporting higher SDLRS scores than

males. Finally, birth order (β = .026, p= .79), father’s educational background (β =

.076, p = .50), and mother’s educational background (β = .086, p = .74), did not make

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significant contributions to explain SDLRS post test scores (dependent variable).

Therefore, as hypothesised, group and gender were important contributors to SDLRS

scores, while birth order and parents’ educational level were not. Students who

participated in the educational intervention program and female students had high

levels of readiness for SDL.

6.6 Summary

This chapter has presented the quantitative results. The demographic data showed

that intervention and control groups had equivalent demographic characteristics in

the sample. Levels of students’ readiness for SDL were assessed and compared to the

norm score. Intervention and control group scores on pre- and post- tests were

provided, as well as results from multiple regression. It was found that students’

scores in SDL measures in the intervention group changed during the educational

intervention program, compared to these measures for students in the control group.

Levels of readiness for SDL improved for the intervention group from ‘below

average’ to ‘average’ compared to the control group who scored in the ‘below

average’ range before and after the study. The next chapter presents the qualitative

findings.

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 CHAPTER SEVEN

QUALITATIVE FINDINGS

7.0 Introduction

This chapter presents the findings from the focus group discussions (FGDs) from

both students and clinical instructors. The FGDs for students in the research study

was designed to investigate the research question: What were the students’

perceptions of self-directed learning before and after the educational intervention

program? The FGDs for clinical instructors addressed the research question: What

were the clinical instructors’ perceptions of students’ activities in clinical practice

during the educational intervention program? The chapter begins by presenting an

overview of data collection and this is followed by data analysis. Findings from

students’ FGDs before EIP, from both intervention and control groups, are presented

in the next section followed by FGDs after the EIP for both groups. Findings from

clinical instructors are presented in the final section. The chapter then concludes with

a summary.

7.1 Data collection

In order to understand students’ perceptions of self-directed learning (SDL) and to

enrich the quantitative results, a qualitative technique was employed. Focus group

discussion (FGD) was used as the data collection technique. The FGD can be defined

as a qualitative research technique using discussion among a small group of people

(4–12 people) in a comfortable, non-threatening environment to obtain perceptions

about an area of interest, a topic of study or a given problem (Kitzinger, 1994;

Krueger, 1994; Lederman, 1990; McDaniel & Bach, 1994; Morgan, 1995).

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It has been suggested that FGD is particularly useful to explore people’s shared

knowledge and experiences and can be used to examine not only what people think

but how and why they think that way (Kitzinger, 1995). According to McDaniel and

Bach (1994) the FGD facilitates group interaction to stimulate participants and

provide insights and data that are not accessible without the stimulus of a group.

Furthermore, McDaniel and Bach state that the use of FGD can stimulate new ideas

that may never surface in an individual interview. Group participants can also be

encouraged to add to those commentaries as they hear what other group participants

contribute. Lederman (1990) indicates that, in a FGD, the group rather than the

individual is interviewed and being within the group provides a safe atmosphere.

Data generated in FGD are often richer and deeper than data in one-on-one interview

situations. Lederman (1990) also noted that openness is encouraged because the

participants in the group understand and feel comfortable with one another.

Participants also draw social strength from each other as the group provides support

to its members in the expression of new ideas.

Considering the benefits of FGD among homogenous participants on focal topics, it

was sufficient to use FGD as a data collection technique for this study cohort of

nursing students in Central Kalimantan as they are not accustomed to expressing

their perceptions or opinions individually in their everyday learning activities. Eight

FGDs were conducted to collect qualitative data. The FGDs for students included six

focus groups: four focus groups were conducted before the educational intervention

program (EIP), comprising two FGDs from the intervention group and two FGDs

from the control group. Two FGDs were conducted after the EIP, one FGD from

each group. The number of participants in each FGD was eight, giving a total of 48

participants for the six FGDs.

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Two focus groups were conducted to collect clinical instructors’ perceptions about

students’ clinical activities in clinical settings. One FGD was conducted for clinical

instructors from the intervention group and one FGD for the control group. All

clinical instructors’ focus groups were held after the intervention. The number of

participants in each FGD was six, giving a total of 12 participants for the two FGDs.

All the FGDs for students and clinical instructors were held in the nursing schools’

meeting rooms as the rooms were comfortable, air-conditioned, non-threatening and

conducive to discussion of sensitive topics. The setting of the FGDs was around the

table as this allowed the participants to see each other. The researcher acted as the

moderator and was responsible for ensuring that key questions were discussed and

that all individual students or clinical instructors participated in the discussion.

Within the FGD sessions, the researcher was helped by an assistant who was

responsible for keeping notes of the discussion and managing the tape recorder. The

length of each FGD ranged from one and a half to two hours.

The FGDs used the modified guidelines developed by Myers (1999). The guidelines

outline each step of the process for the researcher and the assistant from before

participants arrive, to when they leave (see Chapter Three). The FGDs used an

interview script: a plan for covering topics so that the desired information was

obtained. The scripts began with an ice-breaker question that required little reflection

and worked up to more penetrating questions (key questions) thereby allowing

participants to warm to the context and subject matter before being asked to explore

the subject, which took more thought or was more difficult to discuss.

The FGD script for students before the educational intervention program (EIP) was

used for the intervention and control group before the intervention, and was also used

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for the control group FGD after EIP. The script contained one icebreaker question,

three key questions and two summary questions (see Chapter Three). Once

introductions had been made, the purpose of the study explained, and permission

granted to tape record the session, the researcher began with an icebreaker question.

One participant was asked to answer this question, and then each participant was

asked to respond to, add to, or clarify the response. After each participant had

answered the icebreaker question, three key questions were asked with each

participant answering. The researcher ended the session with a summary of the

discussion, seeking verification from the student participants. The same processes

were used to conduct all FGDs.

The FGD script after the intervention was used after the EIP was completed. This

interview script was only used for the intervention group, as only this group could

talk about the SDL activities. The script contained two icebreaker questions, four key

questions and two summary questions (see Chapter Three).

Two clinical instructor FGDs were held after the intervention was completed. The

FGD interview script was used for clinical instructors from both groups. The script

contained two icebreaker questions, four key questions and two summary questions

(see Chapter Three). Again, the same processes as described for the students’ FGDs

were used to conduct FGDs for clinical instructors.

7.2 Data analysis

All focus group discussions were tape-recorded and the recordings were then

transcribed into the original language (Indonesian). The transcripts were read and

content analysed using the guidelines by Burnard (1991). Burnard’s original

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guidelines comprised 14 stages and, for this study , this was modified to 17 steps (as

described in Chapter Three). These steps were as follows:

• Step 1: The recordings were transcribed into the original language

(Indonesian) by the researcher. Eight recordings were transcribed, which

resulted in 84 pages of transcriptions.

• Step 2: The transcripts were read and notes made on the general themes

arising from the data.

• Step 3: The transcripts were translated from their original language

(Indonesian) into English by the researcher.

• Step 4: The English transcriptions were checked by a registered translator for

accuracy of translation and quality of data.

• Step 5: The English transcripts were then read and a list of themes developed.

This process of “open coding” helped focus the analysis on the concept being

explored and statements unrelated to this were excluded at this point. Open

coding is the process of organising, sorting, and coding data. Open coding by

words was used, rather than by number, as words provide more meaning than

the conversion of words to numbers, which can render data meaningless

(Miles & Huberman, 1994).

• Step 6: The English transcripts were also read independently by two

researchers for quality of data and preliminary themes. Together with the

researcher’s list, three lists of themes were developed.

• Step 7: These three lists of themes were transcribed into a separate document

by the researcher.

• Step 8: The three lists were reviewed for commonalities/links between any of

them and grouped together into categories.

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• Step 9: Once grouped together, further refinements were undertaken and each

group was explored for subcategories. Repetitious or very similar categories

were removed to produce a final list.

• Step 10: In an effort to enhance the validity of the categories and guard against

researcher bias, the two researchers were also asked to verify the accuracy of

the category system.

• Step 11: After discussion with them, minor modifications were made to the

categories and some of the original categories were collapsed and reduced to

produce the final list of categories and subcategories.

• Step 12: Transcripts were then re-read alongside the final list of categories to

check that a true representation of the interviews had been captured.

• Step 13: Sections of transcript were then identified and coded, under

corresponding categories.

• Step 14: Sections of the transcripts in Step 13 were ‘cut’ and ‘pasted’ onto

separate documents.

• Step 15: The results from Step 14 were translated back into the original

language (Indonesian).

• Step 16: As the validating step, the results of the thematic content analysis in

the original language (Step 15) were returned, via email, to the focus group

participants to check for “truth values.” No comment or corrections were

made so it was assumed that the participants agreed with the interpretation of

the transcripts.

• Step 17: The final steps in Burnard’s method of thematic content analysis are

related to the writing up of the findings alongside relevant literature and

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 research, using direct quotes from the transcripts to further illustrate the point

under discussion.

7.3 Findings

This section presents the findings from both students and clinical instructors. The

student FGDs will be presented in two parts: students’ perceptions before EIP and

students’ perceptions after EIP. The clinical instructors’ FGDs will be presented in

one part. All parts use a similar structure and include examples of FGD transcripts,

followed by category development from open coding, and quotes from the FGDs.

The same processes were used to analyse all FGD data.

7.3.1 Students’ perceptions of SDL before the intervention

Two groups from the intervention group and two groups from the control group were

analysed separately. In the course of this process it became clear that themes and

categories were similar. Therefore, these data are being presented as representative of

both control group and intervention group prior to the commencement of the EIP.

Two categories were generated from the students’ focus group data before the

intervention and, under these categories, all of the data were accounted for. Data

from students’ FGDs was examined for themes using open coding. This process is

exemplified by the following data in Table 7. 1.

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Table 7.1: Themes developed from FGDs before the intervention
Line FGD Transcript Open Coding
1 R: What does self-directed mean to you?
2 S: Self-directed learning is looking for and Learning alone
3 retrieving knowledge alone
4 S: Self-directed learning is to know anything that Learning without help
5 I do not know without help from other
6 S: Self-directed learning such as learning after Activities outside
7 school hours, reading materials that have been given to classroom
8 us and doing home work.
9 S: Self-directed learning is the learning method Distant learning
10 That is similar to distant learning. We are given learning
11 materials and study guide, and we learn using our
12 self-effort.
13 S: Self-directed learning is an individual learning for Learning for test
14 test.
15 R: What teaching and learning issues will arise if
16 self-directed learning is implemented
17 S: A major problem of self-directed learning method Teachers inactivity
18 could be inactivity by lecturer. Students and others
19 may perceive teachers are lazy and students learn
20 by themselves.
21 S: In self-directed learning we do constant learning, Less leisure time
22 we will get more stressed because in doing this we
23 do not have enough time for relaxing
24 S: In self-directed learning we can do badly in test Incorrect learning
25 because the material we have learnt could be
26 different from test material, so students could fail in
27 test. For me it is safe to learn the materials from our
28 lecturers.
29 S: I think in using self-directed learning we need a Increased cost
30 lot of books as learning resources and it can
31 increase cost to buy the books

Students’ perceptions about SDL focused on two areas: ‘self-activity’, and

‘consequences’. The students expressed their concept of SDL as a ‘self-activity’.

However, they also acknowledged that SDL had consequences. Each of these two

categories comprised a number of subcategories as shown in Table 7.2.

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Table 7.2: Category development from FGDs before intervention
Category Subcategory
Self-activity • Learning alone
• Learning without help
• Activities outside classroom
• Distant learning
• Learning for test
Consequences • Teacher inactivity
• Less leisure time
• Incorrect learning
• Increased cost

The category of ‘self-activity’ had five subcategories: ‘learning alone’, learning

without help’, ‘activities outside classroom’, ‘distant learning’, and ‘learning for

test’. The category of ‘consequences’ had four subcategories: ‘teacher inactivity’,

‘less leisure time’, ‘incorrect learning’, and ‘increased cost’.

The category, ‘self-activity’, and the five subcategories highlighted that students

viewed SDL as something that they did alone and without help. In addition, they

considered SDL was something that took place outside of the classroom, which they

did to prepare for tests. The following statements give examples of the five ways in

which students viewed SDL as a ‘self-activity’.

Learning alone

One student highlighted this by stating:

“Self-directed learning is to learn alone; to know anything that I do not

know without help from others.”

Another student reiterated this by adding:

“Self-directed learning is looking for and retrieving knowledge alone.”

Learning without help

One student identified this subcategory by stating:

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 “Self-directed learning is learning without direction from others.”

Another student supported this by stating:

“Self-directed learning is to know anything that I do not know without

help from others.”

Activities outside classroom

For this subcategory a student stated:

“Self-directed learning activities, such as learning after school hours,

reading lecture materials that have already been given to us, and doing
homework as well as possible.”

One student confirmed this by stating:

“Self-directed learning means to me I learn alone with activities outside

classroom.”

Distant learning

This subcategory was identified by the following student statement:

“Self-directed learning is the learning method that is similar to distance

learning. We are given learning materials and a study guide, and we
learn using our self-effort.”

Another student highlighted this subcategory by stating:

“Self-directed learning is learning similar to open junior high school, no

teacher present, no classes; it uses materials and a study guide without
help from others.

Learning for test

This subcategory was identified by the following example:

“Self-directed learning is an individual learning for tests.”

One student supported this by stating:

“Self-directed learning is learning alone, reading and memorising

lecture materials, tidying up lecture notes, finishing assignments, so I
will ready for the test.”

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The second category, ‘consequences’, showed that students had concerns about the

effects that SDL may have on them and their teachers. The following statements give

examples of the four consequences that most concerned students.

Teacher inactivity

One student identified this subcategory by stating:

“A major problem of a self-directed learning method could be inactivity

by lecturers. Students and others may perceive teachers are lazy and
students learn only by themselves.”

Another student highlighted the issue of teacher inactivity by stating:

“Problem of self-directed learning could be decreased face to face

lecture. Students may perceive teachers are not capable in either
teaching or subject content.”

Less leisure time

One student highlighted the issue of using self-directed learning by stating:

“In using self-directed learning we do constant learning, we will get

more stressed because in doing this we do not have enough time for
relaxing.”

Another student supported this subcategory by stating:

“We will have less time for relaxing because the self-directed learning
makes us do constant learning, concentrating on learning and thinking
critically.”

Incorrect learning

A student identified this subcategory by stating:

“We can do badly in test because the material we have learnt could be
different from test material, so students could fail in test.”

Another student supported this subcategory by stating:

“ . . . if we make a mistake it could be a fatal mistake because no one will

give correction before it happens.”

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Increased cost

This subcategory was highlighted by one student who stated:

“I think in using self-directed learning we need a lot of books as learning

resources and it can increase our costs to buy the books.”

Another student stated:

“Self-directed learning will increase the cost of learning due to high

price of books.”

These categories and subcategories, which were expressed before the study

commenced, indicated that the students had a limited view of SDL and were

concerned about its impact. They appeared to have some understanding of the shift

away from the focus on the teacher as the only way to obtain knowledge. However,

they expressed a view that the ‘self-activity’ needed to be done ‘alone’ and ‘without

help’. Naturally, the students had concerns about the impact ‘self-study’ could have

on them and their teachers.

7.3.2 Students’ perceptions of SDL after the intervention

The same processes were used to develop categories, and this time the categories

were different between the control group and the intervention group. The control

group categories were the same as at the pre- data collection point. The main control

group categories were still ‘self-activity’ and ‘consequences’. These results are now

presented in Table 7.3. Two categories emerged from open coding of FGD data from

the control group after the study. Students’ perceptions about SDL still focused on

two areas: ‘self-activity’, and ‘consequences’. The students expressed their concept

of SDL as a ‘self-activity’. However, they also acknowledged that SDL had

consequences. Each of these two categories comprised a number of subcategories as

shown in Table 7.4.

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Table 7.3: Themes developed from the control group after the intervention
Line FGD Transcript Open Coding
1 R: What does self-directed mean to you?
2 S: Self-directed learning is learning alone to solve Learning alone
3 problems
4 S: Self-directed learning is learning using self effort Learning without help
5 without included other in the activities
6 S: Self-directed learning means to me is informal Activities outside
7 education and activities outside campus we can classroom
8 learn less important things such as cooking and
9 woven
10 S: Self-directed learning is the learning by Learning for test
11 memorising lecture materials for test so I can get
12 better scores
13 R: What teaching and learning issues will arise if
14 self-directed learning is implemented
15 S: Problem of self-directed learning could be Increase laziness
16 learning from teacher become less interesting
17 because I can learn alone using self-directed
18 learning so that increases laziness to listen to the
19 teacher.
20 S: . . . we are young adult because we do self-directed Less leisure time
21 learning by ourselves we lost time for relaxing.
22 S: According to me the results of self-directed Not optimum results
23 learning is different from lecture, the result is not
24 optimum because we use self-effort without
25 guidance
26 S: Problem can arise such as students are Difficult to change
27 Accustomed to learn from teacher and have
28 difficulty changing their learning habit.

The category of ‘self-activity’ had four subcategories: ‘learning alone’, ‘learning

without help’, ‘activities outside classroom’, and ‘learning for tests’. The category of

‘consequences’ also had four subcategories: ‘increased laziness, ‘less leisure time’,

‘not optimal results’, and ‘difficult to change’.

The category ‘self-activity’ and the four subcategories highlighted that students

viewed SDL similarly to their pre-intervention understanding: learning alone and

148
without help. In addition, they considered SDL was something that took place

outside of the classroom, which they did to prepare for tests.

Table 7.4: The category development from the control group after the intervention
Category Subcategory
Self activity • Learning alone
• Learning without help
• Activities outside classroom
• Learning for test
Consequences • Increased laziness
• Less leisure time
• Not optimal results
• Difficult to change

The following statements giving examples of the four ways in which students viewed

SDL as a ‘self-activity’.

Learning alone

One student highlighted this by stating:

“Self-directed learning is learning alone without help from others.”

Another student reiterated this by adding:

“Self-directed learning is learning alone to solve problems.”

Learning without help

One student identified this subcategory by stating:

“Self-directed learning is learning using self-effort without including

others in the activity.”

Another student supported this by stating:

“Self-directed learning is an individual activity to solve problems without

help from others.”

Activities outside classroom

For this subcategory a student stated:

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 “I have heard self-directed learning when I was at junior high school.
According to our teacher self-directed learning is learning alone. Self-
directed learning means to me I learn alone with activities such as
learning at home as well as possible to improve my scores.”

One student confirmed this by stating:

“Self-directed learning means to me informal education and activities

outside campus we can learn less important things such as cooking, and
wavering”.

Learning for test

This subcategory was identified by the following example:

“Self-directed learning is learning individually using such activities:

summarise and memorise learning materials, and prepare for tests.”

One student supported this by stating:

“Self-directed learning is learning by memorising lecture materials for

tests so I can get better scores.”

The second category: ‘consequences’ and the four subcategories showed that

students had concerns about the effects that SDL may have on them and their

teachers. They considered the results of SDL were different from the results of

lectures. In addition, they were concerned that they may have difficulties adopting

the SDL methods. The following statements give examples of the four consequences

that most concerned students.

Increased laziness

One student identified this subcategory by stating:

“The problem of self-directed learning could be learning from a teacher

becomes less interesting because I can learn alone using self-directed
learning so that increases laziness to listen the teacher.”

Another student highlighted the issue of increased laziness by stating:

“A major problem of self-directed learning could be I do not pay

attention to the teacher because I implement self-directed learning that
increases my laziness to attend the class.”

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Less leisure time

One student highlighted the issue of using self-directed learning by stating:

“ . . . we are young adults, because we do self-directed learning by

ourselves we lost time for relaxing.”

Another student supported this subcategory by stating:

“We will have less time for relaxing because if we use self-directed
learning we always learn alone, we do not have time for social life and
less communication with others.”

Not optimal results

A student identified this subcategory by stating:

“According to me the results of SDL is different from lecture; the result

is not optimum because we use self-effort without guidance.”

Another student supported this subcategory by stating:

“If the self-directed learning is implemented I am quite sure the results

will be unsatisfactory because of the limited resources. It will make
students that are initially diligent become lazy because at the time they
have curiosity about something, there are no resources available so that
the curiosity becomes dimmer.”

Difficult to change

This subcategory was highlighted by one student who stated:

“Problems can arise such as students are accustomed to learning from

teachers and have difficulties changing their learning habit.”

Another student stated:

“Problem will arise such as difficulty to adjust to new methods I mean

self-directed learning because students find it very difficult to change
learning habits that have already become a tradition in this school.”

These categories and subcategories, which were expressed after the study had

finished, indicated that the students in the control group still had a limited view of

SDL and were concerned about its impact. They appeared to have some

understanding of the shift away from the focus on the teacher and that it may make

151
them less respectful of their teachers. However, they expressed a view that the ‘self-

activity’ needed to be done ‘alone’ and ‘without help’ and had an impact on their

learning, as the students’ purpose of learning is to pass the tests. Naturally, the

students had concerns about the effect ‘self-study’ could have on them and their

teachers.

However, the analysis of the intervention group data revealed different categories.

The open coding of FGDs from students in the intervention group after the EIP is

shown in Table 7.5

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Table 7.5: Themes developed from the intervention group after the intervention
Line FGD Transcript Open coding
1 R: What does self-directed mean to you
2 S: Self-directed learning is using one’s initiative for Individual initiative
3 learning, using self effort to search for things.
4 S: Self-directed learning is a process of learning, Learning with or
5 where we do self-directed learning with or without without help
6 help from other.
7 R: What did you think the benefit of self-
8 directed learning?
9 S: . . . in using self-directed learning I know how to Direction in learning
10 arrange my study effectively and I have direction in
11 learning
12 S: . . . it increased knowledge and motivation for self- Increased motivation
13 development in learning as compared to previous
14 method of learning
15 S: Self-directed learning renewed my ways of Increased
16 learning , and I felt it changed the process of self-confidence
17 learning and increased my self-confidence
18 S:. . . . using self-directed learning method learning Incremental learning
19 does not pile up, because we learn bit by bit.
20 R: What teaching and learning issues will arise if
21 the self-directed learning will be implemented?
22 S: . . . communication between school of nursing and Communication
23 clinical practice needs to be improved.
24 S: . . . supporting materials for both theory and Learning materials
25 practice should be provided fully.
26 S: . . . training program should be given to clinical Knowledge and skills
27 instructors so they know how to direct students.

Three categories emerged from open coding of data from the intervention group after

the study. Students’ perceptions about SDL focused on three areas: ‘process of

learning’, ‘advantages’, and ‘areas needing improvement’. Each of categories

comprised a number of subcategories as shown in Table 7.6.

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Table 7.6: Category development for intervention group after intervention
Category Subcategory
Process of learning • Individual initiative
• Learning with or without help
Advantages • Direction in learning
• Increased motivation
• Increased self confidence
• Incremental learning
Areas needing improvement • Communication
• Learning materials
• Knowledge and skills

The category of ‘process of learning’ had two subcategories: ‘individual initiative’

and ‘learning with or without help’. The category of ‘advantages’ had four

subcategories: ‘direction in learning’, ‘increased motivation’, ‘increased self-

confidence’ and ‘incremental learning’. The category of ‘areas needing

improvement’ had three subcategories: ‘communication’, ‘learning materials’, and

‘knowledge and skills’.

The category ‘process of learning’ and the two subcategories highlighted that

students in the intervention group had changed their view of SDL as something that

they did based on individual initiative and with or without help. The following

statements give examples of the two ways in which students viewed SDL as a

‘process of learning’.

Individual initiative

This subcategory was identified by the following example:

“Self-directed learning is using one’s initiative for learning, using self

effort to search for things”

Learning with or without help

A student identified this subcategory by stating:

“Self-directed learning is a process of learning where we do self-directed

learning with or without help from others.”

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The category of ‘advantages’ and the four subcategories highlighted that students in

the intervention group had changed their view of SDL as they considered SDL was

something that benefits them. The following statements give examples of the four

ways in which students viewed that SDL has ‘advantages’.

Direction in learning

The following student statement highlights this subcategory:

“Using self-directed learning, I know how to arrange my study effectively

and I have direction in learning”

Increased motivation

For this subcategory a student stated:

“Self-directed learning increased knowledge and motivation for self

development in learning as compared to previous methods of learning.”

Increased self-confidence

This subcategory was identified by the following example:

“Self-directed learning renewed my ways of learning, and I felt a change

in the process of learning and an increase in my self-confidence.”

Incremental learning

One student stated:

“In self-directed learning we can arrange the time for learning

effectively and learning does not pile up”

One student supported this subcategory by stating:

“ . . . using self-directed learning method learning does not pile up

because the learning materials are learnt little by little.”

The category of ‘areas needing improvement’ and the three subcategories highlighted

that students in the intervention group had changed their view of SDL as they had a

tendency to see learning changes as challenges to improve rather than merely as

155
problems. The following statements give examples of the three ways in which

students viewed SDL has ‘areas needing improvement’.

Communication

This subcategory was identified by the following example:

“Communication between school of nursing and clinical practice needs

to be improved.”

Learning materials

One student suggested this by stating:

“Supporting materials for both theory and practice should be provided in

full.”

Knowledge and skills

This subcategory was identified by the following example:

“Training program should be given to clinical instructors so they know

how to direct students.”

These categories and subcategories, which were expressed after the study, indicate

that the students in the intervention group had changed their views of SDL. They

appeared to have some understanding that the shift away from the focus on the

teacher would help their self-confidence improve.

7.4 Clinical instructors’ focus group discussions

Two focus groups were conducted to collect clinical instructors’ perceptions about

students’ clinical activities in clinical settings. One FGD was conducted for clinical

instructors in the intervention group and one FGD for clinical instructors in the

control group. All clinical instructors’ focus groups were conducted after the EIP,

however, they were asked about activities in clinical practice before and after the

intervention. The analysis of data used the same process of coding. These two groups

156
were analysed separately and the group categories were compared. It is interesting to

note that for categories before the EIP their responses were the same. Post-

intervention, the control group categories were the same as they were at pre-

intervention, however, the post intervention data for the clinical instructors from the

intervention group was different because the students were doing different activities.

Five categories were generated from the clinical instructors’ focus group data from

the intervention group, and four categories emerged from clinical instructors in the

control group. Under these categories, all of the data were accounted for. The section

begins with FGD from clinical instructors from the control group, followed by

findings from clinical instructors from the intervention group.

7.4.1 Clinical instructors from the control group

Data from clinical instructors in the control group were examined for themes using

open coding. The coding process is exemplified by the following data in Table 7.7.

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Table 7.7: Themes development from control group clinical instructors
Line FGD Transcript Open coding
1 R: Can you tell me what students did in clinical
2 practice?
3 CI: All of them are passive when doing practice in the Doing everything in
4 hospital, whereas not all nurses take care of them. Nurses group
5 did not care if students understand or not,
6 moreover they always working in group.
7 CI: In reality they are passive and many times students Passive
8 can not give proof to clinical instructor about their
9 activities in hospital.
10 R: What do you think about the clinical practice?
11 CI: There is no appropriate planning on what students Unclear clinical
12 do and expect to accomplish in clinical practice. objectives
13 CI: There is lack of coordination between clinical field Lack coordination
14 and school of nursing, teacher only comes twice—at
15 the beginning and the end of clinical practice.
16 R: Do you think second year students are “more
17 active” in clinical practice compared to three
18 months before?
19 CI: . . . is still the same, they are only waiting for orders Waiting for orders
and
20 many time they come late and go home early. These is
21 my observation recently.
22 CI: . . . they do not have initiative and after finishing the Do not ask questions
23 procedures they never ask any questions
24 CI: I have seen them still inactive and they have less Less curiosity
25 curiosity, even though they have already been given tasks
26 such as in laboratory, they only do the task and do not
27 have curiosity about other units

In addressing the research question regarding the students’ clinical activities in

clinical settings, three categories emerged from open coding of data from clinical

instructors in the control group. Two categories emerged from the clinical

instructors’ perceptions of clinical practice before the EIP: ‘lack of self-confidence’,

and ‘lack of planning’. One category emerged from clinical instructors’ perceptions

of clinical practice after the EIP: ‘lack of initiative’. Category development from

clinical instructors in the control group is presented in Table 7.8.

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Table 7.8: Category development from control group clinical instructors
Category Subcategory
Before intervention
Lack of self-confidence • Doing everything in group
• Passive
Lack of planning • Unclear clinical objectives
• Lack of coordination
After intervention
Lack of initiative • Waiting for orders
• Do not ask questions
• Less curiosity

The category of ‘lack of self-confidence’ and the two subcategories highlighted that

clinical instructors had their views of students in doing their clinical activities as

lacking in self-confidence. The following statements give examples of the two ways

in which clinical instructors viewed students’ clinical activities as ‘lacking in self-

confidence’.

Doing everything in groups

One clinical instructor highlighted this by stating:

“They always work in groups when doing practice in the hospital.”

Passive

The following clinical instructor statement highlights this subcategory:

“In reality, students are passive and many times they cannot give proof
to clinical instructor about their activities in hospital.”

Another clinical instructor supported this by stating:

“All of them are passive when doing practice in the hospital, whereas not
all nurses take care of them.”

The category of ‘lack of planning’ and the two subcategories highlighted that clinical

instructors viewed student clinical activities as lacking preparation. The following

159
statements give examples of the two ways in which clinical instructors viewed

students’ clinical activities as having ‘lack of planning’.

Unclear clinical objectives

This subcategory was identified by the following example;

“There is no appropriate planning as to what students do or what they

are expected to accomplish in clinical practice.”

Lacking of coordination

One clinical instructor stated:

“There is a lack of coordination between the clinical field and school of

nursing, the teacher only came twice, at the beginning and at the end of
clinical practice.”

The category of ‘lack of initiative’ and the three subcategories highlighted that

clinical instructors in the control group had their views of students doing their

clinical activities as still inactive. The following statements give examples of the

three ways in which clinical instructors viewed students’ activities in clinical settings

as ‘lacking in initiative’.

Waiting for orders

For this subcategory a clinical instructor stated:

“ . . . is still the same, they are only waiting for orders from nurses and
many times they come late and go home early. This is my observation
recently.”

Do not ask questions

One clinical instructor confirmed this subcategory by stating:

“They do not have initiative and after they finish the procedures they
never ask any questions.”

Less curiosity

This subcategory was identifying by the following clinical instructor’s statement:

160
 “I have seen them still inactive and they have less curiosity, even though
they have already been given tasks such as in laboratory, they only do
the task and do not have any curiosity about other unit.”

7.4.2 Clinical instructors from the intervention group

Data from clinical instructors from intervention group were analysed for themes

using the same process as the clinical instructors’ FGD from the control group. The

coding process is exemplified by the following data in Table 7.9.

161
Table 7.9: Themes development from clinical instructor in intervention group
Line FGD Transcript Open coding
1 R: Can you tell me what students did in clinical
2 practice?
3 CI: They do not have self-confidence to communicate Doing everything in
4 with patients, they were confused and did everything group
5 in groups
6 CI: They always wait for us to give orders, whereas we are Passive
7 very busy caring for the patients.
8 R: What do you think about the clinical practice?
9 CI: There is no evidence that students can do the skill Unclear clinical
10 and clinical objective is unclear. objectives
11 CI: The clinical practice is uncoordinated even though Lack coordination
12 the distance between hospital and nursing school is
13 very close but the nursing school staff never come to
14 the hospital to monitor whether the students practice
15 or not
16 R: Do you think second year students are “more
17 active” in clinical practice compared to three
18 months before?
19 CI: They are more active than before. They have more Ready for practice
20 confidence and curiosity to do the skills, when I guided
21 them they were more ready. I thought they got both
22 theory and practice beforehand in the laboratory
23 CI: Obviously they have clinical practice goals and Have clinical
24 they can articulate clearly the competencies they are objectives
25 looking for.
26 CI: Students are more active in wanting to accomplish Actively accomplishes
27 the competencies they should get in clinical practice the skills
28 CI: It is easy to discuss things with them; we can Teaching becomes
29 exchange opinions and knowledge. Teaching more interesting
30 becomes more interesting and worthwhile, both of us are
31 ready for collaboration
32 CI: . . . because they asked many questions we got Increased motivation
33 many ideas, and we came to know what we did not
34 know, or we know only partly, so that I have motivation
35 to improve my knowledge and to learn more deeply.
36 CI: It is easier to guide them in clinical practice Reduced burden
37 because their participation is high, they have self
38 confidence so that I do not need to direct them over
39 and over so clinical teaching becomes more interesting
40 CI: There is an interaction between students and Increased interaction
41 tutors. Sometimes they know the knowledge earlier
42 and we discussed it.
43 CI: They were more creative and want to practice all Good learning
44 things. They feel free and asked many questions, with environment
45 students like this I felt more enthusiasm to direct them
46 and it challenges me to read more to improve my
47 knowledge

In addressing the research question of the students’ clinical activities in clinical

settings, five categories emerged from the open coding of data from clinical

instructors in the intervention group. Two categories emerged from clinical

162
instructors’ perceptions of clinical practice before the EIP: ‘lack of self-confidence’,

and ‘lack of planning’. Three categories emerged from clinical instructors’

perception of clinical practice after the EIP: ‘confidence working alone’, ‘enhancing

job satisfaction’, and ‘improve clinical teaching’. Category development from

clinical instructors in the intervention group is shown in Table 7.10.

Table 7.10: Category development from intervention group clinical instructors

Category
Before intervention
Lack of self-confidence
Lack of planning
After intervention
Confidence working alone
Enhancing job satisfaction
Improve clinical teaching
Subcategory
• Doing everything in groups
• Passive
• Unclear clinical objectives
• Lack of coordination
• Ready for practice
• Have clinical objectives
• Actively accomplish the skills
• Teaching becomes more interesting
• Increased motivation
• Reduced burden
• Increased interaction
• Good learning environment

The category of ‘lack of self-confidence’ and the two subcategories highlighted that

clinical instructors viewed students in clinical practice as working with less

confidence and being inactive. The following statements give examples of the two

ways in which clinical instructors viewed students’ clinical activities as ‘lacking in

self-confidence’.

Doing everything in groups

One clinical instructor highlighted this by stating:

“They always practice in groups, one student does the skills and other
watches him/her.”

Another clinical instructor agreed and stated:

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 “ . . . it seems likely that the preparation of clinical practice either in
theory or practice is inadequate. Students seem to lack self-confidence
and feel uncertain about doing nursing tasks, and they always work in
groups.”

Passive

The following clinical instructor statement highlighted this subcategory:

“They are always passive and wait for us to give orders, whereas we are
very busy caring for the patients.”

Another clinical instructor agreed and stated:

“ . . . it’s always the case that it’s the nurses who always actively ask
them, whereas the students are still passive.”

The category of ‘lack of planning’ and the two subcategories highlighted that clinical

instructors viewed student clinical activities as lacking in preparation. The following

statements giving examples of the two ways in which clinical instructors viewed

students’ clinical activities as ‘lack of planning’.

Unclear clinical objectives

This subcategory was identified by the following example;

“Their activities are not arranged properly because there are no

guidelines for clinical learning so they only follow routine activities in
the wards.”

One clinical instructor supported this by stating:

“Students doing practice in our ward just do routine tasks, such as when
they come they read the ward report, and there is no clear concept of
what they want to learn or to do in clinical practice.”

Lack of coordination

One clinical instructor confirmed this subcategory by stating:

“The clinical practice is uncoordinated even though the distance between

hospital and nursing school is very close, but the nursing school staff
never come to the hospital to monitor whether the students are practising
or not.”

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These categories expressed the students’ activities before intervention. The

category of ‘confidence working alone’ and the three subcategories highlighted

that clinical instructors in the intervention group had changed their views of

student clinical activities after the intervention as something that students did

confidently working alone. The following statements give examples of the three

ways in which clinical instructor viewed students as ‘confident working alone’.

Ready for practice

For this subcategory a clinical instructor stated:

“ . . . there is really a change in clinical practice, they are more

confident to do nursing intervention under guidance such as inserting
drips, calculating medicine doses, and giving injections to clients.”

The following clinical instructor statement highlights this subcategory:

.” . . . they did nursing interventions in groups, and they just used to

hang around, but now they have confidence to do nursing interventions
alone; if they have spare time they read patient reports and also they go
to patient’s room to communicate, something that they did not have the
confidence to do before.”

Have clinical objectives

This subcategory was identified by the following example:

“Obviously they have clinical practice goals and they can articulate
clearly the competencies they are looking for.”

Actively accomplish the skills

One clinical instructor confirmed this subcategory by stating:

“Students are more active in wanting to accomplish the competencies

they should get in clinical practice”

The category of ‘enhancing job satisfaction’ and the three subcategories highlighted

that clinical instructors had changed their views of student clinical activities after

intervention. They viewed the students as being more active, which had an impact on

their clinical teaching workload and their professional development. The following

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statements give examples of the three ways in which clinical instructors viewed the

clinical teaching activity as ‘enhancing job satisfaction’.

Teaching becomes more interesting

This was highlighted by one clinical instructor who stated:

“ . . . because students are more active and they asked many questions,
tutors know what students prefer to learn in clinical practice; it is easy to
discuss things with them, there is an interaction between students and
tutors. Teaching becomes more interesting and worthwhile; both of us
are ready for collaboration.”

Another clinical instructor stated:

“It is easier to guide them in clinical practice because their participation

is high; they have self-confidence so that I do not need to direct them
over and over so clinical teaching become stimulating.”

Reduced burden

One clinical instructor stated:

“ . . . the implication of students being more active is to make it easier for

me to guide them in clinical practice, because their participation is high
and they have self-confidence. Maybe they have read the theory
beforehand and prepared in the laboratory or library, such as I saw from
second-year student performance at a recent clinical practice.”

Another clinical instructor supported this by identifying:

“Actually with students being more active it is not a burden for us; on the
contrary it is makes our workload lighter. For example, in the
Emergency Department when a patient comes in, the students ask what
and how things are to be done, the tutor gives directions, and they do it.”

Increased motivation

This subcategory was identified by the following example:

“They asked many questions and we got many ideas, and we came to
know what we did not know, or we know only partly, so that I have
motivation to improve my knowledge and to learn more deeply.”

The category of ‘improved clinical teaching’ and the two subcategories highlighted

that clinical instructors had changed their views of student clinical activities after the

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intervention and their views of students being ‘more active’ had a good impact on

clinical teaching/learning. The following statements give examples of the three ways

in which clinical instructors viewed the clinical teaching activity as ‘improved

clinical teaching’.

Increased interaction

For this subcategory a clinical instructor stated:

“There is an interaction between students and tutors. Sometimes they

know the knowledge earlier and we discuss it.”

Good learning environment

This subcategory was identified by the following clinical instructor statement:

“They were more creative and wanted to practise all things. They feel
free and asked many questions; with students like this I felt more
enthusiasm to direct them and it challenges me to read more to improve
my knowledge.”

7.5 Summary

This chapter presented the qualitative findings from FGDs for both students and

clinical instructors. Data analysis was outlined and theme and category development

was presented with quotes to support each category. The FGDs revealed that

perceptions of students’ in the intervention group changed during the EIP, compared

to the students in the control group. Increased self-confidence, incremental learning,

and having direction in learning were identified as benefits of SDL. Knowledge and

skills in SDL, learning materials and communication were identified as important

issues that needed to be improved. Clinical instructors’ perceptions of students’

clinical activities confirmed that students in the intervention group were ‘more

active’ compared to the control group who were considered to be ‘still inactive’. The

following chapter outlines the discussion and recommendations.

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 CHAPTER EIGHT

DISCUSSION AND RECOMMENDATIONS

8.0 Introduction

Getting a new idea adopted, even when it has obvious advantages,

is often very difficult. Many innovations require a lengthy of
period, often of many years, from the time they become available
to the time they are widely adopted. Therefore, a common problem
for many individuals and organisations is how to speed up the rate
of diffusion of an innovation. Rogers (1994, p.1)

The previous two chapters have outlined the results from the quantitative and

qualitative data related to self-directed learning readiness collected prior to, and

following, an educational intervention. Levels of nursing students’ readiness for self-

directed learning (SDL) in the sample collected prior to the educational program, as

measured by self-directed learning readiness scale (SDLRS) developed by

Guglielmino (1978), were: 64% in the ‘below average’ range; 32% in the ‘average

range’ and only 4% in the ‘above average’; there were no students in the ‘high’

range. This result was similar to those of pilot study, 78% ‘below average’, 20% of

students in the ‘average’, 2% ‘above average’ and also no students scoring in the

‘high’ range for SDL. Therefore, the data collected prior to the intervention program

confirmed low levels of readiness for SDL and confirmed the traditional teacher-

centred approach in Indonesia.

The introduction of SDL concepts through an educational intervention program (EIP)

improved the level of readiness for SDL in the intervention group from ‘below

average’ to ‘average’ compared to the control group who remained in the ‘below

average’ range. Group and gender variables contributed significantly to the

prediction of readiness for SDL. The intervention group’s perceptions of SDL

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changed during the EIP from SDL as ‘learning alone without help’ to ‘process of

learning based on individual initiative, with or without help’. Increased self-

confidence, incremental learning, increased motivation to learn and having direction

in learning were identified through focus group discussion (FGD) as benefits of SDL.

Knowledge and skills in SDL, learning materials and communication were identified

as important issues that needed to be improved. Clinical Instructors’ perceptions of

students’ clinical activities supported the change in students and confirmed that

students in the intervention group were ‘more active’ compared to the control group

who were ‘still inactive’. Overall, the results from the study confirmed the expected

effect of the EIP on students’ SDL readiness.

This study is the first of its kind to examine an intervention to improve nursing

students’ readiness for SDL in Indonesia. This final chapter discusses the outcomes

of the study and the factors which contribute to the readiness for SDL in nursing

students. The findings will be examined in relation to contemporary literature on

readiness for SDL. The results of the quantitative data are discussed first followed by

those from the qualitative data according to the research questions examined.

Limitations of the study are then discussed. The chapter concludes with a discussion

of implications and recommendations for research and nursing education.

8.1 Research Question One

• What were students’ levels of readiness for self-directed learning (SDL)

before the educational intervention as measured by the Self-Directed Learning

Readiness Scale?

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Hypothesis 1: The students’ level of readiness for SDL as measured by SDLRS

before the educational intervention would be lower than established group norms

(Guglielmino, 1978).

The self-directed learning readiness scale (SDLRS) scores for this study, before the

educational intervention program were lower than the scores reported by

Guglielmino (1978) when SDLRS was established 27 years ago. The majority of

students’ readiness for SDL was found to be ‘below average’ (64%) and no students

scored in the ‘high’ range for SDL. The students’ mean SDL score was significantly

different from the established norms (Guglielmino, 1978). The studies that were the

basis for the norms involved participants from a developed country (USA) in which

the cultural and educational system are different and learning resources are not a

problem. The present study used second-year nursing students from a relatively rural

area in a developing country, Indonesia.

The mean scores from the study were also lower than other studies in Indonesia

(Darmayanti, 1994) and other countries—such as with undergraduate students in

Australia (Delahaye & Choy, 2000) and Ireland (McCauley & McClelland, 2004).

The lowest score in the current study was also lower than that noted in the

Indonesian study (Darmayanti, 1994). In addition to having significantly lower

SDLRS scores than normative data (based on the USA students), the students in the

current study also had lower scores than studies in Australia, Ireland and Indonesia.

The overall lower scores of readiness for SDL may reflect the educational and

cultural background of the participants. To understand why, it is necessary to

consider the cultural and educational system in Central Kalimantan and Indonesia.

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Despite the extraordinary pace of modernisation, the phenomenon of human

communication in education through the oral tradition is still strongly held in Central

Kalimantan and Indonesia. Traditional beliefs and expectations in Indonesia

regarding learning have placed the teacher in the roles of content expert and authority

figure. Students have not been given many opportunities to assess their personal

needs as a basis for learning; the students usually expect the teacher to be an

authority on whatever topic matter is being discussed. According to Dunbar (1991),

the strong tradition of oral communication in Indonesia has created a popular

perception that learning is a relationship with a teacher that is oral and hierarchical.

The dynamics of the relationship are usually described as learning as a passive

activity, whereas teaching is active. Furthermore, Dunbar says acquisition of

knowledge and development of skills and techniques in Indonesia are seen to be

passive replications of what a teacher does and says, leading to the widespread use of

rote learning to pass semester examinations from primary school through to

undergraduate programs. This perception is still present today in nursing students in

Central Kalimantan, as reported by the Sister School Project (2002) (see Chapter

One).

Teacher-centred methods have dominated Indonesian nursing education. Indonesian

nursing students focus their efforts on passing examinations and passively submit to

the authority and direction of their teachers. The students are acculturated to believe

they are not empowered to teach themselves and create meaning through independent

cognitive effort. Teachers speak their knowledge and students take notes, often

verbatim, as they are used to traditional teaching approaches. Furthermore, the

students view learning activities using various resources outside the classroom as a

waste of time because they believe the learning may not be optimal or correct.

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In Indonesia or Central Kalimantan, most teachers in nursing education can

communicate only in the official language (Indonesian) of the country and therefore,

to explore professional innovations in nursing education outside Indonesia depends

on information being available through translation. This influences the diploma

nursing education courses, specifically in Central Kalimantan, to still use traditional

approaches. It is assumed that the reason why teachers and students in Central

Kalimantan not using SDL methods is that they have not been introduced to, or

prepared for, SDL.

Confessore (1991) states that some students have a low level of readiness for SDL

because they have consistently been exposed to “other-directed” instruction [teacher-

centred approaches]. The findings of the current study seem to support Confessore’s

views as the educational system used in all nursing schools in Indonesia involves

teacher-centred approaches. Furthermore, the nursing students had graduated from

high schools in Indonesia, which also use teacher-centred approaches.

The real situation in the nursing schools in Central Kalimantan may have influenced

how nursing students interpreted the questions. For example, one question, ‘I think

libraries are boring places’, was likely to be influenced by their experience of the

libraries, which have only a small number of books, the majority of which are out of

date and not relevant to course content, limited chairs and tables, limited lighting,

and no air conditioning in a hot equatorial climate. It is therefore understandable if

the majority of students gave a high rating to the statement regarding the library

being a boring place, leading to a low score on that question. According to Dunbar

(1991) there is no pressing need in Indonesia for serious reading, and the skill of

writing is not fostered in teacher–centred methods. For most students, there is no

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need to express ideas, observations, or opinions in an extended literacy form. This is

a possible reason why the nursing schools pay less attention to the development of

their own libraries.

This situation is different in countries where the original SDLRS was developed

(USA). The libraries in countries such as Australia, United Kingdom, Canada and

USA are likely to have a much richer and broader collection of recent journals, books

and other learning materials than is available in the school or university libraries in

Indonesia or Central Kalimantan. Furthermore, the SDL model in western culture

assumes that students are capable of independent learning behaviours and tha, on

entry, they are psychologically prepared for the personal demands imposed by a

teacher-independent, self-study regime (Guglielmino & Guglielmino, 1991).

However, Indonesian learners are acculturated from primary school to avoid

behaviours or statements that may be interpreted by others to be expressions of

personal autonomy (Dunbar, 1991).

Prior to the study the students appeared to have an understanding that confirmed

Dunbar’s (1991) views about Indonesia: that learning is a passive activity and

teaching is active. This was also indicated by the students who were passive in their

learning and waiting to be taught by their teachers. These data confirmed the

hypothesis that students’ readiness for SDL as measured by SDLRS before the

educational intervention would be lower than established group norms (Guglielmino,

1978).

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8.2 Research Question Two

• Was there a difference in students’ readiness scores for SDL between the

intervention and control groups at pre-test?

Hypothesis 2: There would be no significant difference between the intervention and

control group SDLRS scores at pre-test.

It was assumed that there would be no significant difference in pre-test scores

between the intervention and control group as they came from the same population,

and use the same educational system and curriculum. Furthermore, human resources,

funding and size of these schools were similar. Demographic variables of these two

groups including gender, age, birth order, father’s educational background and

mother’s educational background were checked and no significant differences were

found.

Despite having randomly assigned the two schools to either intervention or control

group, there was a significant difference in SDL readiness scores prior to

commencing the EIP. The mean SDLRS score was higher in the control group than

in the intervention group. More students in the control group scored in the average

and above average range than in the intervention group (46% vs 24%).

To understand this difference, it is necessary to examine the external factors

influencing readiness for SDL in both intervention and control groups. As noted

previously, the library is a very important learning resource for SDL. The library, in

terms of number of books and opening hours, was better in the control group than in

the intervention group. Another explanation could be that “homework”, often used as

a traditional method of SDL in Indonesia, was used more in the control group than in

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the intervention group. However, this traditional method of SDL is not systematically

used in teaching/learning and is only used as a substitute for face-to-face lectures.

The homework method is often used by medical doctors who teach tropical diseases

topics. At times when they are very busy with patients in hospital or out-patient

clinics, they cannot attend classes to teach so they give learning materials to the

subject coordinator and asked students to copy and read the learning materials. The

doctors would then explain the reading materials in the next lectures. This situation

was more likely to occur in the control group than the intervention group.

As the pre-test scores were significantly different between intervention and control

group it was considered necessary to control for pre-test SDLRS scores. Therefore,

the pre-test scores for each participant were used as co-variates in data analysis. The

different SDLRS scores between intervention and control groups did not support the

hypothesis that pre-test scores between the groups would not differ.

8.3 Research Question Three

• Was there a difference in students’ readiness scores for SDL following the

educational intervention?

Hypothesis 3: Self-directed learning readiness scores of students who participated in

the educational intervention program over fourteen weeks would be significantly

increased compared to scores of students who did not participate.

The educational intervention program (EIP) was designed to introduce the concept of

SDL and to facilitate students to increase their understanding of the concepts and

basic skills of SDL. Given the low level of readiness for SDL, the different cultural

and educational system, and the many constraints in nursing education—such as

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limited teaching and learning materials and limited books in the library—it was

reasonable to aim for Stage 2 as an optimal goal for students in the study. Stage 2 of

the SSDL model is the stage in which students have moderate self-direction.

The effect of the EIP was supported by the significant increases in readiness for SDL

in the intervention group following implementation of the education program. The

results of this study indicate that, after controlling for pre-test differences, the mean

readiness scores of the intervention group improved compared to the control group.

The change in the intervention group by only one category (e.g. from ‘below

average’ range to ‘average’ range) was expected, given the low base that the students

had at the commencement of the study.

According to Grow (1991), the important movement implicit in the SSDL model is

the movement from dependent to self-directed learning. The EIP involved changes in

thinking and behaviour in learning for second-year nursing students in the

intervention group. Given the low level of readiness for SDL, it was considered a

realistic goal to move students from Stage 1, dependent learner, to Stage 2, motivated

learner. In doing this, it was very clear that it was not possible to just pick up the

SDL approach from western culture and introduce SDL in a western way. The study

confirmed that it is really important to select elements of SDL, to introduce those

elements and then to work incrementally on those elements to see how they are

working. For the current study, SDL was introduced through a classroom setting and

a teacher-centred approach. The EIP introduced selected elements that would fit

within the culture and background of students and the nursing schools in Central

Kalimantan. This study was designed to introduce the innovation by melding Grow’s

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(1991) and D’A Slevin and Lavery’s (1991) ideas with the culture of nursing

education in Central Kalimantan.

In addition, the EIP was designed to incrementally move the students through the

early stages of SDL. The strategies used in the EIP were selected relevant to the

stages of SDL that were being targeted in the EIP. According to Grow (1991), as the

students in Stage 2 of SSDL are interested learners, it was important in this stage to

introduce students to the basic skills of SDL, such as goal setting. Based on this

assumption, this study was designed to focus only on two stages of SDL: Stage 1 and

Stage 2. The reason not to include Stage 3 and Stage 4 of Grow’s SSDL model was

because in Stage 3 students are involved learners (learners of intermediate self-

direction), and in Stage 4 they are learners of high self-direction with the capability

to plan, complete and evaluate their own learning with or without the help of an

expert/teacher. According to Grow (1991) fully self-directed learning is not possible

in an institutional setting due to statutory educational regulations and time

constraints. Because of time and cost constraints of this study, as well as many

constraints in nursing education, such as limited teaching and learning materials and

limited books in the library, it was reasonable to aim for Stage 2 as an optimal goal

for these students. Stage 2 of SSDL model is the stage in which students have

moderate self-direction.

8.4 Research Question Four

• What factors contributed to students’ readiness for SDL?

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Hypothesis 4: Variables such as group (intervention–control), gender, birth order,

father’s educational background and mother’s educational background would

significantly contribute to students’ readiness for SDL.

From the five variables that were examined as potential influencing factors on

students’ readiness for SDL, two contributed significantly to the prediction of

readiness. These were group (intervention–control) and gender. Students who were

in the intervention group and were female were more likely to report higher SDL

readiness.

Several explanations may explain why female students had higher readiness for SDL

than male students. As the nursing area is dominated by female students, and the

nursing school is not the first choice for male students in Indonesia, it may influence

male students in responding to SDL readiness. The male students may not be highly

motivated to study nursing in the first place and therefore may be less likely to want

to be self-directed in their studies. Another explanation could be the different

learning styles between female and male students. Price (1978), states that male

students prefer a more unstructured design than female students. Using learning

plans, as suggested by Knowles (1986), might be an example of a learning strategy

that would be preferred by those who have a structured learning style. Since the

study used learning plans to develop readiness for SDL, this strategy may have

worked better for female students than male students. However, more research is

needed to clarify this assumption. Many studies have reported that female students

had higher SDLRS scores compared to their male counterparts (Darmayanti, 1994;

Guglielmino, 1978), however these studies did not report the reason for the

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differences and no study has been found in the literature that has examined this

difference.

The other three factors that were assumed to influence readiness for SDL in nursing

students in Central Kalimantan included birth order, father’s educational background

and mother’ educational background. These factors did not influence students’

readiness for SDL and the possible reasons are outlined below.

Birth order is a unique value in Indonesian culture, specifically in Central

Kalimantan. Traditional beliefs and expectations in Indonesia regarding the first-born

child have placed the first-born child in the role of authority figure for their little

sisters or brothers. First-born children learn from their early childhood to have

responsibility and that they should be a good role model for their sisters and brothers.

Their parents place great pressures on them to succeed, in both education and career

no matter what their gender is. In Central Kalimantan, the importance of a first-born

child has created a new attribute for their parents. For example, when a married

couple have not yet had their first-born child, they may be called by their given name

in informal daily communication. After their first child is born the parents are

identified by their first-born child’s name. For instance, if the child’s name is

‘Katrina’ the father is known as ‘Bapa Katrina’ (Katrina’s father), and so the mother

is known as ‘Mama Katrina’ (Katrina’s mother).

Considering the unique aspects of the first-born child in Central Kalimantan culture

it was assumed the birth order might influence readiness for SDL. This assumption

was based on the characteristics and attributes of control and authority that are given

to first-born order. Control is identified as an important variable in SDL. However,

this assumption was not supported in this study as first-born order did not influence

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the readiness for SDL. The possible explanation for this finding is that the first-born

child may obey their parents and do whatever their parents ask them, rather than

taking their individual initiative, especially in learning. Therefore, it appears that any

control and authority given to first-born students did not carry over into their learning

process and that, like the other students, they were more comfortable with the teacher

as the authority figure directing their learning.

The role of father and mother in Indonesian culture are unique compared to western

culture. Traditional beliefs and expectations in Indonesia regarding parents’ roles

have placed the parents (father and mother) in the roles of authority figures. The

culture has shaped how children behave towards their parents. The children should

respect and obey their parents and the parents have the responsibility to educate their

children as well as possible. The responsibility for funding will end when the child

gets married or gets a job. Considering the unique aspect of the relationship between

parents and children in Indonesian culture it was assumed that the parents’

educational background would influence readiness of SDL. However, the results of

the study did not support this assumption. The father and mother’s educational

background did not influence the readiness for SDL in their children. It is difficult to

compare and contrast this finding as this is unique for Indonesia because of the

specific culture. Moreover, no study on these topic areas has been found in

Indonesia. More studies are needed in these topic areas in the future to develop more

understanding and to add to the body of knowledge.

8.5 Research Question Five

• What were the students’ perceptions of SDL before and after the educational

intervention?

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The focus group discussion (FGD) prior to commencement of the study revealed that

students from both the intervention and control groups had similar perceptions of

SDL. They had a limited view of SDL and perceived SDL as a ‘self-activity’ without

direction from their teachers. They also viewed SDL as learning alone without help,

similar to distance learning, with no class and no teacher guidance. In addition, they

viewed the purpose of SDL as an activity to prepare for tests. This view seems to

support Dunbar’s views (1991) that Indonesian students focus their learning efforts

to pass tests. The students also viewed SDL as having consequences, including

teacher inactivity.

The students were concerned about the impact of SDL: if the teachers did not teach

in the classroom then probably the teacher would not teach them and what could the

students do? Again this perception seems to support Dunbar’s (1991) statement that

teaching is active and learning is a passive activity. These views, which were

expressed before the study commenced, indicated that the nursing students in Central

Kalimantan had a limited view of SDL and were concerned about its impact.

However, the FGD data from the intervention group after the EIP revealed that the

perceptions of SDL of students in the intervention group changed during the EIP,

compared to students in the control group. The control group perceptions of SDL

were the same as pre-intervention. The students’ perceptions still focused on self-

activity and consequences. The students were also concerned about the results of

SDL activities. They believed the results of SDL activities would not be optimal or

correct compared to teacher-centred methods. This is understandable because the

students do not have a comprehensive understanding of SDL and they were used to

teacher-centred methods and had never been exposed to SDL approaches. Another

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consequence that concerned students in the control group was ‘increased laziness’ to

attend lectures and ‘difficulty to change’ learning habits. They appeared to have

some understanding of the shift away from teacher-centeredness that may make them

less respectful to their teachers. These views, which were expressed after the study

had finished, indicated that the students in the control group still had limited views of

SDL and were concerned about its effects.

The analysis of the intervention group data revealed that students had different

perceptions of SDL after the EIP. The students’ perceptions about SDL had changed

from self-activity based on learning alone without help from others, to a process of

learning based on individual initiative, with or without help from others. The

intervention students’ perceptions focused on three areas: ‘process of learning’,

‘advantages’ of SDL’ and ‘areas needing improvement’. It seems that they had a

tendency to see learning changes as challenges to improve, rather than as problems.

Increased self-confidence, incremental learning, increased motivation, and having

direction in learning were identified as benefits of SDL by students in the

intervention group. These students identified issues that needed to be improved that

included knowledge and skills in SDL, learning materials and communication. The

views expressed after the EIP indicated that the students in the intervention group

had changed their views of SDL. They appeared to have some understanding that the

shift away from teacher-centred approaches would improve their self-confidence and

increase their motivation for learning. It can be assumed that the changes in the

intervention group were a result of the EIP. The students had an understanding and

basic skills for SDL. Furthermore, they experienced the SDL process in their

teaching/learning for 14 weeks as proposed by Grow’s (1991) SSDL model, this

aimed to move students from dependent to the early stage of self-directed learners.

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8.6 Research Question Six

• What were clinical instructors’ perceptions of students’ clinical activities

during the educational intervention period?

When the clinical instructors were asked about their perceptions of students’ clinical

activities before the intervention program, they perceived them as ‘lacking in self-

confidence’ and ‘lacking in planning’. They indicated that the students always did

their clinical activities in groups as evidence of lack of self-confidence. In addition,

they viewed the students’ clinical activities as lacking in planning. It is interesting to

note that clinical instructors from both intervention and control groups had similar

perceptions of students’ clinical activities.

The post-intervention data for the clinical instructors from the intervention group was

different because the students were doing different activities. The FGD data from the

clinical instructors in the intervention group revealed that the clinical instructors’

perceptions of students’ clinical activities in the intervention group changed during

the EIP compared to those of the clinical instructors from the control group. The

perceptions’ of the clinical instructors from the control group were the same as

occurred before the intervention. Clinical instructors in the control group still

perceived students as being inactive when doing their clinical practice.

The FGD data from the clinical instructors in the intervention group revealed that

clinical instructors had different perceptions of students’ clinical activities after the

EIP. The clinical instructors’ perceptions about students in doing their clinical

activities were: ‘confident working alone’, ‘enhancing job satisfaction’, and

‘improved clinical teaching’. Clinical instructors perceived that students in the

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intervention group were ‘more active’ than before the intervention. It seems that the

students had a tendency to work alone more than in groups. This is consistent with

what the students said about their self-confidence improving. Furthermore, the

clinical instructors believed students were more active in facing challenges to

improve their professional development, rather than as a burden. They also identified

that working with students who are more active would improve their clinical

teaching, as the interaction between the students and the clinical instructors increased

and this raised many discussions between them. The clinical instructors’ views

expressed after the EIP indicated that the clinical instructors in intervention group

had changed their views of student activities in the clinical setting. They appeared to

have some understanding that the students who were ‘more active’ had a good

impact on their job and their professional development. Clinical instructors’

perceptions of students’ clinical activities confirmed that students in the intervention

group were ‘more active’ compared to those in the control group who were

considered to be ‘still inactive’. The clinical instructor’ perceptions of the students

being “more active” and “more confidence working alone” support that the students

were taking more personal responsibility for their learning. The changes in students’

behaviour indicate that they had embraced the concepts of SDL and were trying to be

more active and self directed in their learning.

8.7 Limitations of the study

The findings of the study need to be interpreted after due consideration of the

following limitations. The study was conducted in two schools in Central

Kalimantan, Indonesia. The schools chosen for this study might not adequately

represent the population of second-year nursing students in Indonesia as the majority

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of diploma nursing schools are on Java and Sumatra islands, which are more

developed areas compared to Central Kalimantan. Moreover, since the participants

were not selected randomly, there was a potential selection bias, so the results of the

study may only be generalised to a limited population of nursing schools in

Indonesia. However, the study participants are representative of nursing students in

Central Kalimantan.

This could not be blinded study as both the intervention and control group were fully

aware of their participation in the study and this may have introduced bias to the

results. Another limitation of the study was that the researcher personally conducted

the majority of the intervention and this may have introduced investigator bias. A

further limitation was the nature of the SDL activities in the clinical component. The

students in the intervention group were facilitated by three staff whereas the students

in the control group were facilitated by one staff member. Access to more clinical

facilitators may have encouraged the students in the intervention group to ask more

questions and to seek clarification more often. This access to more facilitators may

have influenced the students learning outcomes.

The instrument (SDLRS) used in this study was selected as relevant to the present

study and it has also generally been reported to have a high reliability and validity in

previous studies. Although it has been tested and widely used in western countries

and the items of the SDLRS can be applied to most students, some of the findings

may have been influenced by demographic features, including cultural differences

relevant to the Indonesian population. There may be variations between the present

study population and the population where the instruments have previously been

developed and tested.

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A pilot test was conducted before the main study and the SDLRS results were lower

compared to those of previous studies in Indonesia or other countries. This may be

related to the different characteristics of participants within this study and the

previous Indonesian study, where the participants in the latter were mature students

compared to the pilot study participants, who were high school graduates. No other

studies were found similar to the present study. It was therefore difficult to compare

and contrast the results of the present study with those of previous studies and the

replication of this study to other settings in Indonesia is needed.

The length of the study was not sufficient to enable students to move to a higher

level of SDL readiness as proposed by the SSDL framework (Grow, 1991). Further

education for students and teachers/clinical instructors, as well as more learning

resources, will be needed to systematically integrate SDL concepts across the whole

curriculum. Therefore, a longitudinal study is needed as SDL is introduced into

nursing schools in Central Kalimantan. In the current study it was not possible to

examine the students’ end of semester examination results because different

assessment techniques were used between intervention and control groups. In the

future studies it may be beneficial to examine the outcomes of any experiential

activities in term of students’ grades in end of semester examinations.

8.8 Implications

This study makes a significant contribution to nursing education in Indonesia,

specifically in promoting lifelong learning and SDL in nursing students, in curricula

development, and in teaching and learning practices for the following reasons.

Firstly, didactic instruction was replaced with an interactive approach by utilising

SDL strategies and devices to facilitate SDL abilities. It showed that a learning

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environment could be systematically and incrementally implemented to assist

students and teachers to integrate theory and practice. Secondly, the conceptual

framework made it easy to manage a complex concept such as SDL. Thirdly, the EIP

was effective and can be duplicated through other studies. This will enable the

effective development and evaluation of SDL.

The findings of this study also present other implications. The SDLRS, which was

developed by Guglielmino (1978) for the North American culture, can be used

effectively in the Indonesian culture. The findings also contribute to the enrichment

of cross-cultural research related to SDL.

The findings imply that Indonesian nursing education can help students to improve

their readiness for SDL. Nursing education can plan activities to assist students to

develop their knowledge, skills and attitudes to be self-directed learners who are

expected to carry over their skills and behaviour in their nursing career. In planning

activities for SDL, nursing schools should realise the culture, educational system,

and the individual students are different from the education within western systems.

The selection of instructional methods to introduce SDL concepts should meet

students’ needs and nursing school budgets, and then gradually use other strategies.

These findings also indicated that external factors such as nursing curricula, learning

materials, knowledge and skills in SDL, and communication between nursing school

and clinical practice, and between teacher and student are important. Student-centred

approaches need to be further developed, implemented and supported.

This study also makes a significant contribution to nursing practice and global health

practice. The study used methods supported by the Technology Model of

Intervention Fidelity (Santacroce, Maccarelli & Grey, 2004). These methods

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included: manual development; training and supervision; and regular monitoring of

intervention delivery. Santacroce, et al. (2004) state that the use of the Technology

Model of Intervention Fidelity can ultimately advance the development of nursing

intervention research and evidence-based practice.

In general, the EIP improved nursing students’ level of SDL readiness. Ongoing

research is therefore needed for further clarification of the strategy and development

of educational innovations to support students’ efforts to become self-directed

learners. Integration of SDL approaches across the subjects in nursing curricula is

recommended to get the maximum benefit of SDL approaches.

8.9 Recommendations

Based on the results of the present study, recommendations are suggested as follows:

1. Systematic and incremental integration of SDL approaches into the diploma

nursing curriculum can be cost effective for developing countries such as

Indonesia.

2. A longitudinal study is recommended to introduce SDL in nursing education

from first-year to third-year students. The results of this study can help

nursing education staff plan activities to assist students to direct their own

learning, since SDL requires a different approach from the teacher-centred

methods used in traditional teaching/learning interactions.

3. Additional instructional methods for SDL—such as critical thinking and

reflection are recommended to be introduced in the future studies.

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 4. Since there is a limited number of studies on the topic of self-directed learning

that have been conducted in nursing education, other studies in this area are

recommended to enable comparison with the current study and to obtain better

understanding of the dynamics of self-directed learning in other nursing

schools. The sample of this study was drawn from two diploma nursing

schools. Further studies are therefore suggested by involving other diploma

nursing schools in other provinces in Indonesia.

5. A comparison of self-directed learning readiness between students at nursing

schools and other conventional diploma programs in Indonesia, such as

nutrition, physiotherapy, and midwifery, is recommended since there has been

no such study. The results of this study might contribute to a more

comprehensive understanding of students’ readiness of SDL from health

diploma programs in Indonesia.

6. Other studies that include variables related to SDL, such as learning style, are

recommended since there has no been such study in an Indonesian culture.

8.10 Conclusion

Overall, the results and findings answered the research questions and were consistent

with the conceptual framework. Some results of this study were also consistent with

those of previous studies. The EIP significantly improved the level of readiness for

SDL in the intervention group compared to the control group. The EIP involved

major changes in thinking and behaviour in learning practice for nursing students.

The outcome of the EIP extended beyond the perspective of nursing students and

included positive perceptions of clinical instructors in the intervention group who

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worked with nursing students in clinical practice. This was encouraging and supports

the EIP’s conceptual framework and the theory of adult learning. Unless the students

start to move from being ‘passive recipients’ to more ‘active participants’, the

nursing students who graduate from Central Kalimantan nursing schools will be left

behind in a rapidly changing health care environment.

It was difficult to compare and contrast the results of the present study directly

because no other similar studies were found. This study provides information about

the impact of the educational intervention program on students’ readiness for self-

directed learning. Although several limitations were found, the students in the

intervention group reported that the EIP had benefits for them. The EIP improved

nursing students’ readiness for SDL and had a positive impact on students’

perceptions of SDL. Introducing the concept of SDL through the EIP was found

acceptable by the sample and was deemed feasible to implement within Indonesian

nursing education.

This chapter has outlined the major findings from the study and drawn conclusions

from the results of the research questions and hypotheses. The study recorded the

level of SDL readiness in Indonesian diploma nursing students before and after an

educational intervention. This provided baseline data for future study comparisons as

the research method incorporated a control group who experienced teacher-centred

approaches and an intervention group who had an educational intervention program

alongside teacher-centred approaches. Implications for nursing education in

Indonesia have been presented, as well as the larger benefits for nursing practice and

global health practice. Recommendations for future research have been outlined,

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including integration of the SDL approaches into the nursing curriculum as well as

replication of the study in other diploma nursing programs.

In conclusion, the study has demonstrated that learning theories can be adapted and

implemented in culturally appropriate ways. Such adaptations can impact on student

learning and prepare students for practice in a complex and rapidly changing health

care system.

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 APPENDIX 1 SDLRS-A

Name: ……………………….. Sex: ……….. Birth date: …………………….

Date of testing: …………………….. Location of Testing: …………………...

Questionnaire
Instructions: This is a questionnaire designed to gather data on learning preferences
and attitude towards learning. After reading each item, please indicate the degree to
which you feel that statement is true of you. Please read each choice carefully and
circle the number of the response which best expresses your feeling.
There is no time limit for the questionnaire. Try not to spend too much time on any
one item, however, your first reaction to the question will usually be the most
accurate.

Responses Almost Not often Sometimes Usually Almost

never true true of me; true of me; true of me; always
of me; I I feel this I feel this I feel this true of me;
hardly ever way less way about way more there are
feel this than half half the than half very few
Items: way. the time. time. the time. times
when I
don’t feel
this way.
1. I’m looking forward 1 2 3 4 5
to learning as long as
I’m living.
2. I know what I want 1 2 3 4 5
to learn.
3. When I see 1 2 3 4 5
something that I don’t
understand, I stay
away from it.
4. If there is something 1 2 3 4 5
I want to learn, I can
figure out a way to
learn it.
5. I love learn. 1 2 3 4 5
6. It takes me a while
to get started on new 1 2 3 4 5
projects.
7. In a classroom, I 1 2 3 4 5
expect the teacher to
tell all class members
exactly what to do at
all times.
8. I believe that 1 2 3 4 5
thinking about who

192
you are, where you
are, and where you are
going should be a
major part of every
person’s education.
9. I don’t work very 1 2 3 4 5
well on my own.
10. If I discover a need 1 2 3 4 5
for information that I
don’t have, I know
where to go to get it.
11. I can learn things 1 2 3 4 5
on my own better than
most people.
12. Even if I have a 1 2 3 4 5
great idea, I can’t seem
to develop a plan for
making it work.
13. In a learning 1 2 3 4 5
experience, I prefer to
take part in deciding
what will be learn and
how.
14. Difficult study 1 2 3 4 5
doesn’t bother me if
I’m interested in
something.
15. No one but me is 1 2 3 4 5
truly responsible for
what I learn.
16. I can tell whether 1 2 3 4 5
I’m learning
something well or not.
17. There are so many 1 2 3 4 5
things I want to learn
that I wish that there
were more hours in a
day.
18. If there is 1 2 3 4 5
something I have
decided to learn, I can
find time for it, no
matter how busy I am.
19. Understanding 1 2 3 4 5
what I read is a
problem for me.
20. If I don’t learn, it’s 1 2 3 4 5
not my fault.
21. I know when I 1 2 3 4 5
need to learn more
about something.

193
22. If I can understand 1 2 3 4 5
something well
enough to get a good
grade on a test, it
doesn’t bother me if I
still have questions
about it.
23. I think libraries are 1 2 3 4 5
boring places.
24. The people I 1 2 3 4 5
admire most always
learning new things.
25. I can think of 1 2 3 4 5
many different ways to
learn about a new
topic.
26. I try to relate what 1 2 3 4 5
I am learning to my
long-term goals.
27. I am capable of 1 2 3 4 5
learning for myself
almost anything I
might need to know.
28. I really enjoy 1 2 3 4 5
tracking down the
answer to a question.
29. I don’t like dealing 1 2 3 4 5
with questions where
there is not one right
answer.
30. I have a lot of 1 2 3 4 5
curiosity about things.
31. I’ll glad when I’m 1 2 3 4 5
finished learning.
32. I’m not as 1 2 3 4 5
interested in learning
as some other people
seem to be.
33. I don’t have any 1 2 3 4 5
problem with basic
study skills.
34. I like to try new 1 2 3 4 5
things, even if I’m not
sure how they will turn
out.
35. I don’t like it when 1 2 3 4 5
people who really
know what they’re
doing point out
mistake that I am
making.
36. I’m good at 1 2 3 4 5
thinking of unusual
ways to do things.

194
37. I like to think 1 2 3 4 5
about the future.
38. I’m better than 1 2 3 4 5
most people are at
trying to find out the
things I need to know.
39. I think of problems 1 2 3 4 5
as challenges, not stop
signs.
40. I can make myself 1 2 3 4 5
do what I think I
should.
41. I am happy with 1 2 3 4 5
the way I investigate
problems.
42. I become a leader 1 2 3 4 5
in group learning
situations.
43. I enjoy discussing 1 2 3 4 5
ideas.
44. I don’t like 1 2 3 4 5
challenging learning
situations.
45. I have a strong 1 2 3 4 5
desire to learn new
things.
46. The more I learn, 1 2 3 4 5
the more exciting the
world becomes.
47. Learning is fun. 1 2 3 4 5
48. It’s better to stick 1 2 3 4 5
with the learning
methods that we know
will work instead of
always trying new
ideas.
49. I want to learn 1 2 3 4 5
more so that I can keep
growing as a person.
50. I am responsible 1 2 3 4 5
for my learning – no
one else is.
51. Learning how to 1 2 3 4 5
learn is important to
me.
52. I will never be too 1 2 3 4 5
old to learn new
things.
53. Constant learning 1 2 3 4 5
is a bore.
54. Learning is a tool 1 2 3 4 5
for life.

195
55. I learn several new 1 2 3 4 5
things on my own each
year.
56. Learning doesn’t 1 2 3 4 5
make any difference in
my life.
57. I am an effective 1 2 3 4 5
learner in the
classroom and on my
own.
58. Learners are 1 2 3 4 5
leaders.
©1977, Lucy. M. Guglielmino

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 APPENDIX 2 DEMOGRAPHIC QUESTIONNAIRE

This questionnaire is designed to collect your demographic data. Please read and
answer all questions in this sheet by ticking the most relevant box.

1. School of Nursing: 1. Kuala Kapuas  2. Sampit 

2. Name: ………………………………...

3. Gender: 1. Male  2. Female 

4. Date of birth: …………………………...

5. First born: 1. Yes  2. No 

6. Father’s educational background:

1. ≤ Senior High School 

2.≥ Senior High School 

7. Mother’s educational background:

1. ≤ Senior High School 

2. ≥ Senior High School 

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 APPENDIX 3 FLUID AND ELECTROLYTE BALANCE (SELF-

DIRECTED LEARNING MODULE)

Introduction to self-directed learning module

Fluid imbalances are very common in Indonesia. Infection and malnutrition are still major

causes of many cases of fluid imbalance especially in children and elderly people. Better

understanding of fluid and electrolyte balance is a foundation for caring for patients with

fluid imbalance. In this module we will lead you through a set of selected readings and

exercises are designed to improve your understanding of fluid and electrolyte balance.

Focus

Throughout this module we focus on fluid imbalance and nursing care for patients with fluid

imbalance.

Aim

The primary aim is to improve the practices of fluid imbalance care through developing

nursing students’ knowledge and its application. The secondary aim of the module is to raise

the quality of care nursing students provide for patients who have fluid imbalance.

Objectives

Upon completion of this module you should be able to:

1. Apply concepts, learned in this module to plan nursing care for patients with fluid

imbalance

2. Recognise the key components of good nursing care plans for patients with fluid

imbalance

3. Demonstrate the ability to systematically evaluate the quality of nursing care for

fluid imbalance patients

4. Recognise the signs and symptoms of fluid imbalance and report them accurately

198
 5. Recognise transfusion reactions and intervene appropriately when a reaction occur.

Audience

This module is intended for the use of nursing students, or other nurses and health care

workers, who wish to improve their skills in fluid imbalance and thus improve general

wellbeing of people for whom they care. It is expected that the people using the module will

have foundation knowledge in anatomy and physiology in fluid and electrolyte homeostasis.

Limitation of the module

This module has been developed at a time when there has been considerable interest in the

care of patients with fluid imbalances. It is limited, however by the knowledge available at

the time of its development and the practices of fluid and electrolyte imbalance that have

been derived from this knowledge. The module is intended for nursing students, nurses or

other health care workers, who have a basic understanding of fluid function in the body. It

should be read in that context. It will not contain sufficient background information for

novice students nor will it contain highly scientific or technical information that is not the

general province of nurses. For that reason other readings have been suggested in references

in conjunction with the body fluid topic.

How to use this module

This module has been designed to step you through a set of selected reading and exercises

that build on each other and that will improve your general understanding of fluid balance

and care. You can work at a pace that is comfortable for you. There are exercises built into

the module that will help you assess your learning progress. If you unable to complete an

exercise we encourage you to re-read the information that precedes the exercise/s and then

attempt the exercise/s again. It is important to understand each section as you work through

the module to build on those that preceded it. Sufficient informational resources will be

included in the module to allow for its completion.

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Part 1: Foundation science: fluid and electrolyte balance

Fluid and electrolyte imbalance are common problems for many patients in all settings.

Physiological homeostasis is dependent on normal fluid and electrolyte balance. Because any

physiologic derangement can upset fluid and electrolyte balance to some degree, virtually

every patient is at some risk of fluid imbalance. The foundation of science is very important

for nurses in Indonesia to understand the phenomena of fluid imbalance in conjunction with

better quality of nursing cares that they provide for patient with fluid imbalance.

Objectives (Part 1)

When you have completed the readings and associated activities in part 1 of the module, it is

expected that you will be able to:

1. Explain the differences between fluid balance and fluid imbalance;

2. Explain the differences between fluid deficit and fluid excess;

3. Recognise the signs and symptoms of fluid and electrolyte imbalance and report

them accurately;

4. Reflect on your own understanding of fluid imbalance and identify opportunities for

self-improvement in this area.

Toward deeper understanding of fluid balance

Why is deeper understanding of the phenomenon of fluid balance so important? One of the

challenges nurses face is caring for patients who are suffering from fluid imbalance. As a

nurse you are very involved in providing care for patients who are experiencing fluid

imbalance. Given the complex nature of fluid balance it is reasonable to assume that

increasing your understanding of this experience will allow you to improve the quality of

nursing care which your patients receive. The following readings provided a broad overview

of key aspects associated with understanding the function of body fluid. Before you start

these readings, take a moment to think about the reflective questions that follow:

200
Reflective question

From your experiences, what is your understanding of the phenomena of fluid balance and

what it means to those who experience fluid imbalance? What are the reasons for your view?

Reading 1.1
Boley, R., Polaski, A. & Porta, D (2001). Anatomy and physiology review: The cell. In J,
Black., J, Hawks., & A, Keene. (Eds.), Medical–Surgical Nursing: Clinical management for
positive outcomes (pp.206-214). London: W. B. Saunders Company.

Reading 1.2
White, B. (2001). Client with fluid imbalances: Promoting positive outcomes.
In J, Black., J, Hawks., & A, Keene. (Eds.), Medical–Surgical Nursing: Clinical
management for positive outcomes (pp.215-232). London: W. B. Saunders Company.

Reading 1.3.
White, B. (2001). Client with electrolyte imbalances: Promoting positive outcomes.
In J, Black., J, Hawks., & A, Keene. (Eds.), Medical–Surgical Nursing: Clinical
management for positive outcomes (pp.233-258). London: W. B. Saunders Company.

Reading 1.4.
Hansen, M. (2001). Acid-Base Balance. In J, Black., J, Hawks., & A, Keene. (Eds.),
Medical–Surgical Nursing: Clinical management for positive outcomes (pp.259-272).
London: W. B. Saunders Company.

Now that you have completed these readings, begin working through the next section of the
module. Go to Activity 1. 1.

Activity 1.1 - Fluid balance

Take a few moments to note down your answers to the questions based on your
knowledge/understanding/experience to date
1. What is fluid balance?
2. What is the purpose of fluid balance?
3. What is fluid imbalance?

When4.youHow
havedo you understand
finished, fluid
proceed to imbalance?
activity 1.2 and 1. 3.

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 Activity 1.2 – Body fluid: composition & function
Review your understanding of anatomy and physiology of body fluid – pay special
attention to:
1. Composition of body fluid;
2. Function of body water;
3. Function of electrolytes.
Hint: consult Boley, R., Polaski, A. & Porta, D.(2001). Anatomy and physiology review:
The cell. In J, Black., J, Hawks., & A, Keene. (Eds.), Medical–Surgical Nursing: Clinical
management for positive outcomes (pp.206-214). London: W. B. Saunders Company.

Activity 1.3 – Fluid imbalance

Review your knowledge and understanding of the following:
1. Type of body fluid;
2. Distribution of body fluid
3. Type of fluid imbalance;
As you read through the information note down key points or make diagrams to assist your
understanding.
Hint: Consult Potter, P., and Perry, A. (2001) Fundamental of Nursing (5th ed.).
Philadelphia: Mosby Inc, pp 1196 – 1197 and any recent anatomy and physiology and/or
nursing texts.

Test yourself by completing the following:

Thirst centre stimuli affect the following:
• ………………….
• …………………
• …………………
• …………………

Nursing knowledge base

Fluid and electrolyte imbalance may affect anyone regardless of age, sex, colour or religious

beliefs. Infants, severely ill adults, and the elderly are frequently at greater risk because of

their inability to respond independently to the early warning of an impending problem.

Severe compromises may lead to irreversible health problems.

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 Activity 1.4
Review your understanding/knowledge of factors which are thought to impact upon an
individual’s is body fluid. While you are reading make a brief note about each of the
following risk factors for fluid and electrolyte imbalances:
ƒ Age;
ƒ Chronic diseases;
ƒ Trauma;
ƒ Therapies; and
ƒ Gastro intestinal losses.
If you wish, refer to White, B. (2001). Client with fluid imbalances: Promoting positive
outcomes. In J, Black., J, Hawks., & A, Keene. (Eds.), Medical–Surgical Nursing: Clinical
management for positive outcomes (pp.215-232). London: W. B. Saunders Company.

Now go to Activity 1.5 to review your knowledge and check out your understanding of key

points contained in this section of the module.

Activity 1.5 – Knowledge review

Body fluids are made up of ………….. and ……….. They also move into and out of the
cells, bringing in ………….., ………….., and ……….. and taking out ………..
The continual movement of fluids is necessary to maintain a stable condition in the
internal environment. The maintenance of a constant favourable condition in the
internal environment is called ………. Many factors contribute to the continuous
motion of the body fluid. Among the more important are ……………….,
……………., and …………….. Types of body fluid are …………., …………,
………. and …………….. Although all of the electrolytes perform important
functions, those of major significance to the nurse who is caring for patients with fluid
and electrolyte imbalance are: ………., ………., …………, ………., ……….. and
………..
Two categories of fluid imbalance are: …………. and …………..

Hint: Refer to White, B. (2001). Client with fluid imbalances: Promoting positive
outcomes. In J, Black., J, Hawks., & A, Keene. (Eds.), Medical–Surgical Nursing: Clinical
management for positive outcomes (pp.215-232). London: W. B. Saunders Company.

203
Therapy for fluid and electrolyte imbalance

Intravenous therapy

Administration through the veins is the most common means by which water; electrolytes,

nutrients and some drugs may be given when oral intake is not possible or must be

supplemented. Some terms related to the concentration of an intravenous fluid, and effect

this has on cells, are important to understand. Before you start Activity 1.6, please take a

moment to think about the reflective questions that follow:

Reflective questions
Take a few moments to jot down 3 terms/categories related to concentration of an
intravenous fluid, and effect this has on cells that you have encountered in your clinical
experience to date.
1. What was the context in which you encountered these terms?
2. Did you use your knowledge about these terms to inform your nursing care? If so,
how?
3. How might you use this knowledge in the future?

Now go to Activity 1.6 to review your knowledge and check out your understanding of key
points contained in this section of the module.

Activity 1.6
Please provide a brief definition and give an example for each of the following:
ƒ Sensible water loss;
ƒ Solution;
ƒ Isotonic;
ƒ Hypotonic;
ƒ Hypertonic;
ƒ Oedema.

Reflection learning

Reflection is an essential part of ongoing personal and professional development. As a

student you are asked to diarise your reflections on pre-set readings and/or learning activities

204
set out in this module. This reflection might be prompted as a result of reading through and

thinking about the material provided, and/or as a result of experiences that happen during the

clinical practice that you are currently undertaking. You can record anything in a diary. Of

particular relevance to this unit, however, are insights that you have developed in relation to

issues contained within the readings, the ideas which arise from your thinking or from

comment of others, your emotional response to people and/or events, and how you feel you

have changed – or not changed. All are examples of entries which you might include.

Reflection
The process of reflecting can be viewed in a number of ways, however one useful strategy
is to ask your self a series of questions and then seek to answer them. Some suggested
questions for your reflection include:
1. What have I learnt most from this set of readings & learning activities?
2. In what ways is this knowledge important? What do I think about this
concept/issue?
3. How will I used this new knowledge in the future?
Your answers to these questions are designed to assist you to ascribe some meaning to
your experience, to understand and validate that meaning and to identify a positive
outcome with respect to your practice.

Part 2: Nursing responsibilities in caring for patients with fluid imbalance

In the healthy person, fluid intake and output are approximately equal. Illness almost always

increases the body’s needs for fluids and causes a decrease or loss of the body’s ability to

ingest or tolerate fluid through the usual oral route. Illness also may interfere with the body’s

ability to eliminate fluid or it may cause the body to excrete excessive amounts of fluids.

Therefore, signs and symptoms of fluid imbalance may either serve as a diagnostic clue for

illness or occur as a result of the drugs and therapies used to treat illness. Monitoring fluid

balance is an important nursing activity because of the significant role that fluid balance

plays in health and illness, and because direct client observations are the most reliable and

accurate ways to do this monitoring. The primary technical skills used to monitor fluid

balance are intake and output measurement.

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Objectives (Part 2):

When you have completed this reading and focus questions/learning activities in Part 2 of

this module it is expected that you will be able to:

1. Discuss general principles of fluid imbalance assessment;

2. Describe principles of effective nursing care for patients with fluid imbalance;

3. Critically analyse the nurse’s role with respect to nursing care;

4. Reflect on your own nursing care practice and identify opportunities for further

improvement.

Nursing assessment of fluid imbalance

There are two main situations where a nurse may be involved in assessing patients with fluid

imbalance. These are in emergency situations and in non-emergency settings. In Part 2 of the

module we will be concerned primarily with assessing patients in non-emergency settings.

Assessment for fluid and electrolyte imbalance includes: the nursing history, physical and

behavioural assessment, measurement of intake and output, daily weight, and specific

laboratory data. To start the learning activities for Part 2, go to activity 2.1

Activity 2.1
Note down what the following terms mean to you (use phrases, word descriptors, etc.)
ƒ Nursing history;
ƒ Nursing assessment;
ƒ Fluid imbalance assessment;
ƒ Measurement intake and output;
ƒ Physical and behavioural assessment.
Hint: If you wish, consult to Potter, P. and Perry, A. (2001) Fundamental of Nursing (5th
ed.). Philadelphia: Mosby Company, pp: 1194 – 1249, and/or other nursing textbooks for
discussion on these terms.

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Physical assessment

There is no specific physical assessment to assess fluid and electrolyte imbalance. Common

abnormal assessment findings involving a number of major body systems offer clues to

possible fluid and electrolyte imbalance. A thorough examination is necessary, because fluid

and electrolyte imbalances can affect all body systems. While examining each system, nurses

observe signs and symptoms expected as a result of any imbalance.

Planning care for patients with fluid and electrolyte imbalance

During the planning process the nurse again thinks critically, synthesising information from

multiple resources. Critical thinking ensures that the patient’s plan of care integrates both the

nurse’s scientific and nursing knowledge, as well as all the knowledge the nurse has gathered

about the individual patient. The patient’s clinical condition will determine which diagnoses

take the greatest priority. Many nursing diagnoses in the area of fluid and electrolyte

imbalance are of highest priority, because the consequences for the patient can be serious or

even life threatening.

As a general rule nursing care for fluid and electrolyte imbalance should be planned to

support the body in its efforts to balance the fluid and electrolytes. The type of body fluid

imbalance is a central factor in deciding what care is appropriate. You have learnt to

distinguish between body fluid deficit and excess. When you plan the patient’s care each of

these factors must be taken into consideration. This is one good reason why assessment

should always precede planning your nursing care, because during assessment you will have

identified any factors that could influence body fluid balance.

Consultation with the patient’s physician may assist in setting realistic time frames for the

goals of care. During planning the nurse collaborates as much as possible with the patient

and family and other members of the interdisciplinary health care team, such as for IV

207
therapy and pharmacy. The nurse also incorporates patient preferences and resources into the

plan of care.

Implementation

Although fluid and electrolyte imbalance can occur in all settings, changes in acute care

delivery systems place more demanding expectations on the nurse. Today the nurse must

manage the patient’s complex medical care in a shorter span of time while being expected to

perform more difficult technological skills. When implementing nursing care plans, some

activities and conditions which should be taken into consideration. These include:

ƒ daily weight and intake and output;

ƒ enteral replacement of fluids;

ƒ restriction of fluids;

ƒ parenteral replacement of fluid and electrolytes;

ƒ health promotion.

Evaluation of patient care

There are two important aspects in evaluation of patient care: patient care and patient

expectations. The evaluation of a patient’s clinical status is especially important if an acute

fluid and electrolyte imbalance exists. The patient’s condition can change very quickly, and

the nurse must be able to recognise signs and symptoms of impending problems. To do this

well, nurses integrate what they know about the health alterations, the effects of medications

and fluids, and the patient’s presenting clinical status.

For patients with less acute alterations evaluation is likely to occur over a longer period of

time. In this situation the nurse’s evaluation may be focused more on behavioural changes

such as client ability to follow dietary restriction. The patient’s level of progress determines

whether the nurse needs to continue or revise the plan of care. If goals do not meet expected

outcomes, the nurse may need to consult with a physician and discuss additional methods.

208
Once outcomes have been met, the nurse can resolve the nursing diagnosis and focus on

other priorities.

Reading 2.1
Lewis, S., Heitkemper, M. and Dirksen, S. (2000). Medical Surgical Nursing: Assessment
and management of clinical problems (5th ed.). St Louis: Mosby Inc, pp. 323 – 351.

Review and application

Take a few moments to work through activity 2.2

Activity 2.2
Case study: fluid and electrolyte imbalance.
Pak Bungas, a-42-year-old man with typhoid fever and mild hypertension.
Subjective data:
ƒ Complaining of overall weakness, and thirst;
ƒ Has diarrhoea and frequent urination;
Objective date
ƒ Heart rate 88 and irregular;
ƒ Blood pressure 150/100;
ƒ Dry oral mucous membranes.
ƒ Body temperature; 390C;
ƒ His physician has ordered a less fibres and soft diet. Kemicytine capsule 500 mgm
four times a day (per-oral) and B Complex three times a day (per-oral)
Critical thinking questions:
1. Based on his clinical manifestations, what fluid imbalance does Pak Bungas have?
What are the reasons for your answer?
2. What additional assessment data should the nurse obtain?
3. What are risk factors for fluid and electrolyte imbalance in general or in this
scenario?
4. What potentially dangerous electrolyte imbalance does his symptom suggest?

Textbook: refer to any tropical medicine and medical surgical or fundamental of nursing
type of textbook and read through the section provided on fluid and electrolyte imbalance
and assessment.

For more practice after finishing activity 2.2 please work with activity 2.3 and activity 2.4 at

your pace.

209
 Activity 2.3
Mr. Wong is a 35-year-old patient who has suffered a severe gastro intestinal upset
producing nausea, vomiting and diarrhoea. His physician has prescribed IV fluids.
ƒ List observations you should make while caring for Mr. Wong; and the reasons for
your choices
ƒ What nursing measures might be taken to relieve his symptoms? What is the basis
of your suggestions? What medication might you expect him to receive?
ƒ What are your responsibilities regarding Mr. Wong’s Intravenous therapy? Why it
is necessary to check the infusion frequently? Would you measure intake and
output? In what electrolytes might Mr. Wong be deficient?

After finishing activity 2.3 please continue to activity 2.4. You can discuss the questions
with your classmates.

Activity 2.4
Caroline has just received a new patient on her unit who is to receive 1 unit of RBCs with
in the next hour.
ƒ What nursing actions are necessary before administering blood?
ƒ What are signs and symptoms of a transfusion reaction?
ƒ Can Caroline delegate the administration of blood to a nursing assistant or a
nursing student on her team? Why or why not?

Ongoing professional development

Working your way through this self-learning module suggests that you are interested in your

ongoing professional development. The module has it limitations, however. In this module

we have considered the care of patients with fluid imbalance that are relatively

uncomplicated and straight forward. As you develop your knowledge and skills, you will

need to care for more complicated patients. A good place to start finding out about the best

care that you can offer is to keep reading about fluid imbalance topics. Use the library

210
facilities that are available to you, ask more experienced nurses about what they have learnt

from their work; as well as doctors who give instruction for balancing body fluids.

Another thing you can do to keep up-to-date in practice is to read the literature that is

published by drug companies (about their product). You may need to get this information

from the pharmacy at the hospital, health centre or from whoever orders the stock. Try

collecting information in the same way as ants would collect and store food for future needs.

You never know when it will be useful.

Final comment is to remind you that you must practice and increase your clinical judgements

because it will reflect your professional development. As your knowledge and skill develops

you will become more confident in judgements you make and you will be able to make more

refined decisions.

211
APPENDIX 4 INFORMATION FOR PARTICIPANTS (PILOT STUDY)

Program title: Improving Indonesian Nursing Students’ Self-Directed Learning

Readiness

Chief investigator: Djenta Saha

Address : Jln. George Obos Gg. Husada no. 2 Palangkaraya 73111 Indonesia
Ph. 536-25214

This study is the basis of a dissertation in a Doctor of Philosophy qualification at

Queensland University of Technology (QUT) and will be performed by Djenta Saha
under the guidance of an academic staff member Prof. Helen Edwards.

Description of the project

This project will develop, implement and evaluate a training program to improve
readiness for self directed learning among nursing students in Central Kalimantan.

Participant involvement in the program will include:

Your participation in this project will be in the pilot study only. This will involve the
completion of one questionnaire about self-directed learning two times. I estimate for
completion of the questionnaire will take about 30 minutes.

The expected outcomes of the pilot study as follows:

• Provide a questionnaire to assess self-directed learning that suitable to use in
nursing education in Central Kalimantan
• Assessed the proposed questionnaire for use in a project on training program
in nursing education in Central Kalimantan.

Expected benefit for you:

Your involvement in this program has the potential to benefit you by increasing your
awareness of self-directed learning within nursing education.

Risks
No risks to you have been identified due to participation in the program.

Confidentiality
All information you supply for the program will be treated in confidence and
securely stored during the study period and for five years afterwards, until the data is
destroyed. Only the researcher will access to the data. Anonymity and confidentiality
will be safeguarded in any publication of results.

Voluntary participation
Your participation in the program is entirely voluntary, and you are free to withdraw
at any time without comment or penalty. Your decision will in no way impact upon
your academic progress or future study.

212
Concerns/complaint
All participants in this study are welcome to contact Djenta Saha (chief investigator)
regarding any questions or concerns/complaints you may have about this study. If at
any time you are not satisfied with this respond or any concern relating to ethical
conduct in this study you may contact the head of ‘BALITBANGDA’ office on 536
– 34364.

Thank you for considering participation in this study, your participation is greatly
appreciated.

213
 APPENDIX 5 INFORMATION FOR PARTICIPANTS

(INTERVENTION GROUP)

Program title: Improving Indonesian Nursing Students’ Self-Directed Learning

Readiness

Chief investigator: Djenta Saha

Address: Jln. George Obos Gg. Husada no. 2 Palangkaraya, 73111 Indonesia
Ph. 536-25214.

This study is the basis of a dissertation in a Doctor of Philosophy qualification at

Queensland University of Technology (QUT) and will be performed by Djenta Saha
under the guidance of an academic staff member Prof. Helen Edwards.

Description of the project:

This project will develop, implement and evaluate a training program to improve
readiness for self-directed learning among nursing students in Central Kalimantan.

Participant involvement in the program would include

Participation in this part of the project involves the completion of two questionnaires
about self-directed learning. You will receive the first questionnaire shortly. The
second questionnaire will be distributed in approximately 4 months time. I anticipate
that will take about 30 minutes to complete each. In addition, you may be invited to
participate in a focus group discussion of approximately 60-90 minutes duration. The
purpose of the focus group discussion is to gain a better understanding of students’
perception about self directed learning. The discussion will be run by chief
investigator. Participation in the focus group will be voluntary and you can withdraw
any time without comment or penalty.

Expected outcomes
Increase students’ knowledge and skills of self-directed learning.

Expected benefit for you

Your involvement in this program has the potential to benefit you because you will
increase your knowledge and skills in self-directed learning as a firm foundation to
be a lifelong learner.

Risks
Neither completion of the questionnaires or participation in the focus group
discussion involves any known risks to participants.

214
Confidentiality of the data
All information you supply for the program will be treated in confidence. All
confidential records will be kept in a locked filling cabinet. Any information stored
in the computer files is protected by password (know only to the researcher) and
coded to protect anonymity. Only the researcher has access to the computer database.
Coding sheets separate to data records. Aggregate data only will be published and no
individual participants will be identified.

Voluntary participation
Your participation in the program is entirely voluntary and you are free to withdraw
from the study at anytime without comment or penalty. Your decision will in no way
impact upon your academic progress or future study.

Questions or concerns/complaints

All participants in this study are welcome to contact Djenta Saha (chief investigator)
regarding any questions or concerns/complaints you may have about this study. If at
any time you are not satisfied with this respond or any concern relating to ethical
conduct in this study you may contact the head of ‘BALITBANGDA’ office on 536
– 34364.

Thank you for considering participation in this study, your participation is greatly
appreciated.

215
 APPENDIX 6 INFORMATION FOR PARTICIPANTS (CONTROL

GROUP)

Program Title: Improving Indonesian Nursing Students’ Self-Directed Learning

Readiness

Chief investigator: Djenta Saha

Address: Jln. George Obos Gg. Husada no. 2 Palangkaraya, 73111 Indonesia
Ph. 536-25214.

This study is the basis of a dissertation in a Doctor of Philosophy qualification at

Queensland University of Technology (QUT) and will be performed by Djenta Saha
under the guidance of an academic staff member Prof. Helen Edwards.

Description of the program:

This research study intends to increase quality of teaching and learning through
development and implement a self-directed training program in nursing education in
Central Kalimantan.

Your involvement in the program would include:

• Giving your written consent
• Having pre and post tests
• Receive training modules in the end of study
• You may be invited to participate in a focus group discussion of approximately
60-90 minutes duration.

Expected outcomes
• Increase students’ knowledge and skills of self-directed learning
• Increase students’ responsibility of their own learning
• Students will become ‘less passive’ and ‘more active’ in their learning.

Expected benefit for you

Your involvement in this program has the potential to benefit you in the following
ways: increased awareness of self-directed learning as a firm foundation to be a
lifelong learner.

Risks
No risks to you have been identified due to your participation in this program.

216
Confidentiality of the data
All information you supply for the program will be treated in confidence. All
confidential records will be kept in a locked filling cabinet. Any information stored
in the computer files is protected by password (know only to the researcher) and
coded to protect anonymity. Only the researcher can access to the computer database.
Coding sheets separate to data records. Aggregate data only will be published and no
individual participants will be identified.

Voluntary participation
Your participation in the program is entirely voluntary and you are free to withdraw
from the study at anytime without comment or penalty. Your decision will in no way
impact upon your academic progress or future study.

Questions or concerns/complaints

All participants in this study are welcome to contact Djenta Saha (chief investigator)
regarding any questions or concerns/complaints you may have about this study. If at
any time you are not satisfied with this respond or any concern relating to ethical
conduct in this study you may contact the head of ‘BALITBANGDA’ office on 536
– 34364.

Thank you for considering participation in this study, your participation is greatly
appreciated.

217
 APPENDIX 7 CONSENT FORM

Program title: Improving Indonesian Nursing Students’ Self-Directed Learning

Readiness

Chief investigator: Djenta Saha Ph. 536-25214.

Participant’s name: __________________________________

My signature below indicates:

1. I have read the Participant Information Sheet;

2. I understand the nature and purpose of the study;

3. I have been given the opportunity to ask questions regarding the research study;

4. I understand that the confidentially of all information I provide will be

safeguarded;

5. I understand that participation is voluntary, and I am free to withdraw from the

study at any time without comment or penalty;

6. I consent to participate in this program.

Signature: __________________________ Date: ____________________

(Participant)

I have explained the nature and purpose of this study to the above participant and
have answered their questions.

Investigator: ___________________________Date: ____________________

218
Appendix 8
Sister School Project (SSP) Central Kalimantan Province
Executive Summary

(Reference: Brown, D. & Cooke, M. (2002). Teaching and Learning Methodologies.

Report. Ministry of Health and Social Welfare, Central Kalimantan, Republic
Indonesia)

This article is not available online.

Please consult the hardcopy thesis
available from the QUT Library

219
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