Influencing factors of self-regulated learning of medical-related students in a traditional Chinese medical university: A cross-sectional study

DOI: https://doi.org/10.21203/rs.3.rs-1840785/v1

Abstract

Background

In recent years, self-regulated learning (SRL) has become a hot topic in medical education. However, the factors that affect the SRL ability of medical-related majors, such as clinical medicine, traditional Chinese medicine (TCM) and nursing specialty in TCM colleges and universities are unclear. Whether the teaching of learning strategies can help improve students’ SRL also needs to be further examined.

Method

A cross-sectional survey was distributed, and 878 medical-related students which are from a TCM university were recruited for this study. An independent t‑test and analysis of variance were used to analyse the factors associated with SRL. The relationship between self‑regulated learning and learning strategies was analysed with multi-linear regression analysis.

Results

The average scores of SRL on learning motivation, learning setting and self-regulation. Total scores were 34.76 ± 4.62, 41.14 ± 4.30, 39.26 ± 4.74 and 115.16 ± 12.42, respectively. The mean scores were all above the midpoint. The metacognitive, affective, cognitive, resource management and the total scores of learning strategies were 58.54 ± 12.02, 43.24 ± 8.42, 35.49 ± 7.34, 22.89 ± 4.20, 160.16 ± 29.45. Some factors can predict 32% of the variation of SRL, including whether they liked their specialty, educational system, and specialty, achievement ranking scholarship, whether they were taught by a tutor in middle school, gender, monthly family income, father’s educational background, metacognitive strategy, resource management strategy and cognitive strategy.

Conclusions

The SRL of medical-related students was better. Learning strategies and methods as well as personal or social factors can affect SRL. Educators should improve attention on the cultivation of learning strategies, exercising learning skills and monitoring, adjustment and guidance of learning time. Educators should also strengthen the professional identity and confidence of medical-related students and strive to improve their SRL ability.

Background

Medicine is a highly specialised discipline. With the development of science and technology, medical knowledge is constantly updated, and medical workers also need to keep learning. Under China’s background as a learning society and its acceleration of the construction of an innovative country, one trend is to establish the concept of lifelong learning. Self-direction and self-regulation are two parts of lifelong learning. Self-regulated learning (SRL) consists of three stages. The first is the anticipation before learning, which includes task analysis and goal setting. The second is performance control, which consists of the use of cognitive strategies such as rehearsal, elaboration, organisation and metacognitive monitoring. The third point is self-reflection, in which students judge and develop the reasons for their learning behaviour. This process is dynamic and cyclic[1], active and constructive[2] and is the result which learners decide to obtain the information they want to experience or learn[3]. Given that individuals are guided and constrained by the background, characteristics of the target and the environment, the SRL ability of individuals is vital to the formation of lifelong learning[2]. Mastering specific learning strategies is necessary for good SRL. Students’ learning strategies have a significant impact on their academic performance. Learning strategies help integrate knowledge and activate experience and are of great theoretical and practical significance for promoting effective learning and realising educational and teaching objectives in universities[4]. However, many medical students adopt unsuccessful learning strategies and study habits. Students with poor time management strategies might get poorer academic performance because they often assume learning strategies such as cramming and surface learning[5]. A total of 49% of the variance in examination scores are accounted for by the preferred learning strategy of students who are in a pre-clinical medical period[6]. The medical-related students in traditional Chinese medical (TCM) universities need to master the knowledge that includes traditional Chinese medicine and medical science. They will carry out heavy tasks in a limited period, and the demand for grasping learning strategies and SRL ability seems to be more critical.

Self-regulated learning and learning strategy

SRL is a process of metacognition, motivation and active behaviour in the learning process[7], which involves four major elements: planning, learning, self-assessment and monitoring. Society expects doctors to always improve their abilities and keep pace with developments in their field. Thus, they need to become lifelong learners, greatly promoting the development of their SRL[8]. Medical students need to control their learning process[1,9] while also handling more ‘high-risk’ tasks such as testing, interviewing and preparing for work, as well as requiring specific SRL skills to effectively manage their learning behaviour, motivation and emotions[10]. The goal of medical school is to develop doctors who can become lifelong learners[11]. Studies have found that clinical medical students’ SRL is influenced by individual, background, social factors and experience autonomy[12], as well as by other variables such as gender, educational environment, teaching methods, personality and family background[13]. A higher level of SRL is positively correlated with academic performance and clinical skills[14–18] and negatively correlated with depression[19]. SRL is a skill that students learn, not naturally acquired, that can be learned and therefore taught[20]. In scaffolding of instructional guidance, the cognitive apprenticeship approach may support SRL; blended learning drives student motivation and SRL[21]. Learning strategy refers to an operating system in which learners actively operate learning procedures, tools and methods effectively in a certain context, according to certain learning tasks and general learning rules to improve the quality and efficiency of learning. It is a multi-level and dynamic operating system, comprising four parts. Cognitive strategies include retelling, finishing and organising. Metacognitive strategies include planning, monitoring and execution strategies. Affective strategies are related to learning motivation, interest and attitude. Resource management strategies include time management, learning environment management and help-seeking[22]. Learners of SRL purposefully activate, maintain and adjust their cognition, emotion and action. They need to adopt different learning strategies to achieve their learning goals. Examples of such strategies include being able to set their learning goals, establish a more productive environment, monitor their understanding and modify their plans, strategies and efforts in response to changing environmental conditions[23]. The significance of this study is to explore the status quo and influencing factors of SRL among students of medical-related majors in TCM universities and to provide an evidence basis for intervention measures to better cultivate the SRL of medical-related students in higher medical education. 

Research question

1.What is the status quo of self-study for students majoring in medicine in TCM colleges and universities? 

2.Does a relationship exist between the SRL and learning strategy of medical-related students? 

3.What are the influencing factors of medical-related students’ SRL in a TCM university?

Method

Setting

A cross-sectional design was adopted in this study. A total of 878 medical-related students comprising 683 females and 195 males were recruited using the stratified cluster sampling method. The inclusion criteria were as follows. Medical and nursing students studying at a TCM university in March 2020–May 2021were willing to participate in this study. Part-time medical-related students were not included, following our exclusion criteria. All participants were informed of the details of the study purpose before the survey was administered. Surveys were directly distributed only to those who consented to study participation. To ensure anonymity, their identities and name information have not been included in this study. This study was approved by the Institutional Review Committee of Zhejiang Shu Ren University. Completing the questionnaire anonymously needed approximately 30 minutes.

Data collection 

The study was conducted in March 2020–May 2021 at one university in China. Data were collected from the samples who were first-, second-, third-, fourth- and fifth-year students who were majoring in nursing in nursing college, TCM science in the first clinical medical college, clinical medicine in the second clinical medical college and nursing in the extended education nursing college using structured questionnaires. In this study, the researchers organised teachers to issue questionnaires together, who were all from the school of nursing of Zhejiang TCM University. Based on informed consent, some samples were drawn in whole groups. The survey objects would fill in independently for about 30 minutes, and the questionnaires were taken back after completion. 

Instruments

Demographic questionnaire

The demographic characteristics of the participants included gender (1=female, 2=male), age, specialty (1=TCM, 2=clinical medicine, 3=nursing), educational system (1=3 years, 2=4 years, 3=5 years, 4=7 years or more), subjects before admission (1=liberal arts, 2=science), only child or not (1=yes, 2=no), received a scholarship (1=yes, 2=no), availing of student loans (1=yes, 2=no), admission batch (1=the second batch, public, meaning that the students with higher scores in the college entrance examination and they fit with the standards and proportion of the Ministry of Education’s undergraduate teaching admission, so their tuition is lower; 2=the third batch, private, meaning that their college entrance examination just missed the threshold for undergraduate course admission, so the Ministry of Education permits them to enter colleges with undergraduate education teaching standard. They do not belong to the security group invested by the Ministry of Education, so their tuition is higher; 3=Others (adult education)), grade (1=first grade, 2=second grade, 3=third grade, 4=fourth grade, 5=fifth grade or more), monthly family income (1=under CNY 2000, 2= CNY 2001–5000, 3= CNY 5001–8000, 4= CNY 8001–10000, 5=above CNY 10000), father’s educational background (1=primary school, 2=middle school, 3=high school, 4=university, 5=above university), mother’s educational background (1=primary school, 2=middle school, 3=high school, 4=university, 5=above university), whether they were taught by a tutor in middle school (1=yes, 2=no), whether they are part of a student cadre (1=yes, 2=no), achievement ranking (1=upstream, 2=midstream, 3=downstream) and whether they like their specialty (1=yes, 2=no) and whether they are in love (1=yes, 2=no).

College Student SRL Questionnaire

The College Student SRL Questionnaire was developed by Xianliang Wang[24] in 2006. It has 33 items in total. A five-point Likert scale was adopted, in which ‘very consistent’, ‘consistent’, ‘sometimes consistent’, ‘inconsistent’ and ‘very inconsistent’ were recorded as 5, 4, 3, 2 and 1, respectively. The total scores of SRL ranged from 33 to 165, and higher scores mean more substantial SRL ability. The Cronbach’s α=0.922 for this study scale.

College student learning strategy questionnaire[22] 

Developed by Yang Yi in 2002[25], the questionnaire has 49 questions, comprising four subscales: metacognitive strategy, emotional strategy, cognitive strategy and resource management strategy. The self-rating scale uses a five-point Likert rating scale in which 1, 2, 3, 4 and 5 were successively used for ‘complete non-conformity’, ‘quite inconsistent’, ‘not clear’, ‘more conformity’ and ‘complete conformity’. The higher the score, the more learning strategies are used. The Cronbach’s α was 0.93 for the full scale, and the Cronbach’s α was 0.972 for this study scale.

Statistical analysis

The descriptive statistical method was applied regarding the characteristics of the sample and research variables, T-test for independent models and one-way ANOVA statistical method to compare the SRL and learning strategy in terms of the categorical socio-demographic characteristics. Pearson correlation analyses were conducted to perceive the associations between all continuous variables using SPSS 25.0 (IBM, Beijing, China). Linear regression analysis was used to analyse the influencing factors of SRL in students of TCM universities. Two-tailed hypothesis tests were considered statistically significant at a 0.05 level.

Results

Descriptive statistics of the SRL and Learning Strategies

A total of 910 questionnaires were issued, all of which were recovered, for a 100% recovery rate. A total of 32 questionnaires were incomplete, resulting in 878 effective questionnaires, with an effective rate of 96.48%. The demographic characteristics are as follows. For gender, 683 (77.79%) were female and 195 (22.21%) male. For specialty, 509 (57.97%) were nursing, 167 (19.02%) TCM and clinical 202 (23.01%). Length of schooling was three years 103 (11.73%), four years 406 (46.24%) and five years 369 (42.03%). For subjects before admission, 255 (29.04%) respondents studied liberal arts and 623 (70.96%) science. For only child status, 389 (44.31%) answered yes and 489 (55.69%) no. For scholarships, 334 (38.04%) were accepted and 544 (61.96%) were not. For student loans, 113 (12.87%) availed and 765 (87.13%) did not. For admitted lots: 290 (33.03%) were in the second batch, 464 (52.85%) in the third batch and 124 (14.12%) in the others. For grades, 253 (28.82%) were in the first grade, 128 (14.58%) second grade, 446 (50.80%) third grade and 51 (5.81%) fifth grade. For income, 60 (6.83%) earned less than CNY2000, 180 (20.50%) CNY2001–5000, 252 (28.70%) CNY 5001–8000, 162 (18.45%) CNY8001-10000 and 224 (25.51%) above CNY10000. For father’s educational background, 143 (16.29%) had fathers who ended their education upon completing elementary school, 413 (47.04%) middle school, 228 (25.97%) high school and 82 (9.34%) college; 12 (1.37%) fathers had a college degree or above. Of mothers, 217 (24.72%) had a primary school degree, 399 (45.44%) had a middle school degree, 212 (24.15%) had a high school degree, 43 (4.90%) had a university degree or above and 7 (0.80%) had a college degree or above. A total of 375 (42.71%) respondents were in a student cadre and 503 (57.29%) were not. A total of 26 (30.64%) employed a tutor in high school and 609 (69.36%) did not. Performance ranking was 185 (21.07%) upper, 523 (59.57%) middle, 170 (19.36%) lower. A total of 262 (29.84%) liked their majors, 580 (66.06%) had average feelings and 36 (4.10%) disliked them. A total of 265 (30.18%) were in love and 613 (69.82%) were not. The scores of SRL and learning strategies are all shown in Table 1.

Table 1

The scores of Self-regulated Learning and Learning Strategies and the Cronbachαcoefficient

Scale

Items

N

Mean ± SD

Average

Alpha

Learning Strategy

 

49

160.16 ± 29.45

 

0.97

 

Metacognitive strategy

18

58.54 ± 12.02

3.25 ± 0.67

0.95

 

Emotional strategy

13

43.24 ± 8.42

3.33 ± 0.65

0.91

 

Cognitive strategy

11

35.49 ± 7.34

3.23 ± 0.67

0.90

 

Resource management strategy

7

22.89 ± 4.20

3.27 ± 0.60

0.83

Self-regulated Learning

 

33

115.16 ± 12.42

 

0.92

 

learning motivation

10

34.76 ± 4.62

3.48 ± 0.46

0.83

 

Learning Settings

12

41.14 ± 4.30

3.43 ± 0.36

0.78

 

Self-adjustment

11

39.26 ± 4.74

3.57 ± 0.43

0.81

Analysis of differences in SRL and learning strategy according to demographic characteristics

Demographic characteristics were used as the independent variables. The t-test and one-way ANOVA statistical methods were executed for SRL ability. The results are shown in Table 2.

Table 2: Differences in Self‑regulated Learning, Learning Strategy, and its subscales by demographic characteristics

Variables

Items

Self-regulated

Learning


 Learning

Strategy


Mean±SD

     p
 Turkey

Mean±SD

     p
 Turkey


Gender

Female

114.45±11.63

0.010

157.49±27.69

0.000 


Male

117.65±14.62

169.49±33.36


Specialty

traditional Chinese

113.76±12.24

0.000
 
21,3

157.40±29.09

0.002
 
21,3


medical science 


Clinical medicine

118.75±13.05

166.31±30.07


Nursing

115.72±11.74

162.02±29.07


Educational
 system

3 years

108.12±11.26

0.000
 
12,3

152.14±30.56

0.001
 
123


4 years

115.19±12.07

158.74±28.58


5 years

115.09±12.43

163.96±29.56


Divide subjects
 before admission

liberal arts

113.31±12.37

0.010 

153.92±28.42

0.000 


science

115.92±12.37

162.71±29.50


The only child

yes

116.23±11.72

0.020 

161.69±28.40

0.171 



no

114.31±12.90

158.95±30.23


Scholarship

yes

118.97±13.50

0.000 

164.20±28.78

0.001 


no

112.82±11.09

158.95±30.23


Student loan

yes

114.07±12.94

0.320 

163.71±26.10

0.170 


no

115.32±12.34

159.64±29.89


Admission batch

Second (public)

115.61±10.86

0.000
 
31,2

164.99±30.38

0.000
 
123


Third (private)

116.64±13.08

156.39±25.97


others

108.59±11.24

150.90±30.28


Grades

1st grade

112.87±12.77

0.000
 
1,23,4

158.51±32.05

0.110 


2nd grade

112.65±9.81

155.79±22.26


3rd grade

116.85±12.59

162.33±30.37


4th grade

118.09±12.42

160.37±21.50


Monthly family
 income

Below CNY 2000 

114.58±13.12

0.000
 
5,41,32

156.73±20.96

0.377 


CNY 2001-5000 

111.9±11.83

158.09±28.56


CNY 5001-8000 

114.42±11.91

160.59±33.16


CNY8001-10000 

116.49±11.63

159.00±25.04


CNY 10000 above

117.82±12.42

163.09±30.55


The father's educational
 background

Primary school

113.27±13.29

0.010
 
51,2,3,4

157.83±26.99

0.041
 
52,431


Middle school

115.66±12.22

160.41±30.61


High school

115.96±12.12

162.24±27.87


University

112.55±12.22

154.45±30.11


University above

123.17±10.22

178.83±33.89


The mother's educational
 background

Primary school

112.94±12.79

0.000
 
12,345

151.54±26.00

0.000
 
52,431


Middle school

115.66±12.06

164.21±29.90


High school

115.30±12.65

159.33±30.35


University

119.63±11.18

165.91±26.84


University above

124.29±8.81

186.57±28.72


student cadres

yes

117.28±12.08

0.000 

162.38±29.06

0.054 


no

113.58±12.44

158.50±29.66


Whether be taught by tutor in the middle school

yes

117.98±13.45

0.000
 
12,3,45

161.00±30.51

0.576 


no

113.92±11.73

159.79±28.99


Score ranking

upstream

121.49±13.00

0.000
 (1
23)

166.94±28.17

0.000
 (1
23)


midstream

114.27±11.61

160.36±29.55


downstream

111.02±11.68

152.15±28.73


Whether like his
 specialty

yes

120.5±13.10

0.000
 
12,3

168.97±29.81

0.000
 
123


commonly

113.02±11.49

157.28±28.65


no

110.78±9.57

142.47±22.10


In love

yes

115.96±13.35

0.210 

159.97±29.44

0.900 


no

114.82±11.99

160.24±29.48


Statistically significant values are indicated in bold,The differences and order among groups in the post-hoc comparison are indicated by superscript letters (1,2,3,4,5).

Relationship between SRL and learning strategies 

The independent variables were gender, age, specialty, educational system, divided subjects before admission, only child status, scholarship, student loan status, admission batch, grade, monthly family income, father’s educational background, mother’s educational background, whether taught by a tutor in middle school, whether part of a student cadre, achievement ranking, whether they like their specialty, in love and learning strategy (the dummy variable setting and assignment of demographic characteristics is gender 1: male = 0, female = 1, gender 2: male = 1, female = 0. Specialty 1: TCM = 1, clinical medicine = 0, nursing = 0; specialty 2: TCM = 0, clinical medicine = 1, nursing = 0; specialty 3: TCM = 0, clinical medicine = 0, nursing = 1. Educational system: 3 years = 1, 4 years = 2, 5 years = 3, 7 years and above = 4. Subjects before admission 1: liberal arts = 1, science = 0; Divide subjects before admission 2: liberal arts = 0, science = 1. Monthly family income: below CNY2000 Yuan = 1, CNY2001–5000 = 2, CNY5001–8000 = 3, CNY8001–10000 = 4, above CNY10000 = 5. Father’s or mother’s educational background: primary school = 1, junior high school = 2, high school = 3, university = 4, university or above = 5. Whether taught by tutor 1: yes = 1, no = 0, whether taught by tutor 2: yes = 0, no = 1. Whether part of student cadre 1: yes = 1, no = 0, student cadre 2: yes = 0, no = 1. Achievement ranking: downstream = 1, midstream = 2, upstream = 3. Like their specialty 1: like = 1, do not like = 0; like their specialty 2: like = 0, do not like = 1. In love 1: Yes = 1, no = 0; In love 2: Yes = 0, No = 1). Taking SRL as the dependent variable, we used forward stepwise regression to screen variables that had an impact on the level of students such as specialty = yes, achievement ranking = upstream, educational system = three years, scholarship = yes, whether taught by tutor in middle school = yes, achievement ranking = midstream, gender = female, father’s educational background = university, monthly family income = 2001–5,000 Yuan, metacognitive strategy, resource management strategy and cognitive strategy indicated a meaningful relationship with the SRL scores (F = 29.61, p < 0.01; R2 = 0.324, Adjust-R2 = 0.313). Regression analysis was performed, and the results are presented in Table 3.

Table 3

The Multiple Liner Regression Analysis Results for Self-regulated Learning

Items

B

SE

Beta

T

p

(Constant)

90.939

2.437

 

37.316

0.000

Like specialty = yes

4.305

0.797

0.159

5.399

0.000

Achievement Ranking = Upstream

5.827

1.252

0.191

4.655

0.000

educational system = 3 years

-5.412

1.185

-0.152

-4.568

0.000

Scholarship = yes

2.239

0.840

0.088

2.665

0.008

Whether be taught by

tutor in the middle school = yes

2.340

0.778

0.087

3.009

0.003

Achievement Ranking = midstream

2.596

0.951

0.103

2.729

0.006

Gender = female

-1.690

0.890

-0.057

-1.899

0.058

The father’s educational background = university

-3.116

1.233

-0.073

-2.526

0.012

the mother's educational background

=primary school

-0.930

0.832

-0.032

-1.117

0.264

grade = 1st year

1.412

0.937

0.052

1.507

0.132

Monthly family income = 2001- 5,000 Yuan

-2.300

0.888

-0.075

-2.590

0.010

metacognitive strategy

0.367

0.064

0.355

5.744

0.000

Resource management strategy

0.285

0.118

0.096

2.410

0.016

cognitive strategy

-0.190

0.096

-0.112

-1.969

0.049

Statistically significant values are indicated in bold, F = 29.61, p < 0.01; R2 = 0.324, Adjust-R2 = 0.313

Discussion

This study discusses the degree of SRL of clinical medicine, TCM, nursing undergraduate and junior college students in TCM colleges and universities; analyses the factors that affect the SRL of students in TCM colleges and universities in China and reveals that individual factors, social factors and learning strategies mastered by students can affect their SRL.

What is the current situation of learning strategies and SRL for medical majors in TCM colleges and universities?

The score of learning strategy of medical-related undergraduates who were studying at the TCM university was 160.16 ± 29.45, and the score of each dimension was above the midpoint (3 points). This showed that the learning strategy of undergraduates of the TCM university is good. The scores were reduced to affective, resource management, metacognitive and cognitive strategies in order. Thus, students have good emotion control ability when they encounter difficulties in the learning process and also can make use of various information or environmental resources effectively in the school. Metacognition can promote the mastery of metacognition skills, and they are also the basic skills of learners in self-regulation, critical thinking and lifelong learning. Metacognitive skills are generally used to monitor and understand, regulate reasoning and solve problems[26]. The better the learners’ metacognitive learning strategies, the better they can plan their learning, monitor and evaluate their knowledge, deepen their perception of learning materials, find and solve problems more efficiently and have more responsibility for their education, thereby urging them to study further[27]. Many studies have shown that metacognitive learning strategies can effectively predict students’ academic success[28–31]. However, metacognitive strategies and cognitive strategies remained low in this study, a point worthy of considerable attention from educators.

Students should learn to take responsibility for their learning to acquire self-directed learning skills and thus the ability to master lifelong learning[32]. The total score of SRL was 115.16 ± 12.42 in this study, lower than that in Zhuang’s research[33] on nurses in TCM junior colleges. This finding showed that the demand produces motivation and the clinical medical practice can enhance the SRL ability of medical workers. This is consistent with Teng’s[34] research that undergraduate nursing students with good clinical practice had better SRL. However, most of our research objects are undergraduate students lacking clinical practice. The scores of learning motivation, learning setting and self-regulation in this study were 34.76 ± 4.62, 41.14 ± 4.30 and 39.26 ± 4.74, respectively. The mean scores were all above the median, and the score from high to low is self-regulation, learning motivation and learning setting in sequence. Medical-related undergraduate students in TCM universities have good SRL ability. Studying medicine, which has many knowledge points to remember, is commonly perceived to be difficult. Owing to the tremendous pressure of learning medical science the need to know medicine and TCM in TCM university as well as the numerous curriculum subjects and tight review time at the end of term, students should possess good SRL ability of their volitional control, self-improvement and self-evaluation. By contrast, because medical science has a solid professional specialty, the students who chose medicine as their future career direction take the postgraduate entrance examination as the starting point to devote themselves to medical science driven by the current tense employment situation. They often have strong learning motivation (including method application, place selection and learning goals). However, learning settings were slightly lower for the choice of learning content, value awareness determination and internalisation. This also reminds us that educators should grasp the emphasis of students’ learning content and the awareness of learning value as the focus. At the same time, it remains necessary to improve the teaching on learning strategies, give students clear objectives in class, answer questions promptly when the students are in doubt and supervise the learning effect after class and further improve students’ SRL ability. As medical knowledge changes daily and continues to grow, it is more important than ever for medical educators to ensure that students have the necessary self-regulating learning skills in addition to teaching medical knowledge[35].

What factors influence the SRL of medical-related students in TCM colleges and universities?

Many factors influence the academic success of medical students, such as previous academic achievements, individual differences in learning strategies adopted in the learning process and even personality characteristics[36]. A study on the gross anatomy course of first-year medical students found that those who use cognitive strategies that reinforce meanings, concepts or generalisations and strategies that promote critical thinking, such as teacher/student questioning and peer teaching, had better academic performance[37]. Our research results showed that learning strategies were positively correlated with SRL, which was similar to the outcomes of Zhang[38] on nursing students. Then, the demographic characteristics and learning strategies all entered into the regression equation of SRL ability. The results showed that whether they liked their specialty, educational system, achievement ranking, scholarship, whether they were taught by a tutor in middle school, father’s educational background, mother’s educational background, monthly family incomes, metacognitive strategy, resource management strategy and cognitive strategy can all be entered into the regression equation. The more passionate a person is about their specialty, the more willing they are to invest in it. The stronger SRL ability they will have, and they will gain better academic performance. They will also more easily earn scholarships will be obtained easily either, and the SRL ability will form positive feedback and promote each other. Students with three years of schooling have lower scores in the college entrance examination than those with four or five years of schooling, and their SRL ability is also weaker. Students with high family incomes who could hire tutors in middle school have higher SRL abilities because tutors also taught learning techniques to gain knowledge. In terms of specialty, the SRL ability of TCM and medicine students is higher than that of nursing students, which is considered due to the differentiation and identification of college entrance examinations. Many studies have found that medical students have better academic performance. According to Zimmerman[39], high academic achievement is closely and positively correlated with the mastery of learning strategies. Therefore, we can infer that medical students have better Learning Strategies than those of other majors. Similarly, this conclusion can also be deduced to nursing students and has been verified[40]. The father’s and mother’s educational backgrounds both affect SRL. Strangely, the SRL and learning strategy mastery of males in this study is better than that of females. Different from the results of Tekkol’s study[41], the SRL and learning strategy scores of science students are also higher than those of liberal arts students, indicating that male students and science students have ways of thinking and a variety of learning strategies that are suitable for medical disciplines. These factors and learning strategies jointly predicted a 32% variation of the SRL ability. The standardised regression coefficients of metacognitive strategies, resource management strategies and cognitive strategies were observably related to SRL. Therefore, it is more important to teach the content and methods of learning strategies, as is professional knowledge for students regardless of a TCM or clinical medicine specialty.

How can the SRL of medical majors in TCM colleges and universities be improved?

SRL is an important strategy for the continuous professional development of medical students. Medical education should not only teach them relevant clinical knowledge of medical-related students but also teach the ability of SRL. Reviewing the previous literature, we made the following reflections on improving the SRL of medical-related students in TCM colleges and universities. Firstly, in terms of improving the learning strategy of medical-related undergraduates, teachers should be able to teach their learning strategies, such as teaching students to plan, monitor and regulate their learning behaviour; training them to restate knowledge, refine and organise; cultivating interest in the ability and teaching them how to manage the learning time and environment and ask for help during difficulties. Secondly, necessary approaches to effectively improve the learning strategies of students in the medial-related specialty in TCM universities effectively include the following. Educators must cultivate students’ ability of self-confidence, challenge and tolerance to deal with setbacks; evaluate and give feedback on students’ learning behaviour and results promptly; select moderate tricky learning tasks and introduce competition mechanisms appropriately. Thirdly, in terms of enhancing SRL ability, improving students’ learning motivation is essential. In social cognition theory, Bandura believed that human behaviour and reason are mutually influenced and people’s prediction of possible results of behaviours plays a crucial role in learning[42]. At the same time, ideological education should be carried on in start-up education and professional curriculum construction. Teachers should strengthen the professional sense of value and mission of medical-related students to study medicine and make them realise the sense of responsibility of medical workers and the importance of mastering professional knowledge. Teachers should also use effective methods to reform or create golden lessons to improve students’ interests in learning, such as case teaching, scaffolding, problem-based learning and case-based learning. Teachers should give full play to the advantages of counsellors and psychological teachers, who can guide students to attribute their failure in final exams, postgraduate entrance exams and other examinations correctly. Teachers should also inspire learning courage, in which students become braver that is the more they are frustrated. In terms of learning settings, teachers should give students straightforward learning content and teaching objectives whenever they are taught new lessons and summarise the key points of the course before class is over. The class teacher can assist the students in making short-term and long-term learning plans. Scholarship recipients can also share their learning experiences which can help other students to use some learning strategies selectively, such as retelling and association according to different learning tasks. Students should be advocated to make full use of the school library, database and other network resources to solve practical problems. Finally, students should be taught to self-regulate in the process of learning. Example strategies are better self-regulation when, self-evaluating learning content, method and learning effect termly, and self-reward and self-reinforcement should be adopt when achieving phased learning victories.

Limitations

This study explored the level of SRL ability and learning strategies and the relationship between them. However, the study design has some limitations. Firstly, this study is a cross-sectional survey, and we only cover the status quo of self-regulation learning ability and some influencing factors of medical-related students in a traditional Chinese medical university. We also only analyse the effect of influence on SRL in terms of demographic data and learning strategies. However, we did not infer the causal relationship among these factors. The impact of psychological and behavioural factors on SRL also compels us to conduct future research. The results of the present study are related to the subjects in its sample, and thus, they cannot be generalised. Therefore, the results should be interpreted with caution. Secondly, the samples of this study are from a TCM university in Zhejiang Province. The interpretation of these results was likely to be limited because of the regional limitations of sampling. Thirdly, this study lacks empirical research to demonstrate the rationality of the inference and the effectiveness of the intervention. Consequently, large-scale samples and longitudinal intervention studies from different regions need to be designed to verify the results of this study.

Conclusions

Through a cross-sectional survey, this study explored the influencing factors of the self-directed learning ability of medical-related students in a TCM university. It analysed the correlation between learning strategies and self-directed learning. The study found that the overall SRL of medical-related students was better. The independent variables (whether they liked their specialty, educational system, specialty, achievement ranking, scholarship, whether taught by a tutor in middle school, gender, monthly family income, parents’ educational background of parents and learning strategies) were significant in predicting self-directed learning. Together, they explained 32% of the variation in self-directed learning. This study emphasised the importance of professional identity and the importance of learning strategies in self-directed learning. The school is recommended to strengthen its focus on students who do not like their specialty, have low family income, are female and are in their third year. For those students with low rankings or inadequate learning strategies, teachers should develop the teaching of professional infiltration learning strategies [43]. Educators should adjust the content of the course and try various teaching methods to instil the concept of self-directed learning in medical-related students, so that they can study independently and learn for a lifetime even after graduation. Therefore, this study can provide evidence for the empirical research on improving students’ self-directed learning ability through curriculum setting, teaching reform and psychological intervention.

Declarations

Ethics approval and consent to participate

This study was approved by the ethical Committee of Zhejiang Shu Ren University. Participation was voluntary, anonymity was guaranteed. Informed consent was provided by all participants prior to participating in the survey. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are in Chinese and are available from the corresponding author on reasonable request but will require translation to English.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors' contributions

Ling Li and Lili Yang were involved in the design of the study, data acquisition, analysis and interpretation of data, drafting and revising the manuscript. Mingling Zhu and Lili Yang provided help with the data collection, analysis and interpretation, and revised several drafts of the manuscript. Yuqing Shi made substantive intellectual contributions to the interpretation of data and draft of the manuscript. All authors have read and approved the final manuscript.

Acknowledgements

We are thankful for the generous contributions of the research participants and the staffs who assisted with data collection during the study.

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