Informal learning during the standardized residency training in the context of “Internet plus” ： an empirical research

1 Background 2 Informal learning refers to learners-sponsored, monitored and regulated learning method, 3 which lays the foundation for medical life-long education of residents with sustainable self-learning 4 ability and permanent learning behaviors. In this article the authors explore the academic value and 5 significance in informal learning to improve the effectiveness for the standardized residency training 6 in the context of “Internet plus” which combines technology with education to promote reforms for 7 learning patterns. Standardized residency training started relatively late in China and there are less 8 empirical studies targeted for the medical students in this phase. Based on it, this study aims to 9 explore online informal learning behavior of medical students in residency training. among variables. The data from questionnaire has been analyzed through descriptive analysis, 18 difference analysis and correlation regression analysis. Informal learning attitudes of residents in standardized training are of high recognition and 21 strong learning belief but need better self-management; The intervention between informal learning 22 motivation and behavior among the levels of self-control, learning target and utilization of online 23 resources resulting in great influence of environmental and individual factors on self-efficacy. Relative weak ability appears in choosing, screening and utilizing effective information online 25 without effective guidance from teachers. methods in informal learning of postgraduate medical education in clinical and intensive online learning COVID-19 in guiding effective in future

2 among variables. The data from questionnaire has been analyzed through descriptive analysis, 18 difference analysis and correlation regression analysis. 19

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Informal learning attitudes of residents in standardized training are of high recognition and 21 strong learning belief but need better self-management; The intervention between informal learning 22 motivation and behavior among the levels of self-control, learning target and utilization of online 23 resources resulting in great influence of environmental and individual factors on self-efficacy. 24 Relative weak ability appears in choosing, screening and utilizing effective information online 25 without effective guidance from teachers. 26

Conclusions 27
In this study we innovatively propose appropriate and practical suggestions for researching Medical education is of a prominent feature of life-long learning, which motivates the medical 38 practitioners to further learning ability and update the knowledge system. Standardized residency 39 8 The management of medical education is categorized into two stages as pre-service and post-150 service, which respectively correspond to medical school education and postgraduate and 151 continuing medical education. The residency training belonging to the category of post-service has 152 the significance of the transition from formal learning in medical school to the learning in clinical 153 context. Referring to the learning content, residents are on the point of turning from theoretical 154 knowledge to clinical skills; Referring to cultivated target, they are on the point of identity changing 155 from medical students to residency doctors; Referring to learning method and context, they are from 156 classroom-learning to working-oriented learning. It is the vital stage of transition and breakthrough 157 aiming to practice the clinical thinking and skill applications, which lays the solid foundation for 158 the independent clinical solution in the future. 159 The implementation of informal learning for standardized residency training 160 Different from formal learning in classroom, when residents begin their study in clinical 161 context, informal learning takes larger account. How to optimize the learning method, improve the 162 learning effectiveness and develop good habit become the key issue for us. Therefore, we need to 163 focus more on the learning course during training, particularly the relevance with factors of informal 164 learning in order to make it standard and systematical. Based on the context, there's great match 165 between residents and method of informal learning, due to their special identity, clinical context, 166 skill requirement and occupation prospect. Medical students must make great endeavor to keep with 167 the constantly renewed knowledge and skills because of fast update of medical information and 168 complicated practical medical environment. "Internet plus" context just meets the requirement of 169 medical learning and development. Based on this, we take informal learning of the residents as our 170 major purpose of study so as to explore the application of informal learning in the context of 9 "Internet plus" by thorough theoretical and practical research. 172

The research significance on informal learning of residents in the context of "Internet plus" 173
Chinese Premier Li Keqiang firstly put forward the innovative concept and implementation of 174 project "Internet Plus" to national level in the government report in March, 2015. Project "Internet 175 Plus" is to profoundly integrate innovative achievement of internet with all different fields in 176 economic society to advance the technical progress, improve efficiency and organizational reforms,

Study-Dimension identification and questionnaire design 217
We are exploring the informal learning behaviors of residents from the Fourth Hospital of 218 Hebei Medical University in the context of "Internet plus". Our goal is effectively to regulate the 219 learning pattern of medical students from theoretical class-based learning to practice-based informal 220 learning in the workplace; to comprehensively study the situation of informal learning or residents 221 to find out the learning pattern and the solution to it. In the context of "Internet plus", this 222 investigation in terms of the features of standardized residency training in China and the 223 occupational situation of the group is scientifically designed, integrally structured, clearly purposed 224 and comprehensively considered. 225 The questionnaire with open questions was self-designed in a small scale. Four aspects related 226 to informal learning as learning attitude, learning motivation, learning behavior and online learning 227 resources were presented in the questionnaire as the following three parts: a. Basic information 228 concerning informant's gender, academic grade, specialty and option for internet resources. b. 229 Online learning situation before and inside with COVID-19. For this part Likert five-rating scale 230 was used. c. Cognition and expectation for the informal learning. 231

Implementation of empirical research 232
The questionnaire took the anonymous form in order to enhance trust and ensure confidentiality.  Table 1: 159 students are from grade one and both 146 from grade two and three. 251 Genders and grades of samples are evenly distributed, and the authenticity of the samples is based 252 on the real situation, which lays the foundation for the future study of residents' informal learning 253 in the context of "Internet plus". 254

Analysis of learning attitude to informal learning 255
Residents' learning attitude to informal learning is considered from the following two aspects: 256 one is the acceptance of informal learning, and the other is the willingness for the residents to utilize 257 online resources when learning in the context of "Internet plus". From Fig.1-1, Fig.1-2, and Fig.1-258 3, it is shown that 88.02% residents recognize the importance and frequency of informal learning 259 13 during training. 66.74% residents perform informal learning on cellphones through online resources, 260 next to phones, 24.83% use computers and other mobile devices take account for only 10%. 261 As it is indicated in the data, there are high recognition and strong learning belief of positive 262 informal learning. And also, mobile devices that all residents own are indispensable during learning 263 online, supplying satisfactory hardware condition of web-based learning. 264

Analysis of learning motivation for informal learning 265
According to the self-determination theory from Deci&Ryan 15 in 2000, learning motivation can 266 be divided into autonomous motivation and controlled motivation. As indicated in Fig.2-1, 267 controlled motivation for completing the online course and autonomous motivation for learning 268 fundamental knowledge and clinical skills are both functioning for the learning behavior of residents. 269 In Fig.2-2, Fig 2-3,there is great influence of environmental and personal factors on the process of 270 informal learning, and over 50% of residents hold the viewpoint that the influential factors of 271 environment involve lack of effective guidance, insufficient learning atmosphere, the payment of 272 network resource and so on. Therefore, which motivation plays major role in the process of informal 273 learning and how the personal, environmental and motivated factors interact with each other will be 274 discussed in the following part of the research. 275

Analysis of informal learning behavior 276
Postgraduate education focuses the learning pattern based on the workplace and working 277 experiences and it stresses the comprehensive evaluation on performances. Our research on informal 278 learning process is conducted from the following three aspects as plan management, process 279 management and self-efficacy to make a further investigation into the self-efficacy of the residents

Analysis of online learning resources in the context of "Internet plus" 292
In virtue of internet platform, we can realize learning whenever and wherever possible as well 293 as in any settings unlimitedly to construct meaningful knowledge system. As in Fig.3-1, the chief 294 advantage of online learning is the convenience of information accessibility, accounting up to 295 82.26%. The following advantages are unlimited learning time and places, and extensive access to 296 information, respectively accounting for 72.51% and 64.30%. "Internet plus education" utilizes the 297 modern informative technology to break through the limitation of time, space and contexts, which 298 is beneficial for the character-changing from students to residents and improvement of learning 299

pattern. 300
Confronting with massive learning resources online, whether the learner could identify the 301 effective information to some extent determines the effectiveness of their learning. From Fig.3-2  302 and Fig.3-3, there are few paths to choosing online courses or software, Baidu Netdisk ranks first 303 15 for the apps they use, and 78.71% residents choose it. The second app is Bilibili, only 34.59%. From 304 the percentage, the shareability of knowledge online doesn't show the positive effect, which leads 305 to severe restricted consequences of fragmentized learning. Fig.3-4 and Fig 3-5 indicate that 52.33% 306 of residents autonomously obtain resources, only 22.17% from the teachers. For the knowledge 307 management, 80% of them take notes on notebooks or apps, but only 5% would share what they 308 have learned, which shows the similar presentation with the low participation in discussion. 309 The analysis above illustrates that residents need to focus some aspects during informal learning: 310 how to make full use of the advantages of "Internet plus education" and through network platform 311 interacting with abundant resources , openness and shareability features, so as to promote the 312 positive development of informal learning activities for residents, and develop the target for active 313 guiding of the effectiveness. 314

315
The current situation of online informal learning has been analyzed from the questionnaire 316 presentation of descriptive data, but the differences of investigative dimensions still need to be 317 indicated. For this part, SPSS24.0 was used to make the differences statistics ranging from gender, 318 grade, learning behavior and efficiency to thoroughly analyze the problems existed in the informal 319 learning of residents. 320

Gender and grade differences 321
Overlapping analysis of gender, grade with learning attitude, behavior and efficiency has been 322 done respectively by Wilcoxon rank sum test and kruskal-wallis rank sum test , It means that the 323 difference has statistical significance(P<0.05). As shown in Table 3-1, Table 3-2, no obvious 324 difference was found illustrating the consistency of performance that residents hold a positive 325 16 attitude to the cognition of the importance of informal learning, also approve the important way of 326 learning, but they are in a situation of lower learning self-efficacy, due to lack of reasonable learning 327 plan, lower degree of learning participation or discussion, and lower in peer review as well. 328 Correlation analysis of gender, grade with learning motivation ， learning resources and 329 influential factors has been done by chi-square test. It means that the difference has statistical 330 significance(P<0.05). As in Table 3-3, differences appear to be less significant in approaches to 331 learning resources but significant in different genders. 62.59% male students voluntarily choose 332 online resources and 32.66% are recommended by teachers or classmates，however，respectively 333 47.37% and 48.03% female student. Through cross-over analysis of gender, grade and learning 334 motivation, male students appear to have more significant performance of self-directed learning, 335 and less in controlled motivation. In terms of learning influential factors, no significant differences 336 between grades but from gender dimension, relatively weaker ability of collecting online resources 337 sees in female students. And female students are more prone to be influenced by learning 338 atmosphere, different from male students being influenced by online garbage resources. Inactive 339 learning initiative and weak willpower could be commonly seen in all grades and genders. 340

Correlation regression analysis between learning efficiency and influential factors 341
We have analyzed the four different dimensions of learning attitude, learning motivation, 342 learning behaviors and online learning resources, and for this part the satisfactory correlation 343 between learning efficiency and influential factors are discussed. By SPSS24.0, Logistic regression 344 analysis has been made among personal, environmental and learning factors. According to 345 efficiency, we categorized "excellence" as 1 and others as 0. In the single-factor analysis, these were 346 included in the multi-factor analysis model(P ＜ 0.2), and indicated that the difference was 347 statistically significant(OR value < 1 and 95%CI between 0 and 1). As shown in Table 4, the 348 regression analysis of learning enthusiasm, willpower, learning atmosphere with learning efficiency 349 were all significantly (OR value＜1), showing a significant positive correlation. 350

In-depth investigation analysis 351
Last question in the questionnaire is in form of subjective gap-filling to investigate into the 352 attitude of residents to informal learning and improvement measures. There are 103 perspectives in 353 total, by analysis of words frequency it is shown in Fig.4  persistence and promotion of informal learning. However, there are still some defectiveness of pre-368 learning plan, regulation of learning process, and knowledge management, meanwhile self-efficacy 369