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1.  Nursing Students’ Self-Graded Motivation to Complete their Programme of Study 
The Open Nursing Journal  2010;4:42-47.
The aim of this study was to explore variation in nursing students’ motivation to complete their programme of study, as well as factors relating to low versus high motivation and students’ opinions of what would increase their motivation to complete their programme of study.
A study was carried out between April 2006 and December 2007. A total of 872 students registered in a 3-year nursing programme randomly participated in self-rating their motivation score once each semester. Descriptive statistics, statistical calculations and content analysis regarding open-ended questions were performed. Most of the students, 73%, rated their motivation as ≥6 on a 0-10 Likert scale; and 16% gave a rating of ≤4.
The desire to become a registered nurse (RN) and having a positive attitude towards the studies were the main factors influencing high motivation to complete the programme of study. Having a negative attitude towards the studies was an explanation of decreased motivation. There was a significant decrease (p=0.001) in the motivation score with respect to number of semesters, and motivation increased with the student’s age (p=0.0119). Suggestions for increasing motivation given by those who rated their motivation as ≤4 mainly focused on improvements in didactics and study organisation.
PMCID: PMC3043268  PMID: 21347211
Nurse education; motivation.
2.  Small group effectiveness in a Caribbean medical school’s problem-based learning sessions 
The Tutorial Group Effectiveness Instrument was developed to provide objective information on the effectiveness of small groups. Student perception of small group effectiveness during the problem base learning (PBL) process has not been previously studied in Xavier University School of Medicine (Aruba, Kingdom of the Netherlands); hence, the present study was carried out.
The study was conducted among second and third semester undergraduate medical students during the last week of September 2013, at Xavier University School of Medicine of the Netherlands. Students were informed about the objectives of the study and invited to participate after obtaining written, informed consent. Demographic information like gender, age, nationality, and whether the respondent had been exposed to PBL before joining the institution was noted. Student perception about small group effectiveness was studied by noting their degree of agreement with a set of 19 statements using a Likert-type scale.
Thirty-four of the 37 (91.9%) second and third semester medical students participated in the study. The mean cognitive score was 3.76 while the mean motivational and de-motivational scores were 3.65 and 2.51, respectively. The median cognitive category score was 27 (maximum score 35) while the motivation score was 26 (maximum score 35) and the de-motivational score was 12 (maximum score25). There was no significant difference in scores according to respondents’ demographic characteristics.
Student perception about small group effectiveness was positive. Since most medical schools worldwide already have or are introducing PBL as a learning modality, the Tutorial Group Effectiveness Instrument can provide valuable information about small group functioning during PBL sessions.
PMCID: PMC3992470  PMID: 24699510
Program evaluation; Medical education; Problem-based learning; Educational measurement
3.  Assessment of burnout in veterinary medical students using the Maslach Burnout Inventory-Educational Survey: a survey during two semesters 
BMC Medical Education  2014;14(1):255.
Burnout among veterinary students can result from known stressors in the absence of a support system. The objectives of this study were to evaluate use of the Maslach Burnout Inventory-Educator Survey (MBI-ES) to assess burnout in veterinary students and evaluate the factors that predict the MBI-ES scores.
The MBI-ES was administered to first (Class of 2016) and second year (Class of 2015) veterinary medical students during the 2012-2013 academic year in the fall and spring semesters. Factor analysis and test reliability for the survey were determined. Mean scores for the subscales determining burnout namely emotional exhaustion (EE), depersonalization (DP) and lack of personal accomplishment (PA) were calculated for both classes in the 2 semesters. Multiple regression analysis was performed to evaluate other factors that predict the MBI-ES scores.
A non-probability sampling method was implemented consisting of a voluntary sample of 170 and 123 students in the fall and spring semesters, respectively. Scores for EE, DP and PA were not different between the 2 classes within the same semester. Mean ± SD scores for EE, DP and PA for the fall semester were 22.9 ± 9.6, 5.0 ± 4.8 and 32.3 ± 6.7, respectively. Mean ± SD scores for EE, DP and PA the spring semester were 27.8 ± 10.7, 6.5 ± 6.1and 31.7 ± 6.8, respectively. The EE score was higher in spring compared to fall while DP and PA scores were not different between the 2 semesters. Living arrangements specifically as to whether or not a student lived with another veterinary medical students was the only variable significantly associated with the MBI-ES scores. Students in this study had moderate levels of burnout based on the MBI-ES scores.
The MBI-ES was an acceptable instrument for assessing burnout in veterinary medical students. The EE scores were higher in the spring semester as compared to the fall semester. Thus students in the first and second years of veterinary school under the current curriculum experience the greatest levels of emotional exhaustion during the spring semester. This has administrative implications for the school, when considering the allocation and use of resources for student support systems during each semester.
PMCID: PMC4256738  PMID: 25429983
Veterinary; Students; Burnout; Maslach
4.  Cultural Intelligence and Social Adaptability: A Comparison between Iranian and Non-Iranian Dormitory Students of Isfahan University of Medical Sciences 
Materia Socio-Medica  2013;25(1):40-43.
At the modern age, to acquire knowledge and experience, the individuals with their own specific culture have to enter contexts with cultural diversity, adapt to different cultures and have social interactions to be able to have effective inter-cultural relationships.To have such intercultural associations and satisfy individual needs in the society, cultural intelligence and social adaptability are deemed as inevitable requirements, in particular for those who enter a quite different culture. Hence, the present study tries to compare the cultural intelligence and its aspects and social adaptability in Iranian and non-Iranian dormitory students of Isfahan University of Medical Sciences in 2012.
The study was of descriptiveanalytical nature. The research population consisted of Iranian and non-Iranian students resided in the dormitories of Isfahan University of Medical Sciences which are 2500, totally. For Iranian students, two-stage sampling method was adopted. At the first stage, classified sampling and at the second stage, systematic random sampling was conducted. In this way, 441 students were selected. To form non-Iranian students’ sample, consensus sampling method was applied and a sample of 37 students were obtained. The research data was collected by using Earley & Ang’s Cultural Intelligence Questionnaire with the Cronbach’s coefficient α of 76% and California Social Adaptability Standard Questionnaire with the Cronbach’s coefficient α of over 70%. Then, the data were put into SPSS software to be analyzed. Finally, the results were presented by descriptive and inferential statistics methods.
The study findings revealed that there was no statistically significant difference between cultural intelligence and cognitive aspect of cultural intelligence in Iranian and non-Iranian students (P≥0/05). However, Iranian and non-Iranian students statistically differed in terms of the following aspects of cultural intelligence: meta-cognitive aspect (61.8% for Iranian students vs. 47.6% for non-Iranians), motivational aspect (59.0% vs. 42.6%), behavioral aspect (31.8% vs. 41.2%) as well as social adaptability as the other variable in question ( 68.9% vs. 56.2%) (p<0.001).
The comparison of the mean scores gained for meta-cognitive and motivational aspects of cultural intelligence as well as social adaptability in Iranian and non-Iranian students resided in the dormitories of Isfahan University of Medical Sciences revealed that the Iranian students had the higher rank. On the other hand, the mean score acquired for the behavioral aspect in Iranian and non-Iranian students were comparable, with non-Iranian students having the higher mean scores. Therefore, it can be said that the meta-cognitive and motivational aspects of cultural intelligence and social adaptability of non-Iranian students and the behavioral aspect of Iranian students’ cultural intelligence may be promoted by educational planning, thereby, taking effective steps towards their achievement in contexts with inter-cultural interaction . In this way, their mental health will be enhanced, as well.
PMCID: PMC3633545  PMID: 23678339
culture; intelligence; cultural intelligence; social adaptability.
5.  Do different medical curricula influence self-assessed clinical thinking of students? 
Objectives: As a fundamental element of medical practice, clinical reasoning should be cultivated in courses of study in human medicine. To date, however, no conclusive evidence has been offered as to what forms of teaching and learning are most effective in achieving this goal. The Diagnostic Thinking Inventory (DTI) was developed as a means of measuring knowledge-unrelated components of clinical reasoning. The present pilot study examines the adequacy of this instrument in measuring differences in the clinical reasoning of students in varying stages of education in three curricula of medical studies.
Methods: The Diagnostic Thinking Inventory (DTI) comprises 41 items in two subscales (“Flexibility in Thinking” and “Structure of Knowledge in Memory”). Each item contains a statement or finding concerning clinical reasoning in the form of a stem under which a 6-point scale presents opposing conclusions. The subjects are asked to assess their clinical thinking within this range. The German-language version of the DTI was completed by 247 student volunteers from three schools and varying clinical semesters. In a quasi-experimental design, 219 subjects from traditional and model courses of study in the German state of North Rhine-Westphalia took part. Specifically, these were 5th, 6th and 8th semester students from the model course of study at Witten/Herdecke University (W/HU), from the model (7th and 9th semester) and traditional (7th semester) courses of study at the Ruhr University Bochum (RUB) and from the model course of study (9th semester) at the University of Cologne (UoC). The data retrieved were quantitatively assessed.
Results: The reliability of the questionnaire in its entirety was good (Cronbach’s alpha between 0.71 and 0.83); the reliability of the subscales ranged between 0.49 and 0.75. The different groups were compared using the Mann-Whitney test, revealing significant differences among semester cohorts within a school as well as between students from similar academic years in different schools. Among the participants from the model course of study at the W/HU, scores increased from the 5th to the 6th semester and from the 5th to the 9th semester. Among individual cohorts at RUB, no differences could be established between model and traditional courses of study or between 7th and 9th semester students in model courses of study. Comparing all participating highest semester students, the 8th semester participants from the W/HU achieved the highest scores – significantly higher than those of 9th semester RUB students or 9th semester UoC students. Scores from the RUB 9th semester participants were significantly higher than those of the 9th semester UoC participants.
Discussion: The German-language version of the DTI measures self-assessed differences in diagnostic reasoning among students from various semesters and different model and traditional courses of study with satisfactory reliability. The results can be used for discussion in the context of diverse curricula. The DTI is therefore appropriate for further research that can then be correlated with the different teaching method characteristics and outcomes of various curricula.
PMCID: PMC4027808  PMID: 24872858
clinical thinking; clinical reasoning; PBL; diagnostic thinking inventory
6.  The process of community health nursing clinical clerkship: A grounded theory 
The performance of the community health nurse depends on a combination of scientific and practical competencies acquired by educational experiences during the nursing course. Curriculum planners of nursing education need to understand nursing education to train professional and community-oriented nurses. The aim of this article is to explore the experiences of nursing students during their community health nursing clinical clerkship courses.
Materials and Methods:
A grounded theory approach was used to conduct this study. Twelve nursing students, 13 health-care staff members, and 10 nursing instructors were interviewed individually in 2011-2012. The interviews were tape-recorded and later transcribed verbatim. The transcriptions were analyzed using the method of Strauss and Corbin.
Ambivalence of motivation was the main category and included five subcategories: Professional identity, educational atmosphere, educational management, motivation-based approaches, and inadequate productivity. This paper presents the aspects of the community health nursing clerkship course from the viewpoint of students in areas such as the role of the community health nurse, attitude toward the course, medical orientation, prerequisite skills/knowledge, poor administrative planning, rotation of students, insufficient activity for students, passiveness, providing service to clients, responsibility, and inproductivity. These categories could explain the nature of the community health nursing clerkship of the Mashhad Faculty of Nursing and probably others in Iran.
The findings revealed inadequate productivity of the community health nursing education; so, it is suggested to define a position for nurses in this setting and remove barriers and provide conditions for them to play more important roles in the promotion of community health.
PMCID: PMC3917128  PMID: 24554943
Clinical clerkship; community health; grounded theory; Iran; nursing students
7.  Achievement Goal Orientation and Situational Motivation for a Low-Stakes Test of Content Knowledge 
Objective. To determine the extent of the relationship between students’ inherent motivation to achieve in a doctor of pharmacy program and their motivation to achieve on a single low-stakes test of content knowledge.
Method. The Attitude Toward Learning Questionnaire (ATL) was administered to 66 third-year pharmacy students at the beginning of the spring 2011 semester, and the Student Opinion Scale (SOS) was administered to the same group immediately following completion of the Pharmacy Curricular Outcomes Assessment (PCOA).
Results. Significant differences were found in performance approach and work avoidance based on situational motivation scores. Situational motivation was also found to be directly correlated with performance and mastery approaches and inversely correlated with work avoidance. Criteria were met for predicting importance and effort from performance and mastery approaches and work avoidance scores of pharmacy students.
Conclusions. The ability to predict pharmacy students’ motivation to perform on a low-stakes standardized test of content knowledge increases the test’s usefulness as a measure of curricular effectiveness.
PMCID: PMC3355285  PMID: 22611274
motivation; achievement goal orientation; Pharmacy Curricular Outcomes Assessment.
8.  Cardiopulmonary Resuscitation Training in High School Using Avatars in Virtual Worlds: An International Feasibility Study 
Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today’s youth (ie, the digital native generation).
Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training.
In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables.
The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use.
By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training.
PMCID: PMC3636066  PMID: 23318253
Serious games; virtual learning environments; MMVW; avatars; students; cardiopulmonary resuscitation; patient simulation; self-efficacy; concentration
9.  Student attitude towards communication skills learning in a Caribbean medical school 
The Australasian Medical Journal  2013;6(9):466-475.
Medical student attitudes towards communication skills are important for curriculum planners and teachers. Xavier University School of Medicine (XUSOM) is a private medical school admitting students mainly from the United States and Canada.
Attitude of students towards communication skills has not been previously studied in the institution. Hence the present study was carried out.
The study was carried out among the first, second, third and fourth semester undergraduate medical (MD) students at XUSOM, Aruba during July 2013 using the communication skills attitude scale (CSAS). Respondents’ age, gender, nationality, occupation of parents, place of residence of family, semester of study were noted. The positive and negative attitude scale scores were calculated and compared among different subgroups of respondents (p<0.05).
Fifty-one of the seventy-three students (69.9 per cent) participated. The majority were between 20 to 25 years of age, of American nationality, from metro cities and had excellent or good self-perceived verbal and written communication skills. The mean positive attitude scale (PAS) score was 47.65 (maximum being 65) and the mean negative attitude scale (NAS) score was 31.06 (maximum 65). PAS score was significantly higher among respondents whose fathers were not in health related professions. NAS scores were significantly lower among the third and fourth semester respondents.
Students overall had a positive attitude towards communication skills but negative attitudes were also noted Based on results of the study and a review of literature we are planning to start communication skills learning in the institution right from the first semester and students will be provided opportunities for supervised practice during early clinical exposure, hospital observership and with standardised patients. The medical humanities module will be expanded and communication skills learning will continue during the clinical years with higher order skills being taught.
PMCID: PMC3794417  PMID: 24133539
Attitudes; communication skills; education; medical school; medical students
10.  Medical Students' Exposure to and Attitudes about the Pharmaceutical Industry: A Systematic Review 
PLoS Medicine  2011;8(5):e1001037.
A systematic review of published studies reveals that undergraduate medical students may experience substantial exposure to pharmaceutical marketing, and that this contact may be associated with positive attitudes about marketing.
The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.
Methods and Findings
We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students' exposure to the drug industry, as well as students' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%–100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs.
Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education.
Please see later in the article for the Editors' Summary
Editors' Summary
The complex relationship between health professionals and the pharmaceutical industry has long been a subject of discussion among physicians and policymakers. There is a growing body of evidence that suggests that physicians' interactions with pharmaceutical sales representatives may influence clinical decision making in a way that is not always in the best interests of individual patients, for example, encouraging the use of expensive treatments that have no therapeutic advantage over less costly alternatives. The pharmaceutical industry often uses physician education as a marketing tool, as in the case of Continuing Medical Education courses that are designed to drive prescribing practices.
One reason that physicians may be particularly susceptible to pharmaceutical industry marketing messages is that doctors' attitudes towards the pharmaceutical industry may form early in their careers. The socialization effect of professional schooling is strong, and plays a lasting role in shaping views and behaviors.
Why Was This Study Done?
Recently, particularly in the US, some medical schools have limited students' and faculties' contact with industry, but some have argued that these restrictions are detrimental to students' education. Given the controversy over the pharmaceutical industry's role in undergraduate medical training, consolidating current knowledge in this area may be useful for setting priorities for changes to educational practices. In this study, the researchers systematically examined studies of pharmaceutical industry interactions with medical students and whether such interactions influenced students' views on related topics.
What Did the Researchers Do and Find?
The researchers did a comprehensive literature search using appropriate search terms for all relevant quantitative and qualitative studies published before June 2010. Using strict inclusion criteria, the researchers then selected 48 articles (from 1,603 abstracts) for full review and identified 32 eligible for analysis—giving a total of approximately 9,850 medical students studying at 76 medical schools or hospitals.
Most students had some form of interaction with the pharmaceutical industry but contact increased in the clinical years, with up to 90% of all clinical students receiving some form of educational material. The highest level of exposure occurred in the US. In most studies, the majority of students in their clinical training years found it ethically permissible for medical students to accept gifts from drug manufacturers, while a smaller percentage of preclinical students reported such attitudes. Students justified their entitlement to gifts by citing financial hardship or by asserting that most other students accepted gifts. In addition, although most students believed that education from industry sources is biased, students variably reported that information obtained from industry sources was useful and a valuable part of their education.
Almost two-thirds of students reported that they were immune to bias induced by promotion, gifts, or interactions with sales representatives but also reported that fellow medical students or doctors are influenced by such encounters. Eight studies reported a relationship between exposure to the pharmaceutical industry and positive attitudes about industry interactions and marketing strategies (although not all included supportive statistical data). Finally, student opinions were split on whether physician–industry interactions should be regulated by medical schools or the government.
What Do These Findings Mean?
This analysis shows that students are frequently exposed to pharmaceutical marketing, even in the preclinical years, and that the extent of students' contact with industry is generally associated with positive attitudes about marketing and skepticism towards any negative implications of interactions with industry. Therefore, strategies to educate students about interactions with the pharmaceutical industry should directly address widely held misconceptions about the effects of marketing and other biases that can emerge from industry interactions. But education alone may be insufficient. Institutional policies, such as rules regulating industry interactions, can play an important role in shaping students' attitudes, and interventions that decrease students' contact with industry and eliminate gifts may have a positive effect on building the skills that evidence-based medical practice requires. These changes can help cultivate strong professional values and instill in students a respect for scientific principles and critical evidence review that will later inform clinical decision-making and prescribing practices.
Additional Information
Please access these Web sites via the online version of this summary at
Further information about the influence of the pharmaceutical industry on doctors and medical students can be found at the American Medical Students Association PharmFree campaign and PharmFree Scorecard, Medsin-UKs PharmAware campaign, the nonprofit organization Healthy Skepticism, and the Web site of No Free Lunch.
PMCID: PMC3101205  PMID: 21629685
11.  Impact of guided reciprocal peer questioning on nursing students’ self-esteem and learning 
Self-esteem is essential for clinical judgments. Nursing students in clinical environments should make a bridge between theoretical education and clinical function. This study was aimed to survey the effect of guided questioning in peer groups on nursing students’ self-esteem and clinical learning.
Materials and Methods:
In this quasi-experimental study, all nursing students in semester 4 (60) were selected. The autumn semester students (n = 28) were chosen as the control group, and the spring semester students (n = 32) as the experimental group. The experimental group underwent the course of cardiac medical surgical training by the Guided Reciprocal Peer Questioning. The control group was trained by lecture. After confirmation of the validity and reliability of tools including Rosenberg Self-esteem Scale and the researcher-made questionnaire, data were collected and analyzed by SPSS version 17.0.
There was no significant difference concerning demographic and educational characteristics between the two groups. Mean score differences of self-esteem and learning were not significant before teaching, while they were significantly promoted after teaching in the experimental (P < 0.001) and control (P < 0.05) groups. Promotion in the experimental group was more considerable than in the control group.
As revealed by the results, inquiry method, due to its more positive impact on self-esteem and students’ learning, can be applied alone or in combination with the other methods. Conducting this study for other students and for theoretical courses is suggested.
PMCID: PMC3872862  PMID: 24403923
Educational models; Iran; nursing student; questioning; self-esteem
12.  Evaluation of a web-based ECG-interpretation programme for undergraduate medical students 
Most clinicians and teachers agree that knowledge about ECG is of importance in the medical curriculum. Students at Karolinska Institutet have asked for more training in ECG-interpretation during their undergraduate studies. Clinical tutors, however, have difficulties in meeting these demands due to shortage of time. Thus, alternative ways to learn and practice ECG-interpretation are needed. Education offered via the Internet is readily available, geographically independent and flexible. Furthermore, the quality of education may increase and become more effective through a superior educational approach, improved visualization and interactivity.
A Web-based comprehensive ECG-interpretation programme has been evaluated. Medical students from the sixth semester were given an optional opportunity to access the programme from the start of their course. Usage logs and an initial evaluation survey were obtained from each student. A diagnostic test was performed in order to assess the effect on skills in ECG interpretation. Students from the corresponding course, at another teaching hospital and without access to the ECG-programme but with conventional teaching of ECG served as a control group.
20 of the 32 students in the intervention group had tested the programme after 2 months. On a five-graded scale (1- bad to 5 – very good) they ranked the utility of a web-based programme for this purpose as 4.1 and the quality of the programme software as 3.9. At the diagnostic test (maximal points 16) by the end of the 5-month course at the 6th semester the mean result for the students in the intervention group was 9.7 compared with 8.1 for the control group (p = 0.03).
Students ranked the Web-based ECG-interpretation programme as a useful instrument to learn ECG. Furthermore, Internet-delivered education may be more effective than traditional teaching methods due to greater immediacy, improved visualisation and interactivity.
PMCID: PMC2394519  PMID: 18430256
13.  Developing a blended learning program for nursing and midwifery students in Iran: Process and preliminary outcomes 
We aimed to develop and evaluate outcomes of a blended learning (BL) program for educating nursing and midwifery students of Tehran university of medical sciences (Tehran, Iran).
Materials and Methods:
This was a participatory action research project. After designing BL website, providing technological infrastructures, and holding preparatory workshops, 22 blended courses were designed. BL method was implemented for one semester. Students’ grade point average, participation with courses, and opinion about educational methods, and instructors’ attitude and opinion about educational methods were assessed.
Most students (n = 181; 72.1%) and 17 instructors (28.3%) consented to participate in the study. Students’ grade point average and participation was significantly higher in BL rather than in face-to-face method (P < 0.0001). Most instructors (n = 11, 65%) had positive attitude toward BL method. Textual analysis of participants’ opinion showed that most students preferred BL method and felt more independent in this method. However, they complained about lack of easy access to Internet and weakness in computer skills. Instructors admired the flexibility and incentives that had been provided in the program. However, some of them complained about the time-consuming nature of BL course design.
The program showed positive effect on students’ learning outcomes and participation. The strengths and weaknesses of the program should be considered for development of next phase of the project. Lessons learned in this phase might be helpful for decision makers who tend to develop similar programs in Iran. Motivational and communicational issues and users’ IT skills should be addressed in every BL program.
PMCID: PMC3748550  PMID: 23983723
Action research; distance education; Iran; midwifery; nursing
The objectives of this study were to assess the knowledge, attitudes and practices of male students at the Health Science College in Abha, towards road traffic regulations.
Material and Methods:
This study was carried out during the second semester of the academic year 2002G among the students studying at the Health Science College for Boys in Abha, Aseer Region, Saudi Arabia. A questionnaire of 28 different questions was distributed to all available students and responded to under the direct supervision of the heads of the six departments of the college. The questionnaire consisted of three main parts; the first was about the socio-demographic and scientific data of the students; the second on the knowledge of road traffic regulations and the third dealt with attitudes and practice of driving and the use of seat belts.
Two hundred thirty eight out of 297 students (80%) responded to the questionnaire in this study. The mean age of the participants was 21 years, 47% lived in cities, 70% and 72% had cars and driving licenses respectively. More than half of the students had been involved in road traffic accidents (RTAs), 22% of these had been injured in these RTAs and 13% admitted to hospital for an average of nine days. High speed was the main cause of their RTAs. The mean speed at which the students drove their cars within and outside the city boundaries were 81 KM/h and 127 KM/h respectively.
The degree of knowledge of road traffic regulation was moderate to high in more than 75% of the students, while more than 90% of them believed in the importance of the use of seat belts. More than 75% of the participants mentioned that they had problems with the use of seat belts, the most common of which were forgetfulness and anxiety.
This study revealed that many students had been involved in RTAs as a result of driving at high speed. Most of the students had good attitudes towards the use of seat belts. The rate of compliance to the use of seat belts increased with the legislation on its use. Continuing health education and the monitoring of compliance to road traffic regulations is necessary if the incidence of RTAs is to be reduced.
PMCID: PMC3410057  PMID: 23012129
Attitudes; Practice; Road Traffic Regulations; Students
15.  Students’ perception of the learning environment at Xavier University School of Medicine, Aruba 
The learning environment at Xavier University School of Medicine (XUSOM), Aruba has not been previously studied. Hence, the present study was carried out using the Dundee Ready Education Environment Measure (DREEM) to obtain student perceptions about the learning environment and compare the same among different subgroups of respondents.
The questionnaire was administered to undergraduate medical students in their first to fifth semester during the first two weeks of June 2013. The students’ perceptions were evaluated by noting their degree of agreement with a set of 50 statements using a Likert-type scale. The mean overall score and the scores of subcategory were calculated and compared among different respondents (P<0.05).
Seventy-three of the 86 students (84.9%) completed the questionnaire. The overall mean±SD score was 131.79±22.86 (maximum score 200). The mean±SD score for students’ perception of teaching/learning was 31.99±6.23 (maximum score, 48), while the score for students’ perceptions of teachers was 30.05±5.54 (maximum score, 44). The mean±SD scores for students’ academic self-perception, students’ perception of the atmosphere, and students’ social self-perception were 21.88±5.11 (maximum score, 32), 30.92±8.59 (maximum score, 48), and 16.96±4.71 (maximum score, 28), respectively. There were no differences in scores according to the respondents’ personal characteristics.
The student responses about the learning environment at the institution were positive. We plan to obtain regular student feedback as the curriculum becomes progressively more student-centered and integrated.
PMCID: PMC3813925  PMID: 24223238
Assessment; Educational environment; Feedback; Medical schools; Medical students
16.  Virtual education effect on cognitive learning and attitude of nursing students towards it 
Along with emersion of the Internet, virtual education increasingly has been growing. Many studies discussed this method and its impact on learning. Present study investigated students’ attitude towards virtual education as well as its effect on learning.
This was a pretest-posttest quasi-experimental study. The nursing students, who had selected fluids and electrolyte disorders course, were randomly divided into two virtual and conventional education groups. The knowledge of students was assessed through a written exam and students’ attitude towards virtual education assessed by a researcher-made questionnaire.
Mean scores of students in pretest were 0.8 (0.3) and 1.1 (0.59) in virtual and conventional group respectively [mean (SD)]. At the end of the semester their scores were 15.9 (0.58) and 16.51 (0.89) respectively. Mean attitude scores at baseline were 3.19 (0.48) and 3.21 (0.33) followed by 3.55 (0.45) and 3.21 (0.46) at the end of the semester in virtual and conventional groups respectively.
Although the scores of conventional group at the end of the course were higher than virtual group, both methods acted similarly in terms of increasing the knowledge. Passing a virtual education course may improve the attitude of the nurses towards it.
PMCID: PMC3583104  PMID: 23450257
Virtual education; learning; attitude
17.  Are postgraduate students in distance medical education program ready for e-learning? A survey in Iran 
Appropriate instructional design plays a crucial role in e-learning success, and analyzing learners is the cornerstone for instructional design process. Students’ readiness for e-learning was assessed in the present study as an example of learner analysis for a distance course in medical education master program.
Materials and Methods:
A census sample of 23 students applied for distance master program on medical education, completed the “Students’ E-Learning Readiness Scale” developed by Watkins, via email. The reliability and validity of the scale has been confirmed before. Average scores in total and 6 subscales were calculated. The score range was 1-5 and scores above 3 indicated good readiness. Data was interpreted using descriptive and non-parametric tests (Mann-Whitney U and Kruskal-Wallis).
Response rate was 100%. The students’ readiness scores in total and all subscales (“technology access”, “online skills and relationships”, “motivation”, “online audio/video”, “readiness for online discussions”, and “importance of e-learning to your success”) were above 3. Comparing different subscales, students’ mean scores in “motivation” and “internet discussion” subscales were less than others, although the difference was not significant. There were no significant gender differences in the readiness scores. Students who were academic staff had significantly higher scores than others in total and in “motivation” and “online skills and relationship” subscales.
Good learners’ readiness, observed in the present study, may imply that the instructional designer can rely on e-learning strategies and build the course upon them. However, according to the slightly lower scores in “motivation” and “online discussion” subscales, it is recommended to stress more on strategies that improve these two components. To generalize the results, it is needed to test students’ readiness in more different degree programs.
PMCID: PMC3908694  PMID: 24524090
E-learning; Instructional design; learner analysis; learner readiness
18.  Gender differences in medical students’ motives and career choice 
BMC Medical Education  2012;12:82.
The main subject is the influence of gender and the stage of life on the choice of specialty in medical education. In particular we looked at the influence of intrinsic and external motives on this relationship. The choice of specialty was divided into two moments: the choice between medical specialties and general practice; and the preference within medical specialties. In earlier studies the topic of motivation was explored, mostly related to gender. In this study stage of life in terms of living with a partner -or not- and stage of education was added.
A questionnaire concerning career preferences was used. The online questionnaire was sent to all student members of the KNMG (Royal Dutch Medical Association). 58% of these students responded (N = 2397). Only 1478 responses could be used for analyses (36%). For stipulating the motives that played a role, principal components factor analysis has been carried out. For testing the mediation effect a set of regression analyses was performed: logistic regressions and multiple regressions.
Although basic findings about gender differences in motivations for preferred careers are consistent with earlier research, we found that whether or not living with a partner is determinant for differences in profession-related motives and external motives (lifestyle and social situation). Furthermore living with a partner is not a specific female argument anymore, since no interactions are found between gender and living with a partner. Another issue is that motives are mediating the relationship between, living with a partner, and the choice of GP or medical specialty. For more clarity in the mediating effect of motives a longitudinal study is needed to find out about motives and changing circumstances.
The present study provides a contribution to the knowledge of career aspirations of medical students, especially the impact of motivation. Gender and living with a partner influence both choices, but they are not interacting, so living with a partner is similarly important for male and female students in choosing their preferences. Moreover, external and intrinsic motives mediate this relationship to a greater of lesser degree. First stage students are influenced by life-style and intrinsic motives in their choice of general practice. For second stage students, the results show influences of life-style motives next to profession-related motives on both moments of choice.
PMCID: PMC3575371  PMID: 22913471
19.  Nursing Challenges in Motivating Nursing Students through Clinical Education: A Grounded Theory Study 
Nursing Research and Practice  2012;2012:161359.
Nurses are the first role models for students in clinical settings. They can have a significant role on students' motivation. The purpose of this study was to explore the understanding of nursing students and instructors concerning the role of nurses in motivating nursing students through clinical education. The sampling was first started purposefully and continued with theoretical sampling. The study collected qualitative data through semistructured and interactive interviews with 16 nursing students and 4 nursing instructors. All interviews were recorded, transcribed, and analyzed using grounded theory approach. One important pattern emerged in this study was the “concerns of becoming a nurse,” which itself consisted of three categories: “nurses clinical competency,” “nurses as full-scale mirror of the future,” and “Monitoring and modeling through clinical education” (as the core variable). The findings showed that the nurses' manners of performance as well as the profession's prospect have a fundamental role in the process of formation of motivation through clinical education. Students find an insight into the nursing profession by substituting themselves in the place of a nurse, and as result, are or are not motivated towards the clinical education.
PMCID: PMC3399339  PMID: 22830005
20.  Nursing students' perceptions of their clinical learning environment in placements outside traditional hospital settings 
Journal of Clinical Nursing  2014;23(19-20):2958-2967.
Aims and objectives
To explore students' opinions of the learning environment during clinical placement in settings outside traditional hospital settings.
Clinical placement experiences may influence positively on nursing students attitudes towards the clinical setting in question. Most studies exploring the quality of clinical placements have targeted students' experience in hospital settings. The number of studies exploring students' experiences of the learning environment in healthcare settings outside of the hospital venue does not match the growing importance of such settings in the delivery of health care, nor the growing number of nurses needed in these venues.
A survey design was used.
The Clinical Learning Environment Inventory was administered to two cohorts of undergraduate nursing students (n = 184) after clinical placement in mental health care, home care and nursing home care.
Nursing students' overall contentment with the learning environment was quite similar across all three placement areas. Students in mental health care had significantly higher scores on the subscale individualisation, and older students had significantly higher scores on the total scale. Compared with other studies where the Clinical Learning Environment Inventory has been used, the students' total scores in this study are similar or higher than scores in studies including students from hospital settings.
Results from this study negate the negative views on clinical placements outside the hospital setting, especially those related to placements in nursing homes and mental healthcare settings.
Relevance to clinical practice
Students' experience of the learning environment during placements in mental health care, home care and nursing homes indicates the relevance of clinical education in settings outside the hospital setting.
PMCID: PMC4263152  PMID: 24460862
Clinical Learning Environment Inventory; clinical placement; community health care; mental health care; nursing homes; nursing students; survey
21.  Does community-based education increase students' motivation to practice community health care? - a cross sectional study 
BMC Medical Education  2011;11:19.
Community-based education has been introduced in many medical schools around the globe, but evaluation of instructional quality has remained a critical issue. Community-based education is an approach that aims to prepare students for future professional work at the community level. Instructional quality should be measured based on a program's outcomes. However, the association between learning activities and students' attitudes is unknown. The purpose of this study was to clarify what learning activities affect students' attitudes toward community health care.
From 2003 to 2009, self-administered pre- and post-questionnaire surveys were given to 693 fifth-year medical students taking a 2-week clinical clerkship. Main items measured were student attitudes, which were: "I think practicing community health care is worthwhile" ("worthwhile") and "I am confident about practicing community health care" ("confidence") using a visual analogue scale (0-100). Other items were gender, training setting, and learning activities. We analyzed the difference in attitudes before and after the clerkships by paired t test and the factors associated with a positive change in attitude by logistic regression analysis.
Six hundred forty-five students (93.1%), 494 (76.6%) male and 151(23.4%) female, completed the pre- and post-questionnaires. The VAS scores of the students' attitudes for "worthwhile" and "confidence" after the clerkship were 80.2 ± 17.4 and 57.3 ± 20.1, respectively. Both of the scores increased after the clerkship. Using multivariate logistic regression analysis, "health education" was associated with a positive change for both attitudes of "worthwhile" (adjusted RR: 1.71, 95% CI: 1.10-2.66) and "confidence" (1.56, 1.08-2.25).
Community-based education motivates students to practice community health care. In addition, their motivation is increased by the health education activity. Participating in this activity probably produces a positive effect and improves the instructional quality of the program based on its outcomes.
PMCID: PMC3114788  PMID: 21569332
22.  Self- and peer assessment may not be an accurate measure of PBL tutorial process 
Universidade Cidade de São Paulo adopted a problem-based learning (PBL) strategy as the predominant method for teaching and learning medicine. Self-, peer- and tutor marks of the educational process are taken into account as part of the final grade, which also includes assessment of content. This study compared the different perspectives (and grades) of evaluators during tutorials with first year medical students, from 2004 to 2007 (n = 349), from seven semesters.
The tutorial evaluation method was comprised of the students' self assessment (SA) (10%), tutor assessment (TA) (80%) and peer assessment (PA) (10%) to calculate a final educational process grade for each tutorial. We compared these three grades from each tutorial for seven semesters using ANOVA and a post hoc test.
A total of 349 students participated with 199 (57%) women and 150 (42%) men. The SA and PA scores were consistently greater than the TA scores. Moreover, the SA and PA groups did not show statistical difference in any semester evaluated, while both differed from tutor assessment in all semesters (Kruskal-Wallis, Dunn's test). The Spearman rank order showed significant (p < 0.0001) and positive correlation for the SA and PA groups (r = 0.806); this was not observed when we compared TA with PA (r = 0.456) or TA with SA (r = 0.376).
Peer- and self-assessment marks might be reliable but not valid for PBL tutorial process, especially if these assessments are used for summative assessment, composing the final grade. This article suggests reconsideration of the use of summative assessment for self-evaluation in PBL tutorials.
PMCID: PMC2605444  PMID: 19038048
23.  Experience and Attitudes towards Information Technology among First-Year Medical Students in Denmark: Longitudinal Questionnaire Survey 
As more and more information technology (IT) resources become available both for support of campus- based medical education and for Web-based learning, it becomes increasingly interesting to map the information technology resources available to medical students and the attitudes students have towards their use.
To determine how extensively and effectively information handling skills are being taught in the medical curriculum, the study investigated Internet and computer availability and usage, and attitudes towards information technology among first-year medical students in Aarhus, Denmark, during a five-year period.
In the period from 1998 to 2002, students beginning the first semester of medical school were given courses on effective use of IT in their studies. As a part of the tutorials, the students were asked to complete a web-based questionnaire which included questions related to IT readiness and attitudes towards using IT in studies.
A total of 1159 students (78%) responded. Overall, 71.7% of the respondents indicating they had access to a computer at home, a number that did not change significantly during the study period. Over time, the power of students' computers and the use of e-mail and Internet did increase significantly. By fall 2002, approximately 90% of students used e-mail regularly, 80% used the Internet regularly, and 60% had access to the Internet from home. Significantly more males than females had access to a computer at home, and males had a more positive attitude towards the use of computers in their medical studies. A fairly constant number of students (3-7%) stated that they would prefer not to have to use computers in their studies.
Taken together with our experience from classroom teaching, these results indicate optional teaching of basic information technology still needs to be integrated into medical studies, and that this need does not seem likely to disappear in the near future.
PMCID: PMC1550582  PMID: 15111276
Information technology; Internet; e-mail; students, medical; education, medical
24.  Medical Students’ Perception of Their Educational Environment 
Background: Students’ perception of the environment within which they study has shown to have a significant impact on their behavior, academic progress and sense of well-being. This study was undertaken to evaluate the students’ perception of their learning environment in an Indian medical school following traditional curricula and to study differences, if any, between the students according to the stages of medical education, i.e., the pre-clinical and clinical stages.
Methodology: In the present study, the Dundee Ready Education Environment Measure (DREEM) inventory was administered to undergraduate medical students of first (n = 227), third (n = 175), fifth (n = 171) and seventh (n = 123) semesters. Scores obtained were expressed as mean ± Standard Deviation (SD) and analyzed using one-way ANOVA and Dunnett’s test. P-value < 0.05 was considered as significant.
Results: The mean DREEM score for our medical school was 123/200.The first-year students were found to be more satisfied with learning environment (indicated by their higher DREEM score) compared to other semester students. Progressive decline in scores with each successive semester was observed. Evaluating the sub-domains of perception, the registrars in all semesters had a more positive perception of learning (Average mean score: 29.44), their perception of course organizers moved in the right direction (Average mean score: 26.86), their academic self-perception was more on the positive side (Average mean score: 20.14), they had a more positive perception of atmosphere (Average mean score: 29.07) and their social self-perception could be graded as not too bad (Average mean score: 17.02).
Conclusion: The present study revealed that all the groups of students perceived their learning environment positively. However, a few problematic areas of learning environment were perceived such as: students were stressed more often; they felt that the course organizers were authoritarian and emphasized factual learning. Implementing more problem-based learning, student counseling and workshops on teaching-learning for educators might enable us to remedy and enrich our learning environment.
PMCID: PMC3939516  PMID: 24596737
Learning environment; Dundee Ready Educational Environment Measure (DREEM) questionnaire; Dunnett’s test ligament
25.  Motivational profiles of medical students: Association with study effort, academic performance and exhaustion 
BMC Medical Education  2013;13:87.
Students enter the medical study with internally generated motives like genuine interest (intrinsic motivation) and/or externally generated motives like parental pressure or desire for status or prestige (controlled motivation). According to Self-determination theory (SDT), students could differ in their study effort, academic performance and adjustment to the study depending on the endorsement of intrinsic motivation versus controlled motivation. The objectives of this study were to generate motivational profiles of medical students using combinations of high or low intrinsic and controlled motivation and test whether different motivational profiles are associated with different study outcomes.
Participating students (N = 844) from University Medical Center Utrecht, the Netherlands, were classified to different subgroups through K-means cluster analysis using intrinsic and controlled motivation scores. Cluster membership was used as an independent variable to assess differences in study strategies, self-study hours, academic performance and exhaustion from study.
Four clusters were obtained: High Intrinsic High Controlled (HIHC), Low Intrinsic High Controlled (LIHC), High Intrinsic Low Controlled (HILC), and Low Intrinsic Low Controlled (LILC). HIHC profile, including the students who are interest + status motivated, constituted 25.2% of the population (N = 213). HILC profile, including interest-motivated students, constituted 26.1% of the population (N = 220). LIHC profile, including status-motivated students, constituted 31.8% of the population (N = 268). LILC profile, including students who have a low-motivation and are neither interest nor status motivated, constituted 16.9% of the population (N = 143). Interest-motivated students (HILC) had significantly more deep study strategy (p < 0.001) and self-study hours (p < 0.05), higher GPAs (p < 0.001) and lower exhaustion (p < 0.001) than status-motivated (LIHC) and low-motivation (LILC) students.
The interest-motivated profile of medical students (HILC) is associated with good study hours, deep study strategy, good academic performance and low exhaustion from study. The interest + status motivated profile (HIHC) was also found to be associated with a good learning profile, except that students with this profile showed higher surface strategy. Low-motivation (LILC) and status-motivated profiles (LIHC) were associated with the least desirable learning behaviours.
PMCID: PMC3691760  PMID: 23782767
Motivation; SDT; Learning outcomes; Academic performance; Intrinsic motivation; Controlled motivation; Motivational profiles

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