Iranian Clinical Nurses’ Activities for Self-Directed Learning: A Qualitative Study

Background: Clinical nurses need lifelong learning skills for responding to the rapid changes of clinical settings. One of the best strategies for lifelong learning is self-directed learning. The aim of this study was to explore Iranian clinical nurses’ activities for self-directed learning. Methods: In this qualitative study, 23 semi-structured personal interviews were conducted with nineteen clinical nurses working in all four hospitals affiliated to Isfahan Social Security Organization, Isfahan, Iran. Study data were analyzed by using the content analysis approach. The study was conducted from June 2013 to October 2014. Findings: Study participants’ activities for self-directed learning fell into two main categories of striving for knowledge acquisition and striving for skill development. The main theme of the study was ‘Revising personal performance based on intellectual-experiential activities’. Conclusions: Study findings suggest that Iranian clinical nurses continually revise their personal performance by performing self-directed intellectual and experiential activities to acquire expertise. The process of acquiring expertise is a linear process which includes two key steps of knowledge acquisition and knowledge development. In order to acquire and advance their knowledge, nurses perform mental learning activities such as sensory perception, self-evaluation, and suspended judgment step-by-step. Moreover, they develop their skills through doing activities like apprenticeship, masterly performance, and self-regulation. The absolute prerequisite to expertise acquisition is that a nurse needs to follow these two steps in a sequential manner.


Introduction
Rapid scientific advances have significantly decreased the half life of medical sciences (Gyawali, Jauhari, Shankar, Saha, & Ahmad, 2011) and posed big challenges to healthcare systems and fields, including nursing (Yang & Jiang, 2014). Accordingly, nurses are expected to have certain kinds of learning skills for managing rapid changes in healthcare settings. Moreover, as nursing is an applied science, nurses need to learn how to transfer their knowledge to practice. Papathanasiou, Tsaras and Sarafis (2014) also noted that nurses' active involvement in their own learning is an absolute prerequisite to lifelong learning.
One of the good strategies for lifelong learning is self-directed learning (Fisher & King, 2010). The concept of self-directed learning (SDL) originates from the Adult Learning Theory. This theory suggests that adults are pragmatic and problem-focused individuals whose learning is mainly affected by experiential rather than passive approaches (Roberson, 2011). SDL is a process in which learners actively participate in identifying their own learning needs, setting learning goals, allocating resources, developing and implementing appropriate strategies and plans, and evaluating learning outcomes either independently or with others' help (Knowles, Holton, & Swanson, 2008). It could help nurses identify their learning needs, plan for fulfilling the identified needs, and turn into independent experts (Montin & Koivisto, 2014). The positive outcomes of SDL include, but not limited to, greater self-control, self-confidence, autonomy, and lifelong learning skills (O'Shea, 2003).
Many studies have been conducted so far in different countries on the concept of SDL, readiness for it, and its effectiveness. The results of an interventional study conducted by Saha (2006) showed that compared with traditional approaches, student-centered learning significantly increased Indonesian students' SDL readiness as well as their accountability for learning. Nokdee (2007) also conducted a qualitative study to explore Thai nurses' experiences of SDL and reported that the main attributes of SDL were greater independence in and responsibility for learning, enhanced problem-solving ability, and improved effectiveness of learning. Moreover, she found that nurses learn through implementing nursing procedures and interacting with patients, colleagues, and physicians. O'Shea (2003) conducted a literature review on SDL in nursing education and found that this concept had different domains including the definition and the entity of SDL, SDL readiness, SDL styles, SDL facilitators, and SDL benefits. O'Shea (2003) also noted that despite great efforts for clarifying the concept of SDL in the last three decades, a comprehensive understanding of the concept is still lacking. Cazan and Schiopca (2014) also conducted a study to examine the relationships among SDL, personality traits, and academic achievements and found that SDL is significantly correlated with academic achievements and personality traits of extraversion and openness. Safavi, Schooshtarizadeh, Mahmoodi and Yarmohammadian (2010) also investigated SDL readiness and styles among 178 Iranian nursing students and reported that 34.3%, 32.6%, and 33.1% of the participating students had respectively high, moderate, and low SDL readiness. However, Karshki, Mohammadzadeh Ghaser, Taghizadeh and Garavand (2013) reported that nursing students' SDL readiness was great.
Despite the wealth of studies on SDL, this concept has not yet been completely clarified and hence, many ambiguities surround it. For instance, terms such as self-planned learning, autonomous learning, project-based learning, independent study, self-teaching, and autodidaxy are used for addressing SDL (Murad & Verkey, 2008). Moreover, most of the previous studies were conducted on nursing students and hence, few studies have dealt with clinical nurses' SDL. On the other hand, learning is greatly affected by culture and social context and therefore, studying SDL in different cultures is needed (Ahmad & Majid, 2010). Nonetheless, few studies have been conducted so far in this area in our country, Iran. This study was designed and done to reduce these gaps. The aim of the study was to explore Iranian clinical nurses' activities for SDL.

Methods
The qualitative content analysis approach was used in this study. This approach deals with inductively developing categories and interpreting textual or verbal data and is used when there is limited knowledge about a certain phenomenon (Cho & Lee, 2014).
The study setting was all four hospitals affiliated to Isfahan Social Security Organization, Isfahan, Iran. The hospitals were located in Isfahan and Najafabad, Iran. All these hospitals included medical-surgical, pediatric, midwifery, and intensive care units at the time of the study. Purposive sampling technique was used for recruiting nurses who had in-depth information about SDL. The inclusion criteria were having a minimum of one-year work experience in clinical nursing, actively participating in continuing education programs, and either holding Bachelor's or Master's degrees or being a postgraduate student in nursing. We kept on sampling until reaching data saturation, i.e. until obtaining no new information from the data (Polit & Beck, 2014).

Data Collection
Study data were collected by carrying out semi-structured personal interviews organized according to participants' preferences. Interviews were conducted in a private room located in participants' workplaces. The length of the interviews ranged from 35 to 115 minutes with a mean of 56 minutes. As immediate documentation of the data is a prerequisite to successful data analysis (Adib- Hajbagheri, Parvizi, & Salsaly, 2013), interviews were immediately transcribed verbatim. The interview opening questions were: Would you please explain your experiences of clinical learning? What do you do for advancing your knowledge and developing expertise? What factors have contributed to your clinical learning? What activities do you perform for promoting your clinical learning? In addition, we employed probing questions for clarifying participants' responses. We reached data saturation after conducting 23 interviews with nineteen participants.

Data Analysis
Study data were analyzed by using the conventional content analysis approach (Graneheim & Lundeman, 2004). This approach is used when the aim is to describe a poorly-known phenomenon. We avoided using predetermined categories and instead let categories emerge from the data (Elo & Kyngas, 2008). Initially, we listened to the interviews and reviewed interview transcripts for several times to immerse in the data and acquire a general understanding of them. This technique helped us identify the meaning units. Then, we read each interview transcript line-by-line and extracted and coded all words, sentences, and paragraphs containing meaning units. The data and the generated codes were constantly compared. Accordingly, codes were categorized according to their similarities. Primary categories were in turn combined to form more abstract categories. Finally, the study theme was generated (Krippendorff, 2013).

Ethical Considerations
This study was primarily approved by the Research Council and the Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran. Before starting the study, we obtained necessary permissions from the administrators of the study setting. Moreover, study participants were informed about the aim of the study, the process of interview, the confidentiality of their information, and the voluntariness of participation in the study. Finally, informed consent was obtained from them.

Trustworthiness
We used the four criteria of credibility, confirmability, dependability, and transferability for ensuring the trustworthiness of the data and the findings (Elo et al., 2014). The credibility of the findings was established by using techniques such as member-checking, prolonged engagement with the study (about two years), and close relationship with the participants. On the other hand, the external peer-checking method was used for enhancing the confirmability of the findings. Accordingly, pieces of the data and the corresponding findings were sent to an experienced qualitative researcher and two PhD students in nursing. They confirmed the soundness of the analyses and provided useful advice. The dependability of the findings was also ensured by exactly documenting all steps of the study. In addition, the maximum variation sampling technique was adopted for enhancing the transferability of the findings.

Findings
Nineteen nurses (thirteen staff nurses, three head-nurses, two supervisors, and one matron) participated in the study. The nurses held either Bachelor's (seven individuals) or Master's degrees (twelve individuals) in nursing. Nine participants were male and ten were female. Participants aged from 25 to 44 with a mean of 32 years. The mean of participants' work experience was eight years with a range of three to nineteen years.
Study participants' activities for SDL were grouped into two main categories including striving for knowledge acquisition and striving for skill development. The main theme of the study was 'Revising personal performance based on intellectual-experiential activities (Table 1). This theme implies that nurses constantly monitor their performance in order to develop their expertise and revise their performance by doing intellectual activities for acquiring knowledge as well as experiential activities for developing their skills. The two main categories of the study are explained in what follows.

Striving for Knowledge Acquisition
This main category encompasses activities which nurses performed in order to collect accurate and credible information for analyzing and evaluating their own performance. The three categories of this main category were sensory perceptions, self-evaluation, and suspended judgment.

Sensory Perceptions
Our participants used sensory stimulations to stimulate their senses and perceive events. Sensory perception is an activity through which a nurse sees, listens, and assesses events from different perspectives. This category included two sub-categories which are explained below.

Careful Observation
One of nurses' activities for SDL was learning through observing patients, colleagues, and physicians. According to our participants, observing the signs and the symptoms of diseases helped them confirm and internalize their already-acquired knowledge. A female nurse having a four-year work experience said,

Self-Evaluation
Self-evaluation is an intentional and masterly activity which necessitates performance evaluation as well as judgment about the effectiveness of one's own performance for finding more effective alternatives. During self-evaluation, our participants assessed their own previous experiences and understood why and how the events happened. The two sub-categories of this category were desire for questioning and reflection on performance.

Desire for Questioning
When being faced with work-related problems, our participants strived to find their underlying causes, challenge the work routines, and review their own knowledge and expertise in order to promote their learning. A male nurse who had a five-year work experience mentioned,

Suspended Judgment
The third category of the first main category was suspended judgment. This category implies using thinking and logic in clinical situations. Suspended judgment is a vital skill for identifying potential risks, establishing early diagnosis by using one's own experience, and evaluating clinical decisions. This category consisted of two sub-categories which are explained below.

Early Risk Identification
Most of our participants mentioned that they employed their cognitive skills and professional knowledge to identify probable risks to patients' health. This screening strategy was implemented in several steps including recognizing the signs and the symptoms of the risk, predicting its probability, making clinical decisions, and developing a care plan. A male head-nurse with a twelve-year work experience expressed, We had a patient in our unit who had experienced an injury to his seventh cervical vertebra (C7

Hypothesis Making
Our participants performed different mental activities such as data collection, hypothesis making, and hypothesis testing to reach an accurate nursing diagnosis. They highlighted that the knowledge which they had gained in university was not helpful to them for making and testing hypotheses. Instead, they had learned these skills through referring to other sources such as their own experiences as well as experienced colleagues and physicians. A male nurse who had a four-year work experience said, I always try to make some hypotheses based on the signs and the symptoms experienced by a patient. For instance, when a patient has tachypnea, I ask myself whether this patient is suffering from oxygen saturation disturbances, or she/he needs a chest X-ray assessment, or this sign is due to other problems such as pain (P. 18).

Striving for Skill Development
The second main category of the study was striving for skill development. This main category covered three categories including apprenticeship, masterly performance, and self-regulation which are explained below.

Apprenticeship
Apprenticeship is a teaching process in which a junior nurse voluntarily chooses to be supervised and trained by an expert colleague. The two sub-categories of this category were learning from an expert colleague and learning support.

Learning From an Expert Colleague
Our participants considered the presence of an experienced colleague in their workplace as an ideal learning opportunity and strived to advance their knowledge, practice clinical skills, and broaden their professional experience under his/her supervision. A female nurse with a work experience of seventeen years expressed,

Masterly Performance
After the apprenticeship step, nurses had strived to independently implement nursing procedures and develop their skills. The two sub-categories of this category were role-modeling and anxiety management.

Role-Modeling
The participating nurses had role-modeled their knowledgeable, experienced, and skillful colleagues who had strong motivation for clinical practice as well as good professional skills such as problem-solving. A male nurse having a work experience of three years mentioned,

Anxiety Management
Primarily, our participants did their work-related activities and performed their tasks while having great anxiety. However, they repeatedly performed their activities and tasks to acquire mastery and manage their anxiety. A male nurse with a work experience of three years mentioned,

Self-Regulation
Our participants tried to efficiently use their attitudes, knowledge and expertise in their daily practice. In other words, their performance was mainly self-regulated. This category consisted of three sub-categories of maintaining a caring attitude, having a subjective care plan, and practicing as a prerequisite to expertise.

Practicing as a Prerequisite to Expertise
Our participants noted that practice, seriousness, and active involvement are the essential prerequisites to SDL. A female participant with an eighteen-year work experience expressed, One of my good experiences was learning cardiac arrhythmias. This was a complex skill which I learned through attending classes, practicing, and observing. However, this did not suffice. The important point was that I had to learn to immediately manage arrhythmias after diagnosing them. I learned how to manage arrhythmias again by practicing in real situations. It is like learning how to drive. Despite having a driver's license, you will not become an experienced driver unless you drive in a city (P. 13).

Discussion
We conducted this study to explore Iranian clinical nurses' activities for SDL. The two main activities of nurses for SDL were striving for knowledge acquisition and striving for skill development. Study findings revealed that participants performed activities such as sensory perception, self-evaluation, and suspended judgment for acquiring and developing their knowledge. These activities are similar to the reflective observation and the abstract conceptualization steps of the Kolb's Learning Cycle. According to Kolb (1981), reflective observation is a step in which a leaner observes, listens, and assesses subjects and ideas from different perspectives in order to find their meanings. On the other hand, abstract conceptualization is the application of thinking and logic for promoting learning. Planning and analysis are parts of abstract conceptualization. Reflective observation and abstract conceptualization are used for assimilating knowledge and experience (Kolb). Accordingly, study participants' activities for acquiring and developing their knowledge can be equated with assimilation learning styles reported by Kolb (1981). Assimilating learners combine reflective observation with abstract conceptualization, use inductive learning, and are more interested in abstract concepts than application (de Oliveira et al., 2015).
One of the sub-categories of the striving for knowledge acquisition category was sensory perception. Activities such as careful observation of patients, colleagues, and physicians' behaviors, active listening, history taking, and participating in nursing and medical rounds were essential to our participants' learning. The results of a qualitative study conducted in Finland also showed that nursing students promoted their learning by observing different patients, particularly patients with new and rare diseases (Suikkala & Leino-kilpi, 2005). Mackey et al. (2014) also reported observation as a major learning style adopted by nursing students. Moreover, Baraz, Memarian and Vanaki (2014) noted that nursing students carefully observe the performance of their clinical instructors, practicing nurses, and physicians for promoting their learning. All these findings confirm that observational learning is one of nurses' strategies for acquiring clinical expertise.
Our findings also revealed that nurses' another activity for SDL was active listening during care provision and ward rounds. Gidman (2013) also noted that care receivers are a valuable source for promoting nurses' learning and hence, active listening to and effective communication with them can help nurses identify their problems and understand their subjective and emotional viewpoints. Gardner, Woollett, Daly, Richardson, and Aittken (2010) also reported ward rounds as a natural environment for patient-centered learning and evidence-based practice.
Study findings showed that the next step to knowledge acquisition was self-evaluation. Our participants described their previous experiences, identified why and how the events happen, questioned routines, and reflected on their own practice to find more effective alternatives. These findings are consistent with Gibbs Reflective Cycle. According to Gibbs, reflection happens in a cyclic pattern which includes the six steps of description, feelings, evaluation, analysis, conclusion, and action plan (Haghani & Sadeghi, 2012). Bulman, Lathlean and Gobbi (2012) also reported that the steps of reflection are sensible perception of experiences, www.ccsenet.org/gjhs Global Journal of Health Science Vol. 8, No. 5;2016 criticism of experiences, and action as a step to reflection. Accordingly, the art of self-evaluation encourages nurses to seek solution for complicated situations during their clinical practice and finally gives them a sense of possession over the acquired knowledge. Moreover, self-evaluation is a means for promoting nurses' critical thinking and clinical judgment (Lasater, 2011) and prepares them for the next step of knowledge acquisition, i.e. suspended judgment.
Suspended judgment was another activity performed by the study participants for SDL. The complexity of patients' conditions as well as nurses' professional experience affected their information processing, critical thinking, and suspended judgment. In other words, nurses' critical thinking was focused on screening, early risk identification, and hypothesis making. These findings are in line with the findings reported by Javadi, Paryad, Roshan, Fadakar and Asiri (2011). They found that nursing students processed information step-by-step to decide upon the likelihood of risks. Kuiper, Pesut and Kautz (2009) also noted that for effective patient management in emergency situations, nursing students need to have a general picture of potential risks, relevant nursing diagnoses, and care plans. Consequently, critical thinking is among the most effective learning strategies and helps nurses make accurate clinical judgments.
The second main category of the study was striving for skill development. Study participants performed activities such as apprenticeship, masterly performance, and self-evaluation for developing their clinical skills. These findings are in agreement with the concrete experience and the active experimentation steps of the Kolb's Learning Cycle (Kolb, 1981). In other words, our participants used the accommodation learning styles reported by Kolb (1981). Concrete experience denotes active involvement, interpersonal communication, and learning through experiences while active experimentation necessitates engaging in the implementation of plans. Accommodating learners are excellent in doing activities and like new experiences (El-Gilany & Abusaad, 2013).
One of the activities performed by the participating nurses for skill development was apprenticeship which implies learning from expert colleagues in a supportive learning environment. Freeling and Parker (2015) also reported that new graduate nurses are not qualified enough for clinical practice and hence, they need to develop their clinical skills through apprenticeship. The findings of a qualitative study done by Eller, Lev and Feurer (2014) also revealed that mutual respect and supportive feedbacks were among the key elements of apprenticeship programs. In apprenticeship programs, junior nurses imitate experienced colleagues and seek knowledge from them. Apprenticeship improves nurses' performance and broadens their professional experience. Carlson (2014) also noted that apprenticeship programs gives rise to critical yet friendly colleagues who evaluate each others' performance while maintaining friendship and mutual trust.
Another activity performed by our participants for developing their skills and promoting their learning was masterly performance which implies role-modeling for better clinical performance. Myrick, Yonge and Billay (2010) also noted that as a requisite skill to ethical patient care, good and punctual practice is acquired through the process of role-modeling. Moreover, the findings of a review study conducted by Baldwin, Mills, Birks, and Budden (2014) indicated that nursing students role-modeled experienced nurses for transferring their knowledge to practice and demonstrating professionalism. Accordingly, nurses need to observe and model experienced role-models' behaviors and receive constructive feedbacks from them for promoting their learning and acquiring professional competence.
After learning from role-models, our participants strived to practice the learned skills in order to manage their anxiety, promote their learning, and improve their clinical performance. Öztürk, Caliskan, Gocmen Baykara, Karadag and Karabulut (2015) also reported a similar finding. They conducted a four-year interventional study to evaluate the effects of regular trainings on nursing students' basic psychomotor skills and found that after their intervention, students were more competent in doing nursing procedures learned in the first year due to practicing the procedures for many times. Moreover, students who were incompetent in doing some procedures had strived to acquire competence by doing those procedures repeatedly.
The final activity performed by our participants for SDL was self-regulation which entails effective use of attitudes, beliefs, and skills in daily clinical practice. The sub-categories of this category were maintaining a caring attitude, having a subjective care plan, and practicing for gaining expertise. Our findings revealed that self-regulation promoted nurses' self-supervision and self-evaluation. Chen, Stocker, Wang, Chung and Chen (2009) also found that nursing students who actively participated in self-regulation activities had more positive attitude towards and deeper pleasure at doing learning activities. Moreover, they found that students gradually developed self-supervision and independence through attending continuing education programs and using the trial and error technique.

Limitations
In this qualitative study, we explored a group of Iranian nurses' activities for SDL. Despite attempting to recruit a maximum variation sample, the study findings cannot be widely transferred to other settings and populations. Further studies are needed for exploring nurses' activities for SDL in other countries and contexts.

Conclusion
Study findings suggest that Iranian clinical nurses perform different self-directed intellectual and experiential activities for promoting their learning. Nurses continually revise their personal performance by performing self-directed intellectual and experiential activities in order to acquire expertise. The process of acquiring expertise is a linear process which includes two key steps of knowledge acquisition and knowledge development.
To acquire and advance their knowledge, nurses perform mental learning activities such as sensory perception, self-evaluation, and suspended judgment step-by-step. On the other hand, they develop their skills through doing activities like apprenticeship, masterly performance, and self-regulation. At any given time, a nurse is on different points of this expertise acquisition process. In other words, she/he may be in the knowledge acquisition step for learning skill A and at the same time, in the skill development step for skill B. The absolute prerequisite to expertise acquisition is that a nurse needs to follow these two steps in a sequential manner.