DE GRUYTER International Journal of Nursing Education Scholarship.

2019; 20180079

Modi Owied Al Moteri1

Self-Directed and Lifelong Learning: A

Framework for Improving Nursing Students’
Learning Skills in the Clinical Context
1 Nursing Department, Taif University, Taif, Saudi Arabia, E-mail: [email protected]

Abstract:
Self-directed lifelong learning is an important competency for nursing students to meet their professional devel-
opment, yet it can be challenging for some students to acquire self-directed learning skills in a clinical context.
A framework based on Hiemstra and Brockett’s “Person, Process, Context” model was developed to promote
nurses’ self-directed lifelong learning. The implication stems from our expectation that the framework can ac-
celerate the development of interpersonal and intellectual skills valuable to a nursing student’s lifelong learning
process.
Keywords: self-directed lifelong learning, collaborative learning, problem based learning
DOI: 10.1515/ijnes-2018-0079
Received: November 11, 2018; Revised: July 19, 2019; Accepted: July 30, 2019

Introduction
Self-directed lifelong learning is an important competency that nurses must acquire during their undergraduate
study as healthcare organizations expect nurses to take responsibility for their own professional development
to achieve excellence in clinical practice.

Background
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Throughout the past few decades, self-directed learning has emerged as an important concept in the education
of nurses (Qalehsari, Khaghanizadeh, & Ebadi, 2017). The interest stems from the fact that self-directed learn-
ing improves the quality of care (Holmboe, Prince, & Green, 2005). If students gain the skills of self-directed
learning, there will be a reduced need for continuous medical education and if these skills are not learned, it
might reduce patient care quality (Qalehsari et al., 2017). Indeed, through self-directed learning skills, nurses
keep up to date and this has the potential to make nurses more fit to practice, leading perhaps to better patient
care.
It is important to understand what self-directed learning is, what it involves, and how it can be enhanced.
Self-directed learning can be described as an active process in which students take the initiative for their own
learning, with or without the assistance of educators (Qalehsari et al., 2017). The definition emphasizes how self-
directed learning strategies empower students to actively search for, analyze, understand and use information to
meet their own learning needs, with the educators working as facilitators in carrying out the learning objectives.
This suggests that self-directed learning is the responsibility of the learner (person) but it also does not suggest
that self-directed learning is a merely learner role. The process of self-directed learning is influenced by both
learner (person) and context (Berkhout, Helmich, Teunissen, van der Vleuten, & Jaarsma, 2018).
Brockett & Hiemstra initially developed theories of self-directed lifelong learning with two dimensions: self-
directed learning process and person attributes (Hiemstra & Brockett, 2012). The process involves the teaching-
learning transaction, learning skills, learning styles, and evaluating abilities … ; and person attributes refer
to the “characteristics of the individual,” such as “creativity, critical reflection, enthusiasm, motivation … ”
(Hiemstra & Brockett, 2012, p 158).  Hiemstra and Brockett (2012) admitted that the two dimensions’ model
underestimated the effect of context on self-directed lifelong learning, consequently, they proposed a “Person,
Process, Context” model (PPC model) in which the three elements are equally important. The PPC model is
Modi Owied Al Moteri is the corresponding author.
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an extension of their earlier model, combined with years of research work in self-directed lifelong learning
literature (Berkhout et al., 2018). The aim is to highlight the context, which was not fully appreciated in the
previous model, as important element in understanding self-directed lifelong learning.
Context may include people involved in the learning process (e. g. student and educator), their interactions
and interpersonal relationships, the learning techniques, the physical environment (e. g. classroom and labora-
tory) in which learning takes place. Berkhout et al. (2018) claim that context is dynamic and can be interpreted
differently by learners. For instance, being alone without direct supervision in clinical placement might be seen
by some students as an opportunity to independently apply and practice their learned skills. By contrast, other
students might see it as limiting their chance to learn because there is no instructor to provide feedback, which
is one of their learning strategies in a clinical placement. Context also entails utilizing technology. Researchers
generally tend to agree that technology has a direct positive impact on students’ interaction, interpersonal
relationships and engagement in the process of learning (Rashid & Asghar, 2016). Although technology is a
powerful tool that can expand students’ learning experiences through enhancing their abilities to retrieve and
share information (Fahnoe & Mishra, 2013, March), it has not been formally included in the curriculum (Al-
suraihi, Almaqati, Abughanim, & Jastaniah, 2016; Rung, Warnke, & Mattheos, 2014). It seems that educators
have ignored the fact that students are no longer those students who were formerly taught with the traditional
methods (Brandon & All, 2010; Candela, Dalley, & Benzel-Lindley, 2006).
Enhancing the development of self-directed lifelong learning strategies necessitates equipping students
with needed intellectual skills to continue learning beyond the end of their formal education (Candy,
1991). Based on Brockett and Hiemstra model (2018), query-based learning approaches, which highlight learn-
ing as being a self-directed, collaborative and contextual, is appropriate  (Sayyah, Shirbandi, Saki-Malehi, &
Rahim, 2017). In query-based learning, the student works to understand an open-ended problem and applies
cumulative knowledge to solve the problem (Sayyah et al., 2017; Stone, Cooper, & Cant, 2013). The approach
requires context to build coherent argumentative dialogues in which students make claims and support their
claims with evidence. This places students as active information seekers. The argumentative dialogue helps
students think and reflect upon their actions, e. g. “why they do what they do” and decisions “why they make
that particular decision” (Walker, 2003). This type of questioning technique builds confidence in students and
decreases students’ anxiety (Stone et al., 2013). It triggers students’ curiosity and reinforces their ability to use
a set of cognition skills that are critical to their lifelong learning (Dinkins, 2015). Researchers tend to agree that
argumentation is collaborative in nature (Dinkins, 2015) and that learning takes place through collaborative
interactions (Palincsar, 1998). Collaborative learning within pedagogical activity has been gaining attention re-
cently (Loes & Pascarella, 2017). Studies on collaborative learning show that the approach enhances students’
critical thinking and skills acquisition (Loes & Pascarella, 2017), and it can be utilized to teach large numbers of
students with less clinical instructor involvement (Stone et al., 2013). Thus, collaborative learning can manage
some challenges facing those involved in clinical placement.
Nursing schools have improved teaching methods to actively engage students in the learning process within
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classroom contexts (Sayyah et al., 2017). By contrast, little is known about how to further enhance self-directed
learning skills in clinical settings (Li, Paterniti, & West, 2010; Qalehsari et al., 2017). This is significant since
a major part of nursing education occurs in authentic clinical setting. The clinical placement experience has
distinctive features not found in classroom or other contexts. Indeed, teaching and learning in a clinical prac-
tice is much more complex. Learning takes place by engaging in activities relating to patient care in which
nursing students are required to constantly care for patients, with each case having different treatment needs.
Therefore, learning is shaped by the interactions of the students within the varying clinical contexts. Yet, not
all students have self-directed learning skills to operate in varying clinical contexts. The need for additional
rigorous research on how to develop self-directed learning skills during clinical practice is obvious (Li et al.,
2010; Qalehsari et al., 2017), but the challenge is how to evaluate this construct. Perhaps underpinning the eval-
uation approach with Hiemstra and Brocketts (2012) model of self-directed lifelong learning, will offer a useful
evaluation method.
In medical education, many researchers have used PPC model to study self-directed lifelong (Sawatsky,
Ratelle, Bonnes, Egginton, & Beckman, 2017), however, to our knowledge, in nursing education, no compre-
hensive model of self-directed lifelong learning – which incorporates process, person, and context — currently
exist. Hence, using Hiemstra and Brocketts (2012) model of self-directed lifelong learning, this study sought
to identify if the current clinical placement at the Nursing Department of a Saudi University helps students to
be self-directed lifelong learners. The resulting data became the basis of the development of a framework for
improving students’ lifelong learning skills during clinical placement.

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Methods
Study design

In this study, the case study methodology was utilized to describe the current clinical training in nursing pro-
gram. A case study is appropriate when the investigator wants to fully understand a particular phenomenon
(Baxter & Jack, 2008) that must be described and illustrated. Case study inquiry is only successful when built
on the collection and analysis of data from multiple sources (Yin, 2003). Triangulation of all data leads to un-
derstanding of the case.

Setting and participants

The current project was carried out in 2017 in the Nursing Department of a Saudi University. The Nursing
Department consisted of twelve lecturers, and four clinical instructors. All the lecturers and two of the clinical
instructors were from the Middle East and the other two were of East Asian descent. It is worth noting here
that the clinical instructors are clinically experienced Registered Nurses (RNs) who are employed by the Faculty
and eventually become Faculty members. The students were all Saudi, and had multiple levels of academic per-
formance. The nursing program is a free-of-charge four-year baccalaureate program and is comprised of eight
levels. In Levels One and Two students study introductory courses and in Levels Three and Four students have
laboratory-based training. Only at Level Five do students start their clinical placement and they are considered
as beginning learners. Therefore, data was collected from Level Six. Level Six included 76 students (41 female
and 35 male) between the ages of 19–21. During clinical placements, the students were divided into groups
ranging from 10–12 students. The average weekly clinical hours for each student was eight (8) hours per week.

Data collection

The data was collected through multiple observations of clinical placements using field notes, records auditing
and interview. The data that resulted from these methods were qualitative. Table 1 provides a holistic picture
of how data were collected, and analyzed in this study.

Table 1: Data collection plan.

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Source Collecting method Type of data Analyzing method

Clinical placement Field notes textual Content analysis
Student assignments Auditing textual Content analysis
Clinical instructors Interviewing textual Content analysis

Field observation

This study involved unstructured observations in which the author observed and recorded students’ clinical
activities for 60 minutes, once for each clinical placement group. The observations were made at any time during
the beginning, middle, and end of the clinical placement day. During each of the 60 minute periods the author
recorded the students’ activities and behavior, clinical instructor behavior, students’ interaction with the clinical
environment, using field notes.

Records auditing

A sample of the students’ clinical assignments were randomly selected and checked for originality using iThen-
ticate program. The originality reports that were generated from the program were reviewed for identifying
patterns. The data that resulted from the auditing process were discussed with the clinical instructors during
the interview phase. Discussions helped in supporting the data.

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Interviewing

Unstructured interviews were conducted with the four clinical instructors whose activities within the students’
clinical placement was observed. The interview aimed to analyze how clinical instructors perceive the students’
behavior, performance, and interaction with the clinical environment.

Ethical considerations

The work began from an interest of the author to carry out an academic intervention plan designed to repair
areas of concern related to self-directed learning. Ethical approval was granted for this study from the research
committee at the university. Informed consent was taken from all the participants before the data collection.
The privacy and confidentiality of the data were considered as the data were collected and manipulated anony-
mously.

Content analysis

Data collected during this study were in the form of narrative text. In order to explain and describe teaching
and learning in clinical placement, an inductive content analysis approach was utilized to analyze the narrative
text (Elo & Kyngäs, 2008).
The content analysis process involves coding, categorizing and forming themes. Coding was done by writ-
ing notes and headings in the text while reading and rereading the written material. Similar codes were then
grouped. Preliminary categories were merged to form more abstract ones. The purpose of creating categories is
to increase understanding of the phenomenon and generate meaning. Finally, the study themes were generated.

Trustworthiness

The credibility and confirmability of the study findings were obtained using external peer checking. To do so,
findings were checked with an experienced qualitative researcher. The researcher approved the results and
gave some useful suggestions. Meanwhile, dependability of the findings was obtained through precise docu-
mentation of the steps of the study.
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Results
Field notes

The analysis of field notes revealed that students were seldom given autonomy in clinical practice. For example,
students could not choose independently the case or the sequence and the amount of time invested in the clinical
case. It was noticed that training was conducted in a ways that do not encourage them to learn by themselves.
Further, the analysis of field notes revealed that some students never asked questions or sought answers when
they were unsure about something. Some students were not able to answer challenging question, no matter
how important the question. The engagement level was insufficient. However, they were good at answering the
non-challenging questions that did not require thought. Even in the practicing phase of the psychomotor skills,
it was difficult to arouse their interest. Indeed, they seldom took the initiative to practice their learned skills.

Records auditing

Thirty-six originality reports were audited. The analysis of originality reports showed that the similarities score
ranged from 21 % to 86 %. Nursing, diagnosis, interventions and outcomes were found to be the most copied
sections. Matches were linked to internet sites.

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Interview

Analysis of the data revealed four themes that describe the current clinical placement status: limited time for
direct observation and training, dependent learners, unintentional plagiarism and lack of motivation.
Theme 1: “Limited time for direct observation and giving feedback”
All instructors expressed their concern that the limited time in clinical placement might have impacted the
student’s opportunity to learn. In this regard, some expressed concern that teaching was not always optimal for
students because of the many teaching tasks and the limited timeframe. Some clinical instructors also reported
that they may have had insufficient time to apply direct supervision or obtain feedback. Clinical instructors’
concerns were as follows:

”… .’We keep running here and there’. ‘Teaching’. ‘Supervising’. ‘Explaining’. ‘Evaluating’. ‘Paper work’. ‘No
time to set with all the students to reflect on their practice because tasks aren’t going to get done’..”

Theme 2: “Dependent learners”

Almost all instructors reported that students were instructed to attend procedures with staff nurses if their
clinical instructor was busy elsewhere. Students were advised to discuss their observations and feedback with
the instructors later or at the end of the practice day. However, many students failed to take this step and waited
for the instructors to tell them what to do and when. They viewed the clinical instructor as the definitive and
the only source of knowledge. Instructors made many comments in this regard, such as the following:

”..’They (students) depend on me for their training and I need to take that into account’ … . ’they always wait for
me to explain things to them’ …”

Theme 3: Unintentional plagiarism

Clinical instructors reported that they found many students´ assignments such as nursing care plans (NCP)
to be copied from references. The analysis of students´ NCPs originality reports confirmed this finding. This
issue has been raised several times during course coordinators and clinical instructors’ meetings. Most clinical
instructors commented as follows:

”..’I know they (students) copy information’ … . ’they had no desire to work hard’. ‘Copying from the internet is
easy.‘ … ’maybe they (students) are not confident about their own thoughts’...”

Theme 4: Lack of motivation

Clinical instructors reported that they found many students are not interested in answering challenging
questions and they get tired of answering too many questions. They passively receive information. The analysis
of field notes confirmed this finding. An example of clinical instructors’ comments were as follows
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… it is habit … I believe this (giving them the information they need) has decreased their willingness to search for
information’.

Integration of the study results

The results clearly indicated that, in this University, the current clinical placement does not help nursing stu-
dents to be self-directed lifelong learners. The study used Hiemstra and Brocketts (2012) “Person, Process,
Context” model as a theoretical lens to guide the final analysis. As shown in Table 2, the integration of the
study results has identified three main barriers to self-directed learning among nursing students. To build
upon existing evidence and develop a framework for nursing students self-directed learning, active-learning
literature was comprehensively searched for evidence-based teaching and learning methods. The author has
experience in searching literature for evidence.  The combination of Hiemstra and Brockett’s (2012) model and
active learning approaches were used to develop a framework to encourage self-directed learning among nurs-
ing students. The framework was then presented and discussed in one of the nursing department meetings.
Academic staff were given the chance to discuss the framework and make comments. Academic staff approved
the framework and suggested minor changes. It was an iterative and reflexive process as the framework was
reviewed, modified and approved. The following section will discuss the proposed framework.

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6
Table 2: Barriers to develop self-directed learning skills.
Al Moteri

Dimension Barrier Supported data Overcoming the barrier

Process No “back and forth” “….’We keep running here and there’. ‘Teaching’. ‘Supervising’. Create back and forth” learning process through problem based
teaching/learning experience ‘Explaining’. ‘Evaluating’. ‘Paper work’. ‘No time to sit with all the learning (Sayyah et al., 2017) and collaborative argumentation
students to reflect on their practice because tasks aren’t going to get (Evagorou & Osborne, 2013)
done’
Person Nursing students’ own “They (students) depend on me for their training and I need to take Promote self-confidence through interactive collaborative
dependency and lack of that into account…. they always wait for me to explain things for learning (Loes & Pascarella, 2017)
self-confidence them…”
“…it is habit… I believe this (giving them the information they need)
has decreased their willingness to search for information’.
“’I know they (students) copy information….. they had no desire to
work hard’. ‘Copying from the internet is easy. ‘…maybe they
(students) are not confident about their own thoughts’
Context Passive training methods which The analysis of field notes revealed that students were seldom given Use active training methods such as Socratic Method (Dinkins,
make nursing students passive autonomy in clinical practice. For example, students could not choose 2015). Increase students’ engagement through guided social
learners independently the case, the sequence and the amount of time invested interaction (Hurst et al., 2013)
in the clinical case. It was noticed that training was conducted in ways
that do not enhance them to learn by themselves.

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A Framework for improving students’ self-directed learning

Based on active learning literature and guided by Hiemstra and Brockett’s (2012), the author proposes an Active
Clinical Training Approach (ACTA) for nurses self-directed lifelong learning. The idea of ACTA focuses on
learners who must construct knowledge to learn effectively. ACTA connects the process of generating new
knowledge to the social activities within clinical context, with an emphasis on student’s personal attributes. This
connectedness supports the formation of interpersonal and mental models to develop self-directed learning
habits (Yew & Goh, 2016).

ACTA Framework
ACTA of self-directed learning in nursing education is built upon Hiemstra and Brocketts (2012) elements and
the pedagogical activities for active learning. ACTA includes aspects of process, context and person in which
each element presented in the framework has a set of active learning strategies and skills for the formal process
of self-directed learning. The framework focuses specifically on the influence of ACTA’s implementation on
students’ development of self-directed learning skills in clinical context.
(1) Creating “back and forth” teaching/learning process. The process begins when a patient case study
exposes students to challenges, with queries and opportunities to problem solve (Holden, Rivera-Rodriguez,
Faye, Scanlon, & Karsh, 2013). A case study is an inquiry based modality that can trigger the process of learning
(McLean, 2016). It is an active-learning strategy that can help students develop critical thinking and problem
solving skills while increasing their knowledge and confidence (Brandon & All, 2010). In a clinical context,
problem solving is defined as the process of exploring of a problem to reach a solution and identifying learn-
ing opportunities that appear in the process of reaching the solution. Problem solving is a critical soft skill in
medical education (Ibrahim, Al-Shahrani, Abdalla, Abubaker, & Mohamed, 2018) and is a knowledge inten-
sive process. During such a process, knowledge is continuously stored, retrieved, related, organized, analyzed,
modified and used, to generate new knowledge (Whalen & Samaddar, 2004). Processing information makes
knowledge meaningful so that new knowledge could be developed (Yilmaz, 2011). Problem solving is an in-
teractive learning process that enhance the development of self-directed learning skills (Yew & Goh, 2016). On
the one hand, problem-solving allows students to handle the challenges in order to answer the queries (Burns,
Beauchesne, Ryan-Krause, & Sawin, 2006). On the other hand, through the argumentative dialogues, students
will have the opportunities to critically solve a problem, provide evidence and receive feedback. Hence, it is a
dynamic process that change as the learning context change.
(2) Active confident learner. The person aspect, which includes confidence and becoming autonomous, can
be enhanced through interaction and collaboration . Collaboration is a positive, confidence-building social ac-
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tivity. Interaction builds up an active, self-conscious and autonomous student attitude, supported by interac-
tive relationships within the social context. Interaction and collaboration between students’ groups can increase
students’ self-efficacy (Pålsson, Mårtensson, Swenne, Ädel, & Engström, 2017). Self-efficacy refers to one’s own
feeling when performing tasks. High self-efficacy in the nursing context refers to the feeling of confidence to
manage clinical context challenges.
(3) Active training methods. The educator needs to adopt appropriate training techniques to ensure inter-
active learning context. This can be achieved through using ‘Socratic Technique. Within the patient case study,
students interact with the educator, who becomes the facilitator. Meanwhile, problem solving serves as an im-
portant anchor for the students’ interaction with the clinical environment. Further, the social interaction with
colleagues, patients and the health care team enables knowledge to be transferred from one individual to an-
other (Loes & Pascarella, 2017). Sharing and reviewing information is a kind of collaborative, brainstorming
exercise between colleagues with mutual benefits.

Application of ACTA
ACTA can be easily applied into clinical settings. To assure that standardized expectations are met, the clinical
instructor collaborates with the course coordinator to integrate ACTA prior to the clinical rotation. The primary
expectation is that students will actively participate in the learning experience. The application of ACTA is
composed of six steps. (i) the student selects a patient case; (ii) the student collects information about the patient.
This can be achieved through using patients’ records, textbooks, journals, and technology. The technology such
as smartphone and tablets allows students to have online access to the most recent scientific evidence of nursing
practice (Jebraeily, Fazlollahi, & Rahimi, 2017). However, to prevent the negative impact of technology on the
training experience, it is important to identify when and for how long the smartphones and tablets should

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be used (Wu et al., 2013); (iii) the student is then encouraged to write a short outline or brief report detailing
the signs and symptoms, diagnosis, treatment, and follow-up of the patient case; (iv) and to briefly present
the patient case to the clinical instructor; (v), during the presentation, the student is cognitively challenged to
provide supporting information to defend their findings. For example:
The student identifies a health problem and the clinical instructor may state, “What do you think?” The
clinical instructor may continue to probe for further information by asking the student a question such
as, “What led you to that assumption?” This kind of argumentative dialogue enhances critical thinking
abilities that will help them learn the strategies to become lifelong learners (Walker, 2003). It further,
allows the instructor to correct any misconceptions that the student may have and to assess the students’
intellectual abilities to transfer previous knowledge into a new situation,
(vi) the students will then have post-conferences in which the student takes the lead, sharing the information
with their colleagues. A student chooses the style of presentation and leads the group discussion in the active
learning exercise. Once sufficient engagement is demonstrated, students can be trusted to perform tasks with
distance supervision or without direct supervision (Berkhout et al., 2018). Trust is likely to nourish feelings of
autonomy (Berkhout et al., 2018). The above mentioned six steps of the ACTA application, promote students’
interaction in the clinical practice and provide opportunities to learn and share knowledge.

Discussion
The current study was aimed at identifying if the current clinical placement at the Nursing Department of a
Saudi University enhance students’ autonomy to be self-directed lifelong learners. Several issues were identified
that can adversely affect students’ self-directed lifelong learning in a clinical context. These issues are consistent
with those found in the literature. For instance, although providing direct observation and giving feedback are
essential components of the learning process in health professions (Gordon, 2003) studies found that little time
is spent conducting direct observation and training during clinical placements (Smith et al., 2017). In fact, stu-
dents are rarely observed or assessed doing certain important clinical tasks (Smith et al., 2017). Giving feedback
helps in identifying clinical deficiencies and increases learners’ confidence and competence both of which are
important in student nurses´ lifelong learning (Qalehsari et al., 2017).
“Dependent or passive learners” was another learning issue raised in the present study. This is understand-
able because many of students’ in their early years of education were likely to be in a typically Middle Eastern
teacher centered learning culture (Filatova, 2015), and students have adjusted their own learning strategies to
this. They know the importance of self-directed learning but due to a lack of the required skills to manage their
own learning, students struggle in this regard.
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The medical profession in general and nursing in particular is a profession where ethics are vital (Smedley,
Crawford, & Cloete, 2015). Students may not be aware that copying information from a website is considered
plagiarism. Indeed, a study conducted by Kim, and his colleagues (2016) found that 62 % of medical students
included in a study copied their assignment from different resources and these students were not aware that
they had plagiarized. Self-directed learning might reduce plagiarism as students work on an authentic health
problems of their own finding.
One desired outcome from the undergraduate nursing program is a nurse who has a self-directed learning
style. However, the outcomes of self-directed lifelong learning are greatly affected by the motivation of the
learner and this can only be achieved through intrinsic motivation (Bodkyn & Stevens, 2015). Intrinsic motiva-
tion needs psychological traits such as autonomy and a feeling of competence (Berkhout et al., 2018, p 39). Thus,
the challenge for the nursing educators is to foster the development of self-directed lifelong learning skills so
that students may become responsible and autonomous learners.
The application of ACTA is expected to accelerate the development of both intellectual and cognitive skills
and the ability to learn opportunistically. These skills are necessary to self-directed lifelong learning and will
allow students to develop competencies leading to the enhancement of autonomy. Several studies have empha-
sized that nursing students need to feel like a nurse in a clinical context (Dinkins, 2015).
Despite the change in nursing education, many nursing educators continue to view themselves as the main
player of teaching and the primary transmitters of knowledge in the clinical sites (Brandon & All, 2010; Can-
dela et al., 2006). Clinical instructors must be capable to equip nursing students with the skills required to be
independent learners. A fundamental challenge is transforming students from passive to active participants in
a collaborative learning environment. This can be only achieved through changing the control of learning from
educator to the student. Educators who practice quality improvement and explore approaches that enhance
self-directed learning such as case studies, problem solving, and collaborative learning can overcome the chal-
lenges of the teaching-learning process. Collaboration between courses coordinators and clinical instructors to

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develop teaching and training to institute best practices for actively engaging students is an important step in
the reform of nursing students clinical training for nursing students.
Preparing students to be self-directed learners and autonomous actors, to care for patients in complex en-
vironments where things tend to go wrong if not intelligently adjusted is essential (Habimana, Tuyizere, &
Uwajeneza, 2016). Skills such as communication, problem solving and critical thinking, social interaction are
fostered by ACTA. For instance, the interaction of students with patients/relatives, healthcare providers and
clinical instructors, can improve communication skills. Searching for information independently and taking the
initiative to participate in clinical activities on the ward can assist in developing lifelong learning skills. Involv-
ing students in an argumentative discussion helps students to develop problem solving and critical thinking
skills. Further, involving students with peer-discussion and obtaining peer-feedback will allow students to gain
social skills that will support their success in practicing nursing and maintaining patient safety (Barton, 2009).
Using smart mobile devices allows students to practice the use of technology resources, a tool that is becoming
valuable to the contribution in improving the quality of care (Vafa & Chico, 2013).

Study limitation
The study has several limitations. Interviews with more clinical instructors would provide more validity and
reliability in the findings. An important key limitation is that we did not interviewed nursing students, however
we observed the students’ activities and behavior and their interaction with clinical instructors.

Conclusion
There is agreement that a critical component of being a qualified nurse is to have self-directed learning skills.
Therefore, if these skills are to be fostered in the clinical context, undergraduate nursing training programs
must enhance the development of both intellectual skills and the ability to learn opportunistically. ACTA may
accelerate the development of skills valuable to a nursing student’s lifelong practice. Under this approach,
training will enhance students´ ability to take advantage of practice opportunities, apply inquiry techniques,
construct meaningful conclusions and demonstrate understanding of concepts. The approach therefore instills
a sense of responsibility in nursing students for their own learning.
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