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Exploring the Cultivation of Self-Regulated Learning (SRL) Strategies Among

Pre-Clinical Medical Students in Two Medical Schools

Article  in  Medical Science Educator · December 2019

DOI: 10.1007/s40670-019-00894-z

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Medical Science Educator
https://doi.org/10.1007/s40670-019-00894-z

ORIGINAL RESEARCH

Exploring the Cultivation of Self-Regulated Learning (SRL) Strategies

Among Pre-Clinical Medical Students in Two Medical Schools
Shuh Shing Lee 1 & Dujeepa D. Samarasekera 1 & Joong Hiong Sim 2 & Wei-Han Hong 2 & Chan Choong Foong 2 &
Vinod Pallath 2 & Jamuna Vadivelu 2

# International Association of Medical Science Educators 2019

Abstract
Purpose Research has shown that many undergraduate students struggle with self-regulated learning (SRL) in clinical year as
they are insufficiently supported by the staff in the early year to prepare them for the transition. Hence, this study aims to find out
the SRL strategies and the approaches that could promote SRL among pre-clinical students in two medical schools.
Method This is a mixed-method study. The Motivated Strategies for Learning Questionnaire (MSLQ) was used to collect student
SRL strategies while semi-structured interviews with faculty members and focus group discussions with students were used to
gather data on the approaches that promote SRL. Student MSLQ was analysed using descriptive statistics while interviews were
transcribed verbatim and thematically analysed.
Results A pilot using MSLQ with 413 students recorded a Cronbach’s alpha of 0.928 for the questionnaire. The actual study
involved 457 Years 1 & 2 students. Students from both institutions are motivated by the Task Value, and they use Elaboration and
Organisation strategies the most in their pre-clinical year. Three themes emerged from the qualitative analysis of this study:
characteristics of strategies that promote SRL, hindrance in promoting SRL, and opportunities in promoting SRL.
Conclusions Our findings indicate that students’ intrinsic motivation is generally high in pre-clinical year. However, metacog-
nition and critical thinking strategies will need to be enhanced among students. Despite knowing teaching and learning ap-
proaches could promote these strategies, many teachers are still not confident in doing so and hence training dang sharing best
practices might be helpful in promoting SRL.

Keywords Self-regulated learning . Teaching and learning . Metacognitive . Self-efficacy

Introduction self-regulated learner. A self-regulated learner strives to con-

Self-regulated learning (SRL) involves complex aspects of
cognitive, metacognitive, behavioural, motivational and
emotion/affective in learning. Zimmerman described learners
who are self-regulated are metacognitively, motivationally
and behaviourally active participants in their own learning
process [1]. Pintrinch [2] illustrated three characteristics for a
* Shuh Shing Lee
medlss@nus.edu.sg
1
Centre for Medical Education, Yong Loo Lin School of Medicine,
National University of Singapore, 21 Lower Kent Ridge Rd,
Singapore 119077, Singapore
2
Medical Education and Research Development Unit, Faculty of
Medicine, University of Malaya, Wilayah Persekutuan, Kuala
Lumpur, Malaysia
trol their behaviour, motivation and cognition. Secondly, s/he
sets a goal or target for him/herself to accomplish. The final
characteristic is the learner must be in control of his/her action.
SRL has been drawing educators’ and psychologists’ attention
for the past four decades, and many have conducted extensive
research in this area since then. The benefits and importance of
SRL and its impact on the practice of doctors and quality of
care delivered have been well documented in medical educa-
tion [3–9]. To illustrate this connectivity, it is a mandatory
regulation in most practice settings as well as a societal obli-
gation to engage in Continuous Professional Development
activities to stay updated with the latest information to main-
tain certification or to improve their competencies. This would
assist in providing optimum care to their patients. Therefore, it
is important to manage one’s learning by setting goals,
assessing their learning, reflecting on one’s own performance
and then closing any gaps by engaging in appropriate learning

activities. This is aligned with Pintrich’s description of a self-
regulated learner.
Although SRL has been broadly explored for the past few
years in medical education, most literature focuses on students
in clinical phases of learning or residents in specialty training
[10–15]. This could be due to several reasons. Firstly, SRL is
critical during clinical or residency phase due to the dynamic
learning environment where systematic and structured teach-
ing is minimal. Secondly, most learning occurs in the work-
place rather than in classrooms [16] and the learners have a
great deal of control over their own time to strategies on what,
where, when and how to learn in their workplace. As com-
pared with the SRL research published in medical education,
investigating student strategies or initiatives that promote SRL
in formative pre-clinical years is somehow limited. With much
emphasis of SRL in clinical or residency training, research still
suggests that most physicians feel unprepared to do so [14, 17]
or they may be unskilled at certain aspects of self-regulation
[18]. Many undergraduate students voiced their struggle with
SRL because they are insufficiently supported by the staff or
lack of initiatives focusing on SRL in the early stage to prepare
them for the transition from non-clinical to clinical phases of
learning [19]. Consequently, most students enter the clinical
setting with sufficient knowledge and clinical skills, but un-
able to function effectively in the new learning environment,
where they need to adapt to the unpredictable and rapidly
changing environment posing a challenge to use appropriate
SRL strategies [16, 20].
Developing self-regulated learning is a long-term process
as highlighted by Pintrich’s work. Learners need time and
opportunity to develop and practice SRL over time.
Therefore, fostering of SRL needs to be planned and
operationalised as early as the learners enter medical school.
Introducing SRL during classroom learning where the envi-
ronment is not as complex in clinical setting is the most ap-
propriate to nurture SRL at the early stage. Guided instruc-
tions could be easily integrated in classrooms by giving cor-
rective feedback to the learners and helping them go back to
the proper path before becoming independent self-regulated
learners. Nonetheless, a different interpretation of the initia-
tives or approaches in fostering SRL among teachers has at-
tributed to lack of support to the students. Some medical
teachers assumed that designing an independent learning ac-
tivity within a learning environment is sufficient to drive the
student’s SRL [9]. This is with the assumption that it is entire-
ly within the learners’ ability and that faculty members play
little or no role in guiding student SRL [21]. Numerous rec-
ommendations from educational research suggest that facili-
tating, prompting, modelling, reflecting or explaining help
learners to realise their learning processes and utilise appro-
priate SRL strategies in their daily learning context subse-
quently. However, there is a lack of evidence in published
literature to understand the actual teaching and learning
Med.Sci.Educ.
approaches the teachers utilised to support SRL, especially
during the pre-clinical year. Given the above gaps in the liter-
ature, this study aimed to examine SRL strategies among pre-
clinical students in two medical schools and to identify ap-
proaches that foster student SRL during their pre-clinical year.
The findings will be useful to inform and provide relevant
faculty development for faculty members on learning oppor-
tunities that support SRL in medical schools so they could
better prepare the students for a smooth transition from pre-
clinical to clinical years.
Methodology
This study employed a sequential explanatory design in a
mixed method approach. This design allows the researchers
to collect the quantitative data followed by qualitative data to
further explain and interpret the findings [22]. The section
below will describe the settings, sampling of participants, data
collection and data analysis.
Study Instruments (Quantitative)
We utilised the Motivated Strategies for Learning
Questionnaire (MSLQ) by Pintrich and DeGroot (1990) [23]
to explore students’ SRL. This 81-item, 7-point Likert scale
questionnaire had been validated in many previous studies
globally with high internal consistency for all MSLQ items
together (Cronbach’s α ≥ 0.90) and for each domain
(α ≥ 0.60) as well as well-established confirmatory factor
analysis and predictive validity [24–26]. The questionnaire
consists of two sections: Part I, Motivation (31 items in 6
subscales), and Part II, Learning strategies (50 items in 9 sub-
scales). Some of the phrasings were amended to suit the med-
ical education context in this study. For instance, question
20—“I’m confident I can do an excellent job on the assign-
ments and tests in this course” was amended to “I’m confident
I can perform excellently on the assessments in this course”
since completing assignments is not relevant in the context.
The content was discussed through several rounds of dis-
course among the researchers in this study as well as validated
by two experts in this field. The list of amended questions is
shown in the Appendix Table 4. After the adaptation of the
items in the MSLQ questionnaire, a pilot was carried out to
find out the reliability of the questionnaire before the use of
this questionnaire in the actual study. This is reported in
“Results”.
Qualitative Data Collection
For the qualitative part of the study, we employed a semi-
structured individual interview with faculty members and fo-
cus group discussions (FGDs) with the students. Individual
Med.Sci.Educ.
interviews were used as the researchers intended to probe in-
depth on SRL and student learning. The importance of these
interviews is to explore in detail the experiences, motives and
opinions of others and learn to see the world from perspectives
other than their own [27]. In the interview, the interviewer
initially asked open-ended questions, with subsequent probes
where necessary. Such questions provided an in-depth oppor-
tunity for discussion on institutional culture affecting the med-
ical curriculum, in particular, on SRL and student learning. A
focus group discussion is a semi-structured group session,
moderated by a group leader, held in an informal setting, with
the purpose of collecting information on a designated topic
[28]. Data generated by focus groups were based on a group
of participants and hence may not represent the perspectives
of each participant [29]. Students were informed of the FGDs
via student bulletin (UM) or email invitation (NUS) as well as
the class representative for each year. Faculty members were
invited for the interviews via email. Students and faculty
members who volunteered to be involved were contacted
and briefed about this study before completing the informed
consent form. An interview guide with probing questions was
used during the individual interviews and focus group discus-
sion process. Both qualitative data collection methods were
conducted by the research team members who were trained
and experienced in qualitative research interviews. The ses-
sions were audio-recorded with a research assistant present as
a note-taker.
Subjects
This research was jointly conducted at the Centre for Medical
Education, the National University of Singapore (NUS) and
the Faculty of Medicine, University of Malaya (UM). Both
institutions are public universities which offer a 5-year
Bachelor of Medicine and Bachelor of Surgery (MBBS),
with an annual intake of approximately 300 and 150
students graduated from secondary schools, respectively.
Their age at admission to medical school is between 17
and 20 years.
For the quantitative part of the study, all year 1 and year 2
students in both institutions were invited to complete the pilot
as well as the actual data collection of the questionnaire.
For the qualitative part of the study, the researchers used
purposive sampling to recruit participants (students and facul-
ty members) for the study. The students who took part in the
focus group discussion have to be pre-clinical students while
only pre-clinical faculty members who have been teaching for
at least 5 years were offered to take part in this study. Data
collection through individual interviews of faculty members
and FGDs of students continued until data saturation has been
achieved or no new information is being uncovered and re-
dundancy is achieved [30, 31].
Data Analysis
In the quantitative section, quantitative data analysis was per-
formed using IBM SPSS® Version 24 Software. Both descrip-
tive and inferential statistics were employed. The reliability of
the entire questionnaire as well as its subscales was assessed
using the Cronbach’s alpha reliability test. A descriptive anal-
ysis was carried out to understand the SRL strategies utilised
by the pre-clinical students. Mean and standard deviations
were computed for each subscale.
In the qualitative section, all interviews were transcribed
verbatim and thematically analysed. The transcriptions were
sent to the interviewees for member checking to ensure the
trustworthiness of the data. First, the authors from both uni-
versities endeavoured to make sense of the data by carefully
reading all the verbatim transcripts. The interview transcripts
were initially coded line by line by two coders separately in
their respective institution in order to grasp participants’ per-
spectives about the topic of interest. In the coding process,
interview transcripts were broken down into small meaningful
units and a coding system was used to identify meaningful
units. Each unit was given a label according to the content
they signify. Then, the authors put together the data that were
similar in meaning to generate codes and then the categories.
To identify categories, codes were clustered based on their
shared concepts, and then they were labelled as categories.
The discrepancies in the coding or categories were resolved
through a discussion until consensus was reached. The codes
were presented and refined at each research team meeting
within the institution before another round of discussion was
carried out between the institutions. Finally, categories were
reviewed to identify significant broader patterns of meaning
which is the themes. The themes were further refined which
involved splitting or combining the categories after two
rounds of discussions. Data analysis was conducted iterative-
ly, with data collection continuing until no new information
was gathered or data saturation was reached [30]. Constant
comparative procedure was used to compare the similarities
and differences from different transcripts to form core catego-
ries and eventually themes.
Results
A total of 413 responses (234 from NUS and 170 from UM)
were collected from both institutions for the pilot. Cronbach’s
alpha for the entire questionnaire was 0.928 for a sample of
n = 413 while alpha for the subscales ranged from 0.468 to
0.865. However, 4 items of the original questionnaire with
low item to total correlation were removed to improve the
reliability of the subscale(s). The items which were omitted
to improve the reliability as well as the 15 MSLQ sub-
scales and the subscales’ corresponding coefficient
 Med.Sci.Educ.

alphas of the questionnaire used for the actual study are
indicated in Table 1.
After omission of those low reliability questions, the ques-
tionnaire is administered to Y1 and Y2 medical students and
457 responded to the questionnaire (217 and 240 from NUS
and UM respectively). The descriptive results for NUS and
UM for each subscale is shown in Table 2.
For motivation subscales, the lowest-rated subscales were
extrinsic goal orientation for NUS while UM scored the low-
est in self-efficacy for learning and text anxiety. Both institu-
tions also scored the highest for Task Value with a mean of
5.83 and 5.93 respectively indicating students are motivated
by how interesting, important and useful the task is.
For learning strategies subscales, students from both insti-
tutions claimed that they use elaboration and organisation
strategies the most. Critical thinking and metacognitive self-
regulation are prominent strategies in medical training; how-
ever, they were rated as less utilised strategies by the pre-
clinical year students. Under peer learning, students in NUS
indicated that they are willing to help other students when they
are being approached (Mean item no.34 = 5.70) or completing a
task (Mean item no.45 = 4.90), but only some of them will set
aside time to discuss course material in a group for study
purpose (Mean item no.50 = 3.95). Moderately low rating for
item 58 (I ask the instructor to clarify concepts I do not un-
derstand well) as compared with other items in Help Seeking
has reduced the mean score in the subscale. The data also
revealed that the time and study environments are not well-
managed and regulated by the UM students (mean for Time/
Study Environmental Management is 4.91) as compared with
other strategies. Help Seeking was rated lowest (i.e. a mean of
4.85) by UM students, and its mean is almost similar to NUS
students (i.e. a mean of 4.89). In contrast, the UM students are
more open and responsive to Peer Learning as compared with
NUS students although both schools employ some forms of
small group peer to peer learning activities such as problem-
based learning (UM), collaborative learning cases (NUS) and
near peer teaching.
For NUS and UM, a total of 3 focus groups (nNUS = 15;
nUM = 16) of year 1 and 2 students took part in the discussion
while 10 (NUS) and 12 (UM) pre-clinical faculty members
were volunteered to take part in this study. There are three
themes that emerged from the qualitative analysis of this
study. The themes are (a) Characteristics of strategies that
promote SRL, (b) Hindrance in promoting SRL and (c)
Opportunities and initiatives in promoting SRL. Contexts of
both NUS and UM will be presented, and a summary of the
themes is illustrated in Table 3.
Theme 1: Characteristics of Strategies that Promote
SRL
Theme 1 is the major focus of the qualitative data collected as
this was constantly brought up by the interviewees (teachers

Table 1 Items within the 15

MSLQ Subscales and the Scale Items in the subscale ɑ if item ɑ if item not
Subscales’ Corresponding removed removed
Coefficient Alphas
Motivation subscales
1. Intrinsic Goal Orientation 1, 16, 22, 24 0.615
2. Extrinsic Goal Orientation 7, 11, 13, 30 0.806
3. Task Value 4, 10, 17, 23, 26, 27 0.796
4. Control of Learning Beliefs 2*, 9, 18, 25 0.654 0.532
5. Self-Efficacy for Learning & 5, 6, 12, 15, 20, 21, 29, 31 0.865
Performance
6. Test Anxiety 3, 8, 14, 19, 28 0.628
Learning strategy subscales
1. Rehearsal 39, 46, 59, 72 0.631
2. Elaboration 53, 62, 64, 67, 69, 81 0.757
3. Organisation 32, 42, 49, 63 0.697
4. Critical Thinking 38, 47, 51, 66, 71 0.750
5. Metacognitive Self-Regulation 33r, 36, 41, 44, 54, 55, 56, 57r, 61, 0.703
76, 78, 79
6. Time/Study Environmental 35, 43, 52r, 65, 70, 73, 77r, 80r* 0.549 0.387
Management
7. Effort Regulation 37r, 48*, 60r, 74 0.526 0.454
8. Peer Learning 34, 45, 50 0.468
9. Help Seeking 40r*, 58, 68, 74 0.675 0.553

Items marked with an “r” are reverse coded

*Items 2, 40r, 48 and 80r were removed to increase the reliability of the questionnaire
Med.Sci.Educ.

Table 2 Descriptive statistics for

each component in MSLQ Scale NUS UM
Mean (SD) of all Mean (SD) of all
student responses student responses

Motivation subscales
1. Intrinsic Goal Orientation 5.32 (± 1.17) 5.48 (± 0.77)
2. Extrinsic Goal Orientation 4.30 (± 1.59) 5.36 (± 1.07)
3. Task Value 5.93 (± 0.97) 5.83 (± 0.71)
4. Control of Learning Beliefs 5.56 (± 1.14) 5.59 (± 0.77)
5. Self-Efficacy for Learning & Performance 4.43 (± 1.22) 4.89 (± 0.91)
6. Test Anxiety 4.36 (± 1.64) 4.76 (± 0.91)
Learning strategy subscales
1. Rehearsal 4.74 (± 1.42) 5.08 (± 1.07)
2. Elaboration 5.35 (± 1.13) 5.53 (± 0.83)
3. Organisation 5.38 (± 1.27) 5.34 (± 1.00)
4. Critical Thinking 4.49 (± 1.37) 5.06 (± 0.85)
5. Metacognitive Self-Regulation 4.48 (± 1.36) 4.96 (± 0.76)
6. Time/Study Environmental Management 5.07 (± 1.39) 4.91 (± 0.65)
7. Effort Regulation 5.02 (± 1.37) 5.03 (± 0.95)
8. Peer Learning 4.85 (± 1.30) 5.30 (± 0.88)
9. Help Seeking 4.89 (± 1.41) 4.85 (± 0.84)

The italicized numbers and words are subscales with highest or lowest mean

and students). Instead of identifying specific approaches that
promote SRL, both students and lecturers shared the charac-
teristics of the strategies that promote SRL. These character-
istics include small and collaborative group learning, reflec-
tive or questioning method being employed, guidance from
the teachers, clinical immersion, flexible use of technology
with proper instruction and non-threatening learning environ-
ment. Data reveals that reflection should be included as a part
of the teaching and learning processes which encourage stu-
dents to explore more at their own time. While students would
like to have some autonomy in learning, they would also like
to have guidance from the teachers, at least in providing the
“structure” or “foundation”. Similarly, students considered
clinical sessions and problem-based learning (PBL) as good
teaching and learning methods that could promote SRL in
Malaysia. This is aligned with the characteristics mentioned
above, which are small, collaborative group learning, with
clinical immersion and guidance from teachers.
At both the institutions, students’ perceived technologies such
as the use of recorded lectures, Webcasts and e-learning plat-
forms are an effective way to promote SRL due to its flexibility.
However, students preferred some guidance or instructions to
help them understand the ultimate goal in using those technolog-
ical tools. Despite that various characteristics of the approaches
have been suggested, the teachers felt that students will have to
take the initiative to acquire SRL skills. One lecturer shared that
“The teachers can only help, like you can bring the horse to the
water (but) you can’t make the horse drink the water”. Similarly,
students also divulged the need of self-discipline for SRL.
Theme 2: Hindrance in Promoting SRL
Apart from illustrating the characteristics of approaches that
will support SRL, both students and lecturers shared perspec-
tives of the hindrances in promoting SRL. Some lecturers
commented that the major hindrance mentioned was student
current learning style which might be due to massive content
and assessment methods.
Students using a senior’s note as study materials and try to
rote memorise as much facts as they could is perceived as a
major hindrance in NUS. While SRL encourages metacogni-
tion regulation, this learning method, which is a common
practice since year 1, could possibly impede SRL. However,
students explained that due to massive content in medicine,
they tend to listen to seniors on the topics that will be covered
during the examination so that they could better focus and
passing the exam is their core priority. Furthermore, the cur-
rent assessment method is not much supportive of SRL.
Teachers interviewed also highlighted that the content load
that needs to be covered during the pre-clinical year has also
led them to fall back to giving didactic lectures. Lecturers
spoon-feeding students with an overwhelming amount of in-
formation during lectures has directly contributed to long for-
mal learning hours of students (i.e. 8 to 5 pm) even though
students felt that didactic lectures are the least useful teaching-
learning strategy in promoting SRL. However, the content
coverage in pre-clinical years is not the only reason that the
lecturers choose didactic teaching. Some lecturers seemed to
have difficulties in developing or identifying appropriate

Table 3 Themes and subthemes with sample quotations
Theme Sub-themes
Characteristics of strategies • Small and collaborative group learning
that promote SRL • Reflective or questioning method
• Guidance from the teachers
• Clinical immersion
• Flexible use of technology with proper instruction
Hindrance in promoting SRL • Student learning style
• Content in medical schools
• Educators’ preparedness
• Recognition
Opportunities and initiatives • Changes to assessment method
in promoting SRL • Faculty development and community of practice
• Mindset evolution
• Sufficient facilities and resources
teaching materials to promote SRL in their classes; hence,
using didactic teaching is the approach that they are familiar
and confident with. Unknown and uncertainty on how to sup-
port SRL were constantly mentioned by interviewees from
both institutions.
Apart from the fear or uneasiness towards unfamiliar con-
cepts such as SRL, the reasons for such a frame of mind among
pre-clinical teachers might be influenced by several other exter-
nal factors. The appraisal systems for teaching and student en-
gagement in the institution could hinder the efforts needed to
implement SRL. For example, counting of the face-to-face
teaching hours and higher student feedback score which are
used as an appraisal parameter has led to some educators to fulfil
the requirement instead of trying out new teaching and learning
approaches. Some educators expressed that implementing SRL
might increase their workload. Hence, it might be difficult to get
buy-in from the stakeholders and resistant to support SRL.
Theme 3: Opportunities and Initiatives in Promoting
SRL
Despite that several hindrances were highlighted by the edu-
cators and students, there is always light at the end of the
tunnel. Changing of the assessment method, training, mindset
evolution and facilities are some of the opportunities and ini-
tiatives mentioned by the participants.
Med.Sci.Educ.
Sample quotations
“Some level of participation for them (students) that they have to
bring a problem back to reflect on whether among themselves
or among peers or even with discussions with their seniors or
tutors or so on. This helps them to feedback on their own
thinking process”.
(NUS, Lecture 2)
“I think personally I like PBL session. Because it kind of like
integrate every teaching session that we had in that week and
then, PBL session ease the contents of what we discuss about
the cases”.
(UM, Student Focus Group 1)
“I have had emails asking me what’s the perfect answer for this
tutorial question…Would I get hundred marks for this? Is that
really the best way for regulating their learning?”
(NUS, Lecturer 2)
“…in lectures we are spoon feeding the students and they do not
have to be prepared for lectures.”
(UM, Lecturer 3)
“You know, upskilling thing is something we are thinking about!
So for example, like, every week or like every couple of weeks,
we have like a twenty-minute session… this helps you in
upskilling your knowledge”.
(NUS, Lecturer 6)
“I think nowadays if you speak to the younger faculty at least they
are more open-minded and they are more prepared to explore new
pedagogies ... So I see an opportunity”.
(NUS, Lecturer 3)
The school and faculty members acknowledge the impor-
tance of SRL towards inculcation of lifelong learning. Hence,
certain initiatives have been ignited and implemented to sup-
port SRL. For example, revising the assessment to a more
application-based clinical scenario format would promote
higher-order cognitive skills and assist students to identify
knowledge gaps. Engaging in extra and co-curricular activities
related to medicine has also been identified by students in
developing SRL. These activities encourage them to draw
their knowledge and apply it to whatever task is given as well
as to learn how to organise their time at the same time.
As for the educators, mindset change is necessary. With
younger faculty members teaching, there are changes in the
use of different pedagogies especially leveraging on technol-
ogy to enhance student learning. However, educating and
training the current educators are critical so that they could
help the students learn better and be more confident in using
approaches which support SRL. Apart from the Centre for
Medical Education in NUS which provides pedagogical
courses, some educators have taken the initiative to form a
community of practice to share successful approaches in
supporting SRL. The emphasis of faculty development can
also be seen in Faculty of Medicine, University of Malaya,
which trains the faculty members in facilitating effective
learning in a large group teaching, a small group teaching,
problem-based learning, etc., in an attempt to modify the focus
Med.Sci.Educ.
of information delivery to inspire learning. The learners also
need to know about evidence-based learning strategies to be-
come effective self-regulated learner through educating them
on how best to learn through a series of faculty and student led
initiatives.
Sufficient infrastructure in NUS and UM, such as the high-
speed internet and free access, study rooms for students and
access to a vast variety of learning resources, is a huge oppor-
tunity to support students SRL. In addition, youngsters today
are exposed to certain elements of SRL in their secondary
school via project work. This concept is not foreign to them;
therefore, if the values and expectations of SRL could be
communicated early to them, nurturing them with this skill
should not be difficult.
Discussion
This study explored the pre-clinical year student SRL and
current strategies that promote SRL. Based on the MSLQ
questionnaire used to explore student SRL, the Motivation
Subscale results revealed students’ motivation from both in-
stitutions was largely derived from Intrinsic Goal Orientation,
Task Value and Control of Learning Beliefs. Similar to other
studies [28, 29], Intrinsic Goal Orientation was generally
scored higher than other subscales.
Student Test Anxiety scored the lowest under motivation
subscales for both institutions. This finding is quite similar to
Kim and Jang’s [31] study whereby they found that student
test anxiety was generally low in year 1. Even though the
score increased significantly in year 2 due to assessment
methods in medical school, this component remains as one
of the lowest as compared with the other components in the
motivation subscale. Test Anxiety is often related to perfor-
mance and self-efficacy. Studies revealed that self-efficacy is
inversely proportional to test anxiety [32, 33] as students with
high efficacy are better in coping with stress and text anxiety
as well as more confident in doing well, which performs better
in examination. Although our study did not explore student
performance, students from both institutions showed low Test
Anxiety score (low score indicates less anxious with assess-
ment) even though they have low self-efficacy. This could be
possibly described by previous research on which students
from Asian countries tend to have lower self-efficacy
[34–37], and having lower self-efficacy does not always trans-
late into lower performance or high test anxiety in our context.
The possible explanation for this might be linked to values and
culture [38]. Modesty, a value that sees oneself as moderate on
the key personal attributes, is often nurtured and valued more
in the East [39]. Schunk, Dale and DiBenedetto [39] disclosed
that more-modest and less-overconfident self-efficacy beliefs
were more accurate in predicting academic outcomes among
the non-Western students. In addition, the emphasis on
collectivism culture in the East and parents’ support might
influence student test anxiety and performance.
With regard to the Learning Strategies subscale, students
from both institutions used elaboration and organisation more
than other strategies. While critical thinking and
metacognitive self-regulation are crucial and highly used strat-
egies as a doctor in reasoning and problem-solving, they were
not frequently practiced by students. However, this is not un-
common as pointed out by Bickerdike [40] that traditional or
strategic learning strategies such as organising material and
monitoring study are still widely used by undergraduate stu-
dents due to the medical curricula. Student help-seeking be-
haviour is generally low in both institutions. However, this is
not surprising as the reluctance to seek help has been con-
firmed by other authors even for academically struggling stu-
dents [41–43]. One of the possible explanations might be that
students tend to hide their weaknesses from others, as it can be
seen as an action to cause them to lose their dignity and pride
when they expose their weaknesses [44]. Nonetheless, why
medical students are unwilling to seek help in learning has not
been well-researched in medical education.
From the qualitative findings, we discovered that students
and teachers are in agreement with the characteristics of teach-
ing and learning approaches that support SRL. Although pre-
vious study had found that a high SRL classroom offers ex-
plicit instruction, extensive support and high metacognition
strategies [45], this study added more features on how to sup-
port SRL, such as relation to clinical cases, small and collab-
orative learning, reflective questioning and flexible use of
technology. Guidance and proper instructions were constantly
mentioned by the students indicating that students require
some handholding at the rudimentary stage to develop SRL
even with the use of technology. Medina [46] emphasised that
one of the key instructional strategies to support SRL is cog-
nitive apprenticeship which is “learning through guided expe-
rience”. This guided experience involves questioning, think-
ing out loud, reflecting and making judgement which can be
integrated in any part of normal instructional approaches.
Knowing that the features of teaching and learning ap-
proaches in promoting SRL is insufficient, our findings re-
vealed that teachers are uncomfortable to implement SRL in
a classroom due to various reasons as identified by them in
Theme 2 Hindrance. Studies have shown that teachers use
SRL in a more implicit way and only a few metacognitive
strategies (one of the SRL strategies) are utilised during teach-
ing and learning [6, 47, 48] when they lack confidence.
Consequently, students are not aware and not being explicitly
exposed to metacognition strategies that could help them to
become a self-regulated learner. The positive association be-
tween teachers’ self-efficacy (confidence in performing their
teaching tasks successfully) and instructional practice is evi-
dent in general education. Teachers with high efficacy are
proven to be more likely to adopt new practices and to select

challenging tasks to experiment in classroom practice [49].
Perhaps due to lack of self-efficacy, our teachers prefer to
use approaches that they are familiar with, such as the didactic
lecture or teacher-directed tutorials. To assist teachers to de-
velop self-efficacy in implementing SRL, faculty develop-
ment plays a major role in preparing them besides the collegial
support from the leadership (Theme 3 Opportunities). Sharing
successful examples among educators might encourage them
to experiment new practices to support SRL. While qualitative
data also revealed that students’ beliefs do matter, it is mostly
due to content-driven curriculum and assessment system.
This present study has its limitations. The study was con-
ducted in only one institution in each country. Wider involve-
ment of institutions is necessary to enhance the
generalisability of the findings. However, the preliminary
findings from the two medical education institutions in both
countries enlighten us on the current status of SRL in these
localities. As abovementioned, SRL changes over time; there-
fore, a longitudinal study to explore students’ SRL strategies
in a different setting would be helpful for teachers to design
effective instructional practices that promote SRL.
Conclusions
SRL is an important attribute to nurture in medical students
due to its positive influence on future practice performance
and lifelong learning in improving the quality of care to pa-
tients. Nevertheless, SRL has not been given much promi-
nence during the pre-clinical formative years in medical
schools. Our study explored the year 1 and 2 students’ learn-
ing strategies and the approaches which supported SRL. The
data presented could be used for faculty members to adopt
appropriate steps to assist students to develop SRL from pre-
Appendix
Table 4 Amendment to the original MSLQ
Item Original item
1 In a class like this, I prefer course material that really challenges
me so I can learn new things.
2 If I study in appropriate ways, then I will be able to learn the
material in this course.
3 When I take a test I think about how poorly I am doing
compared with other students.
4 I think I will be able to use what I learn
In this course in than in other courses.
5 I believe I will receive an excellent grade in this class.
9 It is my own fault if I don’t learn the material in this course.
18 If I try hard enough, then I will understand the course material.
Med.Sci.Educ.
clinical year onwards. Findings show that students’ intrinsic
motivation is generally high, but metacognition self-
regulation and critical thinking strategies need to be enhanced
among the pre-clinical year students. Despite that several
teaching and learning approaches were advocated by the
teachers in promoting SRL, many shared that they are still
not confident in doing so. While students require guidance
in developing SRL, we believe our teachers will also need
some support. Leveraging on the existing opportunities pro-
vided by the schools such as training, technological facilities,
curricula and assessment changes might be helpful in encour-
aging teachers to implement strategies that support SRL in
pre-clinical years.
Acknowledgements We would like to thank Years 1 & 2 medical stu-
dents who voluntarily took part in this research and APME-Net members
for their expertise and guidance throughout all the aspects of our study.
The researchers of both institutions would like to thank faculty members
and students who took part in this study.
Funding For the National University of Singapore, this project is funded
by the Centre for Development of Teaching & Learning Grant (CDTL)
Teaching Enhancement Grant (TEG) 2015 WBS (C-171-000-197-001).
For the University of Malaya, no funding was provided.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethical Approval The study was approved by the National University of
Singapore IRB (NUS-IRB Reference Code: B-15-294) and University of
Malaya Research Ethics Committee (Reference number: UM.TNC2/RC/
H&E/UMREC-111).
Informed Consent Informed consent was obtained from all individual
participants included in the study.
Amended item
In a course like this, I prefer course content that really challenges
me so I can learn new things.
If I study in appropriate ways, then I will be able to learn the
content in this course.
When I take a test I am concerned about my performance as
compared to other students.
I think I will be able to apply what I learn in basic medical science
content in later years.
I believe I will receive an excellent grade for basic science content.
It is my own fault if I don’t do well in this course.
Med.Sci.Educ.
Table 4 (continued)
Item Original item
20 I’m confident I can do an excellent job on the assignments
and tests in this course.
23 I think the course material in this class is useful to for me to learn.
32 When I study the readings for this course, I outlined the
material to help me organise my thoughts.
34 When studying for this course, I often try to explain the
material to a classmate or friend.
36 When reading for this course, I make up questions to help
focus my reading.
37 I often feel so lazy or bored when I study for this class
that I quit before I finish what I planned to do.
39 When I study for this class, I practice saying the material
to myself over and over.
41 When I become confused with something I’m reading for
this class, I go back and try to figure out
46 When studying for this course, I read my class notes and
the course readings over and over again.
54 Before I study for new course material thoroughly, I often
skim it to see how it is organised.
62 I try to relate ideas in this subject to those in other course
whenever possible
71 When I read or hear an assertion or conclusion in this class,
I think about possible alternatives.
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