Self-Regulated Learning Diary Interventions and the Implications for Health Professions Education

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Introduction
There is increasing interest in the application of self-regulated learning (SRL) in health professions education, with evidence that interventions based on SRL can improve academic and clinical learning and performance [1][2][3][4][5][6].There are several SRL theoretical models [7], with Zimmerman's being widely applied within both health and non-health professions education to understand and design interventions for developing SRL [8].In Zimmerman's [9] model, SRL is considered to be a cyclical and dynamic process that occurs in three main phases in relation to a learning task: forethought, performance and self-reflection.In each phase there are also several key specific subprocesses related to the cognitive and motivational aspects of learning [9].In the forethought phase, there is task analysis with goal setting and the choice of appropriate strategies for achieving successful learning.During the performance phase, the chosen strategies, which may also include time structuring, environmental structuring, and help seeking, are implemented.In addition, the student metacognitively monitors their achievement of learning.During the self-reflection phase, the student evaluates their learning and the extent to which their choice of chosen strategies has been successful in achieving their desired learning, with consideration of the need to adapt their motivational and cognitive strategies in response to both the current learning task and future learning tasks [9].
Interventions for improving SRL in health profession education have been mainly based on courses with explicit or direct SRL instruction on how to apply SRL to their overall learning [10,11], but more recently personalized interventions with the focus on identifying SRL subprocesses and providing feedback have been proposed, such as by microanalysis with a focus around a short specific learning task [12][13][14][15][16].An important challenge with these interventions in health professions education is that they are time consuming for both educators and learners but also there is limited time over which SRL processes can develop [17][18][19].In response to the shortcomings of similar current interventions in nonhealth professions education, learning diary-based interventions have become increasingly popular to foster learners' SRL as a situated and dynamic processes over time.
A diary is a self-report instrument in which an individual can document an individual student's experiences in a real and authentic setting over multiple time points [20,21].Learning diaries can be structured to both capture and develop SRL in the context of a specific learning task [22,23].These SRL learning diaries (SRL-LD) can provide an opportunity for the learner to (i) plan their motivational and cognitive aspects of learning within the diary before beginning a learning task.(ii) monitor and reflect upon what aspects of learning went well, and what did not go so well, both during and after finishing the learning task, and (iii) adapt their motivational and cognitive aspects of learning either during the learning task or for a subsequent learning task [23].
There are two general approaches to SRL training: direct and indirect instruction.Direct instruction may be conducted in the form of teaching the SRL process and key subprocesses (explicit instruction) or modeling and scaffolding the main SRL process and key subprocesses by a teacher, a peer or completing a SRL-LD (implicit instruction).Indirect instruction of the SRL process and key subprocesses refers to providing an encouraging learning environment, such as through cooperative learning, situated learning or creating cognitive challenges [24].ASRL-learning diaries (SRL-LD) have the advantage of having the potential to develop SRL and academic performance over time but also being ecologically valid since they have a focus on improving SRL in real learning settings [25].
SRL-LD have been used in three main different formats as an intervention to develop SRL in non-health professions education [26]; unstructured (containing no questions or prompts), semistructured (with open ended questions and/or prompts related to the main phases of SRL), and structured diaries (with specific open ended and/or closed questions related to specific SRL phases and key subprocesses).These SRL-LD can be completed at different time intervals, such as daily, biweekly or weekly, and also in variety of formats, including paper-and-pencil, brief telephone interview and electronic [21].
Over the last 20 years, educators in non-health professions, especially humanities and engineering, have become increasingly interested in SRL-LD interventions [27][28][29][30][31][32][33][34].The intention is that regularly recording of SRL during learning may improve both students' SRL and academic performance over time [35,36] specially diaries those address both learning behavior and content, cognitive, and metacognitive aspects with external feedback on SRL.Diaries also can be useful for all age groups of learners and all educational contexts [36].Despite the potential benefits of SRL-LD to improve academic and clinical performance by strengthening SRL, our experience in planning a study in medical students highlighted that there appeared to be few studies in health professions education.However, SRL-LD interventions have been widely used in non-health professions education and we therefore conducted our systematic review with the aim to identify how SRL-LD interventions have been used in health and non-health professions education, with the intention to provide insights into their use and to inform future implementation and research in health professions education.

Materials and Methods
This systematic review was conducted according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement criteria [37].The authors have previous experience in SRL research and conducting review studies, which guided the overall conduct of the review and the interpretation of the results.The review protocol has not been published before conducting the research.However, all data generated or analyzed during this study are shared in this paper and its supplementary data.We followed a stepwise process in conducting the review.Two authors (ZZH and HA) independently screened the titles and abstracts in terms of inclusion criteria relevance and then discussed any differences until consensus was reached.The full text of selected articles was reviewed against the eligibility criteria and uncertainty about inclusion was discussed between the two authors (ZZH and RG).
2.4.Charting the Data.The data extraction form was developed iteratively through discussions between all authors.The form was initially piloted with a small number of studies by ZZH and then was discussed, reexamined, and revised by ZZH, RG, and JS.
2.5.Collating, Summarizing, and Reporting the Results.We calculated frequencies to describe study characteristics and conducted content analysis [38] using several analytic frameworks for abstraction of findings.For the educational domain, we considered whether interventions were conducted in specific circumstances such as a lesson, an educational subject or an educational objective and identified them as domain-specific through the continuum of domain specificity (Figure S1).Outcomes of the intervention were classified based on the Kirkpatrick and Kirkpatrick [39] levels.Perceptions of the participants were categorized thematically as positive or negative reactions to the "diary," "instruction," or "SRL intervention as whole" based on the studies' findings.
Response rate of studies were classified as high, moderate, or low.Additionally, we classified SRL targeted in SRL-LD interventions based on the three phases of Zimmerman's [9] model (forethought, performance and self-reflection).Study recommendations also were coded in order to gain a comprehensive view about practical considerations to design and implementation of such interventions and further research.The Medical Education Research Study Quality Instrument (MERSQI) tool was used to assess the methodological quality studies [40].The MERSQI includes ten items for investigating the quality of six dimensions: study design, sampling, data type, validity of assessments, data analysis, and outcomes (possible total scores: 5-18).The framework used by Gordon et al. [41] was applied to assess the quality of the reporting of the training intervention for each study and the results were presented as green for high quality, yellow for unclear quality, and red for low-quality intervention across five categories: U = underpinning theory described, R = resources described, S = settings described, E = educational methods described, and C = content described.Clear and detailed description of underpinning theory or model (U), resources such as time and costs (R), educational context and participants' characteristics (S), educational methods (E), and materials or access to the materials (C) got green.If the descriptions were not complete or detailed in each category got yellow and if no information was exist got red [41].
One author (ZZH) undertook initial data extraction and summarizing for each paper, which was subsequently independently checked and verified by RG.The authors iteratively moved through the papers to ensure all extraction topics were comprehensively examined for each paper.The process of quality assessment of the studies was performed by HA and ZZH independently.Any differences were discussed until agreement was reached.

Results
A total of 986 papers were retrieved from selected databases via electronic and hand searching.After removing duplicates, 734 records remained.Following the inclusion-exclusion process, finally 23 papers were selected for the review.Details of the article selection process are shown in Figure 1.
The quality scores of the studies ranged from 9.5 to 15.5 (mean MERSQI = 11.91)showing acceptable quality of the studies' methodology.However, the reporting of the training interventions was often unclear (Table S2).

In What Contexts Have SRL-LD Interventions Been
Used? Table 1 shows a summary of the study characteristics.All studies were published between 2006 and 2020.Most interventions were conducted in Germany (N = 8) and the USA (N = 4 most studies (n = 17) implemented SRL-LD interventions related to a specific domain such as Math lessons.There was one study in health professions education, with a focus on anesthesiology residents.

What Are the Key Components of SRL-LD Interventions?
Please see Table 2.

Types of SRL-LD Interventions.
We identified five types of interventions: diary + SRL instruction (n = 10), diary + feedback (n = 4), diary + SRL instruction + feedback (n = 1), diary only (n = 16), and SRL instruction only (n = 4).Thirteen studies had explicit SRL instruction at least for one of their intervention groups including didactic teaching of SRL key subprocesses; and five studies presented an individualized SRL feedback on participants' learning diaries.In two studies, researchers [42] or instructors [43] collected the participants' daily diary at the end of each week and provided personalized qualitative feedback to each participant.In two studies, participants were provided with an online daily personalized feedback in tabular [44] or graphical [45] format.In one study, highly elaborated online feedback was provided by the trained teaching assistants.Interventions lasted between 3 weeks to two academic semesters.
Eleven studies employed a structured diary, 11 studies also reported a semistructured and one study presented an unstructured diary.In 20 studies, diaries were implemented in a time-based manner, with administration at fixed time intervals, such as weekly or daily.Two studies employed an event-based learning diary, which was delivered after each lesson of students' regular course.An electronic learning diary was used in 14 studies and 9 used a paper-based diary.
Qualitative (n = 8) and/or quantitative methods (n = 12) were used to analyze the data of the diaries based on its structure as outcome measure.In two of the retrieved Education Research International studies, the diary was used only as a stimulation for reflection and no analysis was performed for diary data.

Focus of SRL-LD Interventions on SRL Phases
. There were 10 studies that reported explicit instruction in SRL.In six studies instructions contained all three phases of SRL, two studies covered forethought and performance phases and one study presented SRL explicit instruction only in the performance phase of SRL.
In most studies (n = 17) diaries contained all SRL phases.There were two studies had diaries that contained both forethought and performance phases.In three studies, the diaries included items related to only one phase of the SRL (forethought n = 1 and performance n = 2) (Table S2).

What Are the Outcomes of SRL-LD Interventions?
Studies reported several different outcomes.At Kirkpatrick Level 1, the response rate and participants' perceptions to the intervention were analyzed.The response rate was identified in 20 studies and almost all (n = 18) reported a moderate to high-response rate.Participants' perceptions were explored using questionnaires with closed-and open-ended questions (n = 5), and in most studies participants had a positive attitude toward the diary approach, the instructions and the intervention as a whole (Table S3).Participants' perception about the novelty of instructions were investigated in two studies and participants rated it as average [46,47].
Outcomes were also evaluated at Kirkpatrick Level 2, as (i) SRL outcomes (n = 23) and (ii) academic outcomes (n = 8).Most studies (n = 21) used self-report questionnaires to assess SRL as the pre/post comparison measure (Table S2).In addition, 14 studies used diary data to evaluate SRL quantitative outcomes and 7 studies collected SRL qualitative data.
(1) The combination of diary with explicit training on SRL improved more SRL key subprocesses than diary only or SRL instructions only interventions.Integrating feedback with the diary did not improve more SRL measures than only diary (Table 3).Overall SRL and performance phase measures demonstrated improvement more than the other SRL measures.In nine studies, worsened SRL outcomes was detected for several subprocesses of the forethought and performance phases (motivation, self-efficacy, mood, goal setting, handling stress, and quality of cognitive strategies of high expertise students).There was one study that compared the effectiveness of a personalized SRL-LD intervention based on the participants' use of SRL.Overall, there was an increased use of appropriate cognitive strategies after receiving personalized feedback for students who used inappropriate strategies prior to feedback and also students that used appropriate cognitive strategies before receiving feedback showed a decrease in their use after receiving feedback [48].(2) Academic outcomes were reported in eight studies, with five studies comparing the academic performance of participants and two studies showed statistically significant difference in favor of the intervention group.There was no worsened academic outcome (Table S2).Education Research International research were a larger sample size and longer term follow-up, the identification of the optimal components of an SRL-LD intervention, and the impact on students' performance.

Discussion
The review had the aim to identify how SRL-LD interventions have been used in health and non-health professions education, with the intention to provide insights into their use and to inform future implementation and research in health professions education.There were 23 studies published between 2006 and 2020 that were eligible to be included in the review.Only one study in health professions education was identified, with a focus on anesthesiology residents.In this study the diaries were used only for documenting their study time schedule and assessed the amount of time that residents invested on studying related materials before and after two different short SRL instructions (WOOP: wish-outcomeobstacle-plan and goal setting) [49].
There were five types of SRL-LD interventions identified in the studies; diary + SRL instruction, diary + feedback, diary + SRL instruction + feedback, diary only, and SRL instruction only.Our review found that in almost half of diary interventions, Education Research International SRL in all three phases were improved.In diaries with explicit SRL instruction, improvements in SRL were found in the student's use of SRL in the forethought phase (50%) and performance phase (75%).All diary + feedback interventions achieved improvements in the performance phase, and forethought improvements were obtained in more than half of these groups.
In diary + feedback interventions no improvement was found for the self-reflection phase.Diary with explicit SRL instruction groups had enhancement in all phases; more than half of these studies showed improvement in performance and selfreflection phases and less than half of studies reported improvement in forethought phase.Overall, SRL-LD interventions mostly improved participants' SRL in the performance phase and when used in a combination of SRL explicit instruction and/or feedback, there was additional effectiveness of the intervention in the performance phase.Similar to Theobald's [35] meta-analysis of SRL training programs with explicit instruction for university students (2021), there was also an overall improvement in SRL, especially for interventions that included instruction and feedback.Studies included in this review used and compared different formats of SRL-LD interventions, but none of them were focused on comparing the format of SRL-LD.Therefore, we are limited in making specific inferences from this review about the preferred type of SRL-LD.In addition, most studies also employed structured, time-based and electronic diaries with used different types of quantitative methods to analyze the data.This has implications for future research since the use and design of appropriate SRL-LD are influenced by alignment to the research question [50], feasibility, and educational effect [25].For instance, if the research aim is to explore a rich understanding of the SRL process and key subprocesses, an unstructured or semistructured SRL-LD in which participants document their learning experiences without limitation can provide qualitative data that leads to a deep understanding of their SRL [51][52][53].In contrast, if researchers aim to enhance and/or evaluate specific SRL key subprocesses in participants, a more structured SRL-LD is recommended [25,47,54].A structured SRL-LD may also promote the feasibility by increasing the response rate and by providing quantitative data [25].
Regarding outcomes, in two of the eight studies that investigated the academic outcomes, significant differences were obtained in favor of the intervention group.Interestingly both of these studies had diary + feedback intervention groups.
Theobald's [35] meta-analysis also showed the overall positive effects of SRL on academic performance in higher education.
The reviewed studies showed that low-academic performance students benefited more from the different SRL-LD interventions compared with high-performance students [48].This finding is similar to the findings from Theobald's [35] meta-analysis of SRL explicit instruction programs.
Although the majority of students considered that the longitudinal use of diary and the instructions were useful, some participants were dissatisfied.Their main reasons for being dissatisfied were the lengthy instruction sessions and the lack of motivation to repeatedly complete the diary over a period of time [55,56].
Overall, the positive SRL and academic performance outcome findings and favorable students' perceptions suggest that SRL-LD interventions offer an acceptable and effective approach for health professions education.

Implications for Future Design and Implementation of SRL-LD Interventions in Health Professions
Education.The findings of the review, although limited to insights from nonhealth professions education, suggest that there is potential for using SRL-LD interventions in the health professions education [57].We provide several recommendations to guide future design and implementation which are based on the review.4.1.1.Use an Appropriate Theoretical Framework.A theoretical framework can guide future design and implementation and evaluation of SRL-LD interventions.We recommend Zimmerman's model since it has a practical focus on three important cyclical SRL phases and has been effectively used in our reviewed studies of SRL-LD interventions.Furthermore, Zimmerman [9] considers SRL as a situational variable feature that the diary is more fitted to the development and assessment of SRL across several occasions and situations.

Include All Important Components of SRL in the Diary.
Results of this review showed that the interventions that covered all three SRL phases according to Zimmerman's model had effects on improving most SRL phases; forethought [25,58,59], performance [25,51,56,58,59], and also self-reflection phases [25,58,59].In line with the Zimmerman's theoretical model, we suggest including all three phases of SRL in designing the diary since theoretically there is cyclical feedback loop in which the phases are influenced Note: n/n: number of intervention groups that reported improvement in the domain/total number of studies that reported the outcome in the domain. 6 Education Research International by each other [60] and it is necessary to consider all components together to have a holistic approach to develop and/or assess the SRL.Diaries provide an opportunity for students to self-monitor how each SRL phase and its key subprocesses can have an impact on their performance, allowing them to make adaptive changes for the future performances [23].
Frequent completion of a diary over time can lead to these processes becoming more automatic [61].
4.1.3.Use an SRL-LD Intervention that Combines Explicit Instruction and/or Feedback with Diary.As the results of this review indicate, combining feedback on participants' SRL or SRL explicit instruction + feedback with diaries may increase the effectiveness of SR-LD interventions.This does not necessarily mean providing longer training and the use of more resources since explicit training can be limited to initially providing information on the importance of SRL for academic success as well as including short practical tips related to applying several different SRL/subprocesses.Furthermore, as feedback improves the SRL-LD intervention effectiveness [36,62], the automated online feedback can be a cost-effective approach for this aim [28].

Consider the Feasibility of Implementing an SRL-LD
Intervention.The main challenges that retrieved studies had been mentioned were the issues with diary completion rate and also continuation of student participation in longitudinal SRL-LD interventions.SRL-LD interventions are also a major consideration for health profession students due to their high academic and clinical workload.To resolve this problem in some studies, incentives are considered for the participants while this approach may affect the results of the study.We suggest several potential solutions: (i) emphasizing the importance of the diary in improving their performance.We could introduce the diary and its benefits to provide documentation about ones' planning and reflecting in own learning.In addition, we should train participants how to work with their diary; (ii) using short structured weekly diaries instead of long daily diaries.There is no preferred type of SRL-LD, but it seems to be more efficient if we consider a structured SRL-LD covering key SRL subprocesses.Furthermore, to avoid increasing health professions students' workload, we recommended designing the diary and intervention to ensure that it meets the participants' needs.; (iii) designing short practical SRL training sessions since research suggests that health profession students have less need for extensive training related to SRL because they usually have greater awareness (reached by self-experience or prior training) and they need more emphasis on practicing the application of SRL [63]; and (iv) placing the intervention close to an important assessment to maximize student participation, for example as a test preparation course.4.1.5.Consider the Characteristics of the Students.The reviewed studies highlighted the importance of adapting the SRL-LD intervention to the students' prior academic performance and their differences in the use of SRL.For instance, low-achieving medical students show less use of SRL and its key sub-processes compared with high-achieving students [16,[64][65][66][67]. On the other hand, research has showed that low performance adult learners benefited more from the training on time and resource management strategies [63].Considering students' needs can lead to improve participants' motivation and the outcomes of the intervention in addition to avoiding waste of resources.In preclinical phase of HPE, SRL-LD interventions can be conducted same as other higher education context.HP students in their clinical practice, experience dynamic and complex environments, with time-pressures and stressors.Research in health professions education highlights the need to have a dynamic approach to develop and assess the students' SRL in such complex and work-place context [68].The most prominent features of the SRL-LD are its authenticity and ecological validity [25] so that it has the capacity to capture SRL in various situations in real time and place of occurrence, congruent with the situated nature of SRL.
4.1.6.Familiarize Faculty with the Diary.A significant number of retrieved studies had been conducted in the field of teacher training.As the SRL is an important competency for life-long learners both faculties and health professions students can benefit from instruments that stimulate and develop their SRL in a more thriftily way in terms of its implicit training effects.Furthermore, faculty development is essential for implementing any new intervention to ensure that faculty can support students [69,70].Faculty development courses can introduce the diary as a SRL enhanced tool and encourage health profession teachers to use it for selfawareness and self-improvement in the SRL.Also, teachers can move to a more student-centered learning environment by applying the diary to help students promoting their SRL.

Suggestions
There are several future areas of research to fill the existing knowledge gaps for the use of SRL-D interventions in health professions education.Since the most effective interventions in other disciplines were those that combined explicit SRL training and diary methods [47,59], we recommend replication studies of combined SRL instruction and diaries, as well as studies that compare the combined intervention with diary only in health professions education.Future research can also provide more evidence for validity of the learning diary [71], especially the important question of whether changes in SRL and its key subprocesses are associated with academic outcomes.Other important areas for research are the generalizability of the effectiveness of the diary across different tasks [21,71,72], and the identification of how many diary completions are appropriate for the maximum effectiveness of the intervention [73].

Conclusion
This systematic review investigated SRL-LD interventions and found that there were several types of diary interventions.Overall, there was an improvement in SRL and academic performance, especially for students with low performance.The most effective intervention was a diary in combination Education Research International with explicit SRL training and/or feedback that covers all SRL phases.

TABLE 1 :
Descriptive characteristics of retrieved articles.

TABLE 2 :
Descriptive characteristics of interventions.

TABLE 3 :
SRL outcomes of studies based on overall and three phases of SRL.