Impact of Learner Autonomy on the Performance in Voluntary Online Cardiac Auscultation Courses: Prospective...

Learner autonomy-the ability to self-direct and regulate learning-is a key determinant of success in online education, yet its quantifiable impact in voluntary noncredit courses remains unclear. Understanding how autonomy translates into measurable behaviors and outcomes in clinical skills training may inform more effective online learning design and learning outcomes.

This study aims to quantify the association between behavioral indicators of learner autonomy and performance in a voluntary noncredit online cardiac auscultation course.

We conducted a prospective, self‑controlled, single‑center study. A total of 199 registrants (n=122 physicians and n=77 medical students) were recruited via WeChat and attended four weekly 2‑hour synchronous sessions using authentic patient heart sound recordings with imaging‑based explanations. The primary outcome was the final posttraining quiz score (0-100); training effectiveness was assessed by the pre‑ to posttraining score change. The autonomy indicators were full participation (attendance at all four sessions), in‑class engagement (number of responses to brief content‑aligned prompts posed approximately every 10-15 minutes; responses recorded for participation monitoring only), and postclass review (frequency/duration of reviewing recordings and materials). Analyses included Wilcoxon signed rank tests, χ² tests, multivariable linear regression, and receiver operating characteristic profiling of "excellent learners" (top 10% improvement).

Of the 199 registrants, 146 (73.4%) attended ≥1 session and 46 (23.1%) completed all sessions. Median test scores improved from 40 (IQR 20-50) to 70 (IQR 50-83; P<.001). Intrinsic motivation was associated with full participation (χ²₁=4.03; P=.045). In multivariable models, full participation (unstandardized B=41.55, 95% CI 24.43-58.67; standardized β=0.60; P<.001) and in‑class engagement (B=4.79 per additional response, 95% CI 3.05-6.45; β=0.70; P<.001) independently predicted higher final scores (adjusted R²=0.48). Receiver operating characteristic profiling indicated that greater postclass review (recordings/materials) led to learners achieving excellent performance.

In this voluntary online clinical skills course, showing up consistently, engaging during class, and reviewing after class-practical expressions of learner autonomy-were key correlates of short-term performance. These behaviors may be encouraged through simple, feasible course designs such as clear expectation setting, periodic interactive prompts, and structured review opportunities, which warrant prospective evaluation in future studies.