Background

Although not always considered in medical education teaching models, student motivation provides a forceful instrument to maximise learning [1]. Deci and Ryan’s (2000) interpretation of self-determination theory (SDT), proposes that for individuals to be intrinsically motivated, and hence benefit educationally and professionally from an activity, three key elements are needed: 1) autonomy, 2) competence and 3) relatedness [2]. Students need to be motivated to learn, and by trying to understand the factors that enhance students’ motivation we can better optimise learning environments and ensure future success of teaching programs. The reasons for motivation can be articulated in view of self-determination theory [2].

Autonomy refers to the students’ sense of choice and volition, whether working alone or with others [3]. Having options and choices increases students’ desire and determination to succeed [3]. Students perform best when they are intrinsically motivated to do so, rather than extrinsically motivated. In fact, offering extrinsic rewards for behaviour that is intrinsically motivated can have a negative effect on students’ motivation [4].

Competence refers to the students being motivated by a sense of mastery of the subject [2]. Students like to work towards mastery of a subject, and are motivated by reflective practice, as they work towards higher levels of expertise [2]. It is important that students experience an optimum level of challenge within their activities in order to remain motivated [3]. Additionally, providing students with positive feedback on tasks increases their intrinsic motivation, while negative feedback often has the opposite effect [4].

Relatedness refers to students’ sense of connectedness with others with similar goals and purpose [5]. This sense of connectedness is fostered when a group of students have similar ambitions and work together to attain their goals. Small group work, in particular, can promote a sense of belonging, in which individuals work closely with all of the members [6].

In this paper we apply SDT theory to consider medical students’ motivation to participate throughout an optional summer elective anatomy whole body dissection course. This is an optional course held in the final year elective component of the four year graduate entry medical program at Sydney Medical School, The University of Sydney, Australia. The course takes place on University campus, and participants are from six metropolitan clinical schools. It is an eight week, full-time, intensive, structured course, requiring substantial out of class preparation. Due to the intensive time and resource requirements of the course, only 24 places are offered annually (from a cohort of approximately 300 students), and target students interested in a surgical career. The course was designed to develop a three-dimensional appreciation of the anatomical regions of the body. The course is facilitated by senior surgeons, and requires small group, active learning. The course has been run on an annual basis since 2009, and has become so popular amongst students that applicants are required to attend a face to face selection interview with a panel of surgical dissection supervisors. The success of the course has been well demonstrated by participants’ outstanding academic results and positive feedback regarding the students’ learning expereince [7],[8].

The purpose of our study was to investigate students’ motivation and experiences within the anatomy by whole body dissection course. For our study we posed the research question: “How are students intrinsically motivated during participation in the elective anatomy whole body dissection course”.

Methods

Context

In the 2014 program, 24 final year medical students were selected after interview to participate in an intensive 40 – day (272 hour) dissection elective over eight weeks.

Course design

Team learning strategies were implemented [8],[9]. In groups of six, students were allocated to one of four embalmed cadaver subjects. Pre-class reading from the dissection manual [10] was required for each day of dissection. Each day in class, specific group dissection tasks were clearly outlined on colour-coded spreadsheets from the manual. Each dissection group was provided with dissection instructions that had been transcribed onto laminated colour-coded cards for each anatomical region. To assist with the dissection tasks, a central console was used to provide projected images from the dissection manual. The Supervisors held frequent SCORPIOs, designed to provide students with a problem-based, integrated learning experience, and frequent formative and summative in-class tests and practical assessments. Formative assessments were held daily. Formal, standardised practical assessments, requiring identification of 20 anatomical structures on wet specimens were carried out pre-course, mid-course, end-course and post-course. A total body dissection was completed by all students.

The daily program consisted of a daily dissection briefing given by an allocated student utilising diagrams; allocated dissection tasks on cadavers in the wet lab reinforced by small group wet prosected specimen demonstrations; a 30 minute lecture by a supervisor on the clinical applications of the anatomy being dissected; and completion of the allocated dissection tasks for that day.

Supervision

The course was facilitated by nine highly experienced senior surgeons from various specialities, known as “Supervisors”. The Supervisors were present for their area of anatomical expertise. Two to three supervisors were present at any one time during dissection. Nine surgical trainees were also recruited as Demonstrators.

Data collection

Data were collected by survey questionnaire from students at the end of the course. The questionnaires were distributed by the first author, who has no involvement in teaching or administration of the course. All 24 students were asked to complete a questionnaire regarding their experience in the course. The questionnaire included open ended questions aimed at eliciting responses from students regarding their motivation in relation to the course design, teaching methods and supervision.

Data analysis

Framework Analysis was used to code and categorise data into themes [11],[12]. It was noted that emergent themes in the dataset resonated closely with key constructs within self-determination theory [2]. Subsequently, SDT theory was used as a conceptual framework to identify recurrent themes. A coding framework was developed to code the entire dataset through the theoretical lens of SDT theory.

Ethics approval was obtained from the University of Sydney Human Research Ethics Committee. Written consent was gained from each study participant.

Results

Student demographics

A total of 24 final year medical students (18 male and 6 female) with a mean age of 27.4, SD 3.07, range 24 to 32 years, participated in the course. All students held a prior degree, including degrees in Pharmacy, Engineering, Law, Science, Dentistry and Business.

Survey responses

All 24 students (100%) completed the questionnaire at the end of the 2014 course.

Utilizing self-determination theory as a theoretical framework, we illustrate the student’ motivation and experiences of participation in the anatomy by whole body dissection course. Table 1 displays student motivation in relation to autonomy; Table 2 in relation to competence; Table 3 in relation to relatedness.

Table 1 Student motivation in relation to autonomy
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Table 2 Student motivation in relation to competence
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Table 3 Student motivation in relation to relatedness
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Discussion

According to SDT theory, the three key elements in optimising one’s motivation are autonomy, competence and relatedness [2]. These elements engage one’s motivation from within, producing desirable benefits for learning and behaviour. Each of the elements is considered below in the context of students’ feedback regarding their participation in the anatomy whole body dissection course:

Autonomy

According to the SDT theory, it is more motivating for students if they feel they are acting through their own volition [2]. Certainly, participating students freely chose to undertake the elective dissection course. Rather than choosing an overseas elective placement, individual students came together from six different clinical schools with the joint purpose of developing surgical anatomical skills. Although their grades would not appear on their transcripts, they were driven to achieve high marks for themselves, their teams and their supervisors. Students commented on a “desire to learn and not for a number on your CV”. Autonomy doesn’t mean working separately from others, but rather, using information to guide decision making [13]. The course design provided students with self-directed learning activities, so that students worked in collaboration with their team members, other teams, and supervisors, to make the dissection activities meaningful and worthwhile. With guidance to required information, the curriculum was open for students to shape the quality of their own learning [14]. Autonomy was fostered within the dissection room, where students had opportunities to engage with others and make choices within clear and structured guidelines [13],[15].

Competence

Students like to feel that they are masters of what they do, and a sense of competence was cultivated when they attained particular knowledge and skills [2]. As one student commented, “There is a real atmosphere of teamwork and team achievement, especially regarding exam results with students cheering each other’s success”. Importantly, complex interaction between the supervisor and the students developed student autonomy and competence [2]. It is important to match levels of competence with levels of supervision [16]. By allowing students to undertake the dissections, with appropriate supervision, their responsibilities were aligned with their abilities, and a sense of competence was developed [9]. One student commented that supervisors had “the ability to be flexible and adapt… to the strength of your team”.

Students need to be able to be successful at the tasks at hand. However, in order to remain motivated, they need to have higher levels of proficiency to which to aspire [2],[17]. Students in the anatomy dissection course felt a sense of accomplishment when they finished the assigned tasks for the day, and progressively improved on class tests. Throughout the dissection course, there was no shortage of frequent and affirmative feedback from supervisors. Informal formative assessments were held frequently, acting as incentives for “the pursuit of excellence”, with students receiving regular feedback. Well-defined goals were set. By holding formal standardised practical assessments at four time points across the eight week course, students were able to see their progressive mastery of the course, and could identify specific areas in need of improvement. As students continued to develop their dissection skills along with a sense of mastery, motivation was fuelled, with reflective practices leading to continual improvement in the task [2],[13]. As well as the wet specimen identification assessments, students completed MCQ and Spot Test assessments at the end of each regional assessment. Doing well in the tests reinforced a sense of acquiring competence.

Relatedness

Relatedness refers to a sense of joint purpose to the task. SDT suggests that people need to feel connected, and this may be fostered within groups with the same ideals and goals [5]. Throughout the dissection course, students were made to feel part of a professional community [13]. As one student commented, “You develop a friendship with your group and supervisors as we were all there with the same intentions, to help each other learn anatomy.” Surgical supervisors contributed their stories and examples to provide relevant surgical clinical contexts, contributing to students’ understanding of topographical human anatomy. In these social surroundings, students were able to construct their own detailed knowledge. They developed their own shared practices, such as impromptu quizzes with senior staff. The “overall spirit” of the supervisors and the participants shaped the culture of the learning environment, and helped create a relaxed, collegial atmosphere [13]. Central to SDT theory, a sense of belonging [18], was fostered within student teams and the class itself. Students worked on problem solving group activities, alongside each other, tackling challenging tasks and solving problems together. Students had a joint sense of purpose to master the course [5],[19].

Significance of the study

Use of an existing theoretical framework may assist medical education researchers in understanding and determining the value of the presented research. According to McMillan [20], an educational research study should display consistency with established theory, building on what is already known [20]. By utilizing self-determination theory as a theoretical lens to interpret and understand the data, we have strengthened our study. SDT theory may provide a useful framework to demonstrate students’ motivation to take part in other medical education courses.

Limitations of the study

One limitations of our study is that it is a small scale study. Although 24/24 (100%) of students completed the surveys, this is a small number. Also, it should be acknowledge that the students attending the anatomy by whole body dissection course had voluntarily chosen to do so, and therefore were more likely to put effort into this endeavor, and perform well academically.

Conclusion

The course design and supervision of the anatomy dissection course provided an enriched learning environment that motivated students to build on their knowledge together and apply a surgical context to what had been learnt. The three key features of SDT – autonomy, competence and relatedness, drove students’ desire to achieve. Students undertook the intensive course of their own volition, and were highly motivated by the enthusiasm and expertise of the surgeons; the sense of collegiality and community within the course; and the continuous challenges of group problem solving activities, and the sense of achievement through frequent assessments. By developing a better understanding of the influences on students’ motivation, future course designs may be improved to optimise student learning.