Journal of Educational Evaluation for Health Professions How to Encourage Intrinsic Motivation in the Clinical Teaching Environment?: a Systematic Review from the Self-determination Theory

2015, National Health Personnel Licensing Examination Board of the Republic of Korea This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Purpose: Internalization of students' motivation towards an intrinsic form is associated with increased interest, commitment , learning, and satisfaction with education. Self-Determination theory postulates that intrinsic motivation and autonomous forms of self-regulation are the desired type of motivation; as they have been associated with deep learning, better performance and well-being. It claims three basic psychological needs have to be satisfied in order to achieve intrinsic motivation. These are the needs for autonomy, competence and relatedness. This study aims to provide a review on how these basic psychological needs are encouraged in undergraduate students so they can be transferred to the clinical teaching environment. Methods: Electronic searches were performed across four databases (Medline, Embase, PsycINFO, and ERIC), relevant journals, and retrieved bibliography of selected articles. In total, searches produced 4,869 references, from which 16 studies met the inclusion criteria. Results: Main themes were coded in three categories: The support of autonomy, competence and relatedness. The research-based evidence appears to be of reasonable quality, and indicates that teachers should work to satisfy students' basic psychological needs to foster internalization of self-regulation. Our findings suggest that teachers should interact with students in a more 'human centred' teaching style, as these actions predict motivational internalization. Several themes emerged from different contexts and further investigation should expand them. Conclusion: This review identified actions that clinical teachers could implement in their daily work to support students' self-determination. Autonomy supportive teaching in health professions educations would benefit students and may actually result in more effective health care delivery.


INTRODUCTION
Over the last decade there has been increased research on motivation in health professions education [1,2]. Clinical tea ching has been suggested as an important factor influencing students intrinsic motivation and performance [3,4]. A num ber of studies have found that internalization of students mo tivation towards an intrinsic form is associated with increased interest, commitment, effort, learning, and satisfaction with education [57]. In contrast, a poor quality of learning occurs when students are not willing to learn [6]. It is suggested that students in higher education, especially in health professions education, have natural tendencies to learn and to know the environment that surrounds them, they have a selfconcept of being responsible for their own decisions, and learn things they need to know for real life situations [1,8,9]. However, these behaviours can be supported or diminished by internal or ex ternal factors [9]. Selfdetermination theory [6] supports the idea of students' innate curiosity and desire to learn. This is http://jeehp.org J Educ Eval Health Prof 2015, 12: 8 • http://dx.doi.org/10.3352/jeehp.2015. 12.8 achieved by internalizing and integrating psychic components to build an integrated and unified sense of the self [8]. It posits three quality types of motivation: amotivation (i.e. lack of mo tivation), extrinsic motivation (i.e. driven by external control or demands) and intrinsic motivation (i.e. free engagement in an activity for inherent satisfaction). An internalization pro cess, from external to internal regulation, influences the type of motivation adopted. This relates to how selfdetermined an individuals' behaviour is and can lead to internalization of hab its and motives in order to generate feelings of autonomous selfregulation and value.
Selfdetermination theory claims three basic psychological needs that have to be satisfied in order to achieve intrinsic mo tivation and internalization of autonomous selfregulation. These are the needs for autonomy, competence and related ness [2,8]. The needs for autonomy refers to making decisions by your own will, based on one's own needs and values [9]. The need for competence refers to the desire of feeling capable of performing a determined task and it is related to seek chal lenges that are optimal to one's abilities [6]. Relatedness is de scribed as the need for belongingness or connectedness with significant others, as well as with a significant community [10]. It means being accepted and valued by people surrounding us. The clinical learning environment can promote these needs and foster intrinsic motivation through an autonomysupport ive teaching style, making students feel autonomous, compe tent and supported by their teachers and peers. This opposes to the traditional controlling style in which behaviour is usu ally regulated by punishments and rewards [6], leading to ex trinsic motivation. Evidence suggests that if teachers support students' autonomy, competence and relatedness, they will thrive in educational settings [9], they will take responsibility for their learning [1] and also act in a more autonomy sup portive way in their interactions with patients [11]. Therefore the aim of this systemic review is to describe and analyse how the teaching environment supports students' needs for auton omy, competence, and relatedness and consequently supports undergraduate students to achieving intrinsic motivation and engagement in academic activities.

METHODS
The search for relevant literature was performed during November and December 2013. The inclusion and exclusion criteria are outlined in Table 1. Electronic searches were per formed across four databases (Medline, Embase, PsycINFO, and ERIC), relevant journals, and retrieved bibliography of selected articles via the Science Citation Index (SCI). All se lected articles were exported to a reference manager for fur ther and detailed review.
We designed a three main theme search strategy based on the concepts of 'Clinical Teaching AND Intrinsic Motivation AND Undergraduate Students' . These concepts were expanded and adapted specifically for each database thesaurus. The core strategy for Medline, which was accessed via Ovid, is present ed in Table 2. The results from the database search provided key journals for hand searching. Journals were searched through their electronic websites using their advanced search option. Search criteria included articles available in English and Span ish because of the bilingual characteristics of the authors, and considered a 20year time frame search in order to assess cur rent tendencies. Two reviewers independently assessed wheth er the abstracts were eligible for full article review. Any differ ences of opinion were debated and consensus was reached on which papers to include/exclude. Afterwards the selected ab stracts were exported to the reference manager and duplicates were removed. Subsequently, related articles were searched throughout the reference manager's library, and finally, of the selected articles, an ancestry search of their references through the Web of Science ® was performed. A summary of the litera ture search and review process is presented in Fig. 1.
The selected articles that met the inclusion criteria were an alysed and read as full text. A word processing file was crated for each article in order to extract information about their me thods and outcomes. The 'Critical Appraisal Skills Programme' was used as a guide to critically analyse the articles' methods  [12]. Afterwards, three main themes were used to describe how teachers encourage intrinsic motivation. These themes referred to the three psychological needs mentioned earlier: the needs for autonomy, competence and relatedness. Each relevant idea regarding one of these 'needs' was registered as a topic with a brief description. Subsequently, all the data col lected was used to create a table that summarised the infor mation extracted, including the study reference, research top ics, type of study, sample, data collection method, data analy sis and selected findings and comments. Finally, and attempt ing to make sense and integrate the extracted data, a thematic analysis was performed. The most relevant themes from each article, referring to the 'three psychological needs' were identi fied and grouped in a new table. Two reviewers independently    analysed the selected articles following the described steps and posteriorly met, compared their results, and agreed in the final report. The review was organised following the reporting guidelines of the PRISMA statement [13].

RESULTS
The database, manual, and retrieved bibliography search produced 4,869 references to the encouragement of intrinsic motivation in undergraduate students. Of those, 16 met the eligibility criteria and were included in the final review ( Fig.  1). Articles were excluded mainly because they were not em pirical in nature (i.e. view points, editorials, papers expressing opinion and books), they involved other populations, were not referring to motivation in higher education, they focused on motivation for specific issues not regarding the encourage ment of the three basic psychological needs to foster Intrinsic motivation in higher education, or were focused on instrument construction/validation. Table 3 provides a summary of the key findings from the 16 articles reviewed.
The majority of the studies stated clear objectives or research questions, consistent with the study's development and were found to be relevant for the encouragement of motivation in higher education and particularly to the health professions field. Four studies were centred in overviewing motivation and its applications through the selfdetermination theory concept [2,8,9,11], meanwhile the rest focused either on sup porting autonomy, competence, or relatedness. Although one study was oriented to dental education [3], most studies ex amined the encouragement of intrinsic motivation in medical education [2,9,11], psychology education [1417] and general higher education contexts [8,10,1822]. One study combined medical and nursing education [1]. Most studies were design as quantitative [10,1522], only two studies reported mixed methods [3,14] and one a qualitative design [1]. Crosssec tional studies were predominant. Two studies employed lon gitudinal designs [20,22] with two and three data collection points during a one semester period. No control groups were included. One study made a cultural comparison between Ger man and United States students [10]. Participants were all un dergraduate students. Modest sample sizes were selected rang ing from 117 to 222 participants, with two exceptions. One study collected 1,289 reports from students [10], and a quali tative study recruited 31 students [1]. Student recruitment was through advertisement, email and paperbased invitation. Not surprisingly, selfadministered questionnaires were the most popular data collection method, although in several papers more than one was used, these measured different variables. One study used three data collection sources for the same vari ables (i.e. open and close questions, semistructured interviews and focus group), increasing data triangulation [3]. One study used only focus groups [1].
Data analysis was consistent with the studies objectives or research questions. Statistical analysis (i.e. descriptive an infer ential), thematic and content analysis were performed. Studies with qualitative components showed rigorous and credible analysis [1,14]. More than one author examined the collected information separately, and then crosschecked listed catego ries and made adjustments. These studies were also character ised by transparency about methods, one Swedish study asked students to check the final list of categories created and com pleted a forward and backward translation of results to Eng lish, in order to increase dependability and make findings trans ferable [1]. Most studies did not establish causal relations, in stead providing correlations between variables. Three studies reported selfcriticism in this aspect [16,18,20] arguing that manipulating these 'needs of satisfaction' variables in real group contexts would be difficult and perhaps unethical to conduct.

How to encourage the three basic psychological needs?
The majority of the studies stressed the importance of au tonomy supportive teaching to encourage students' intrinsic motivation. Through the variety of contexts revised, the main approach to promote intrinsic motivation was adopting the principles from the selfdetermination theory that stress the importance of creating feelings of competence, autonomy and relatedness in students [2,811,1518,2022]. Table 4 summaris es the main themes according to each psychological need. Stu dents' perceived that an autonomy supportive teaching style increased their autonomous selfregulation, competence, in terest, wellbeing [2,9,10,20] and predicted positive outcomes [10,11,14,15,17,18,21].

Strategies for enhancing autonomy
The needs for autonomy refer to experience behaviour as volitional and reflectively selfendorsed. For example, students are autonomous and intrinsically motivated when they freely choose to devote time and energy to their studies [8]. Three studies argued the importance of identifying what students really want [1,2,9]. Contents must be relevant and interesting for students. If teachers take the time to acknowledge students' interest, they can turn boring contents into attractive activities by changing the scenario [2]. This usually happens when learn ing basic science content. Students may feel uninterested, how ever, vertical integration incorporating clinically oriented ap proaches and early patient contact, could make basic knowl edge useful and meaningful [1,9]. In one study comparing nursing and medical students' perceptions, both agreed that applying theoretical knowledge into practice motivated them to learn. In the same study, all students expressed that their http://jeehp.org  Teacher autonomy support buffered against the general decline in students' mastery-approach goals over the course of the semester and predicted initial self-determined motivation.  subjects are important for their professional future, consequent ly internalizing an originally externally regulated behaviour [8,9].
Brewer concludes that college teachers should use a variety of alternative teaching methods to capture students' attention and curiosity [19]. In his findings, lectures were ranked by stu dents as the number one "amotivational reason to skip class"; therefore, teachers should avoid relying only on them. When using lectures as a teaching strategy in the clinical setting, teach ers should demonstrate vast knowledge of the subject, as stu dents perceived "knowledge of the subject matter" as the num ber one reason to attend class. Using case studies, role plays, experiments, and group activities made learning easier for me dical and nursing students [1]. The use of alternative teaching methods was supported by two studies which argue that turn ing a passive student into an active learner may hold promise for enhancing students' achievement and psychological devel opment [8,20]. Being an active learner involves having time and space to take ownership of the learning process. In two studies, nursing, medical and dental students expressed the value of clinical freedom [1,3] and complained about too much work and too little time to deepen in their areas of interest.
Traditionally, many teachers and schools have relied on con trolling strategies for teaching and curriculum development. Contrary to this, six studies supported giving choice to students, so they could identify and integrate contents [1,2,8,9,15,22]. Boggian et al. found that students under controlling directives conditions performed significantly worse than students in no controlling directives conditions [15]. Students felt comfort able when being in charge of their own behaviour. Teachers can enhance this by giving choices of learning methods, exer cises and task, leading to intrinsic motivation [1,2]. An envi ronment that provides choices and freedom for students also needs them to take more responsibilities in their learning pro cess, this has been shown to stimulate students' motivation [2,11]. Davies et al. stressed the importance of facilitating the empowerment of dental students in clinical teaching [3]. Stu dents should determine their learning path and plan their own moments of assessment when they feel ready [9]. In order to do this, students must know what is expected from them since the beginning of the semester.

Strategies for enhancing competence
The need for competence refers to the desire of feeling ef fective in whatever actions one pursues and performs. Com petence is not meant as an attained skill or ability per se, but rather a perception of confidence and effectance [9]. Two stud ies argued the importance of providing optimal challenges for students feeling competent and enhancing intrinsic motiva tion [2,8]. Activities shouldn't be too hard, but neither too easy for students to test and expand their capabilities. Medical stu dents considered that too easy tasks made them feel insecure and that the level of demands should be appropriate for their learning stage [1]. The idea of an autonomy and competent student does not imply an independent and 'free from the gov ernment of others' learner. Teachers should provide a struc tured guidance, delivering the necessary tools for students' success [2,8], but also seriously valuing their work and mak ing them feel an important part of the clinical environment [3,9]. Five studies revealed the importance that positive and constructive feedback has when promoting intrinsic motiva tion [2,3,810]. This feedback should be oriented on the task, not on the person so that it doesn't feel like a threat but as a suggestion on how to improve what went wrong. Dental stu dents and medical students from different cultures, valued positive feedback at the end of sessions, relating it with greater autonomy and competence [3,10].

Strategies for enhancing relatedness
In order to achieve an autonomous selfregulation behav iour, students must feel connected with teachers and peers [9]. Supporting this concept, Beachboard et al. claimed related ness as a mediating variable for the relationship between stu dents' participation and educational outcomes [21]. Teachers have a fundamental role when establishing rapport with stu dents. Brewer  were more important in motivating students than were the teaching methods and classroom management practices [19]. The most frequently rapportinducing teachers qualities stated by students were: encouraging, openmindedness, creative, interesting, accessible, happy, having a "good" personality, pro moting class discussion, approachability, concern for students, and fairness [14]. Four studies stressed the importance of re specting and having a positive attitude towards students, pro viding a non threatening environment, and feeling cared [1,3,9,19].
Dental students stated that working together and for the teacher to know them, made them feel 'part of the team' [3]. On the other hand, nursing students felt that sometimes lec turers treated them like teenagers instead of adults, affecting their motivation [1]. Teachers should support an environment were students feel emotionally supported, comfortable and free to express opinions, leading them to be more interested in subjects and to the internalization of tasks [2,8]. Not ac knowledging students' expressions of negative effect under mines motivation. Students claimed that when saying some thing critical, teachers sometimes acted defending themselves instead of listening and discussing [1]. Autonomy supportive teaching also includes being empathic when reasonable stu dents' opinions criticise teachers work [2,9].

DISCUSSION
The researchbased evidence for the encouragement of in trinsic motivation in undergraduate students appears to be of reasonable quality, and indicates that clinical teachers should work to satisfy students' basic psychological needs to foster internalization of selfregulation. Several themes emerged from different contexts referring to satisfying those needs and fur ther investigation should expand them. Autonomy supportive teaching in health professions education would benefit stu dents and may actually result in more effective health care de livery [11]. This review identified actions that teachers could implement in their daily clinical teaching work to improve students selfdetermination. Independent of the context, these actions could be transferred to a broad of educational settings.
Our results suggest that clinical teachers should interact with their students in a more 'human centred' teaching style, as these actions predict motivational internalization. Findings illustrate that research on academic motivation has been fo cused in general higher education, psychology education and to a lesser extent in medical, dental, and nursing education. Selfdetermination theory represents one of the most referred theories in psychology, however, its application in health pro fessions education is not so common [9]. Further research ap plying selfdetermination theory principles should be under taken in health professions education, and especially in clini cal teaching settings that represents a very important venue for students' development. As motivation represents a univer sal truth, cultural differences may also influence the implemen tation of an autonomy supportive teaching style. Although one study established cultural comparison between students from Germany and United States [10], future research in aca demic motivation should take into account this differences between students in order to generalize findings in other cul tures.
Most of the studies were based on quantitative methods, and relying only on students' point of view. Only few studies used mixed or qualitative methods and none of them focused on teachers' perceptions. There is no denying of the valuable data emerged from quantitative studies, but the richness and depth of qualitative and mixed methods constituted the core of the extracted data. For further understanding of teachers' practices, qualitative and mixed methods should be consid ered, and students' perceptions should be combined with tu tors' opinions. Teachers are in charge of supporting students' motivation; therefore, knowing their opinions and apprehen sions would add rich information to the data provided by the students. The majority of the studies relied on one method for data collection, primarily questionnairebased instruments. Future research should consider combining multiple sources of data, therefore increasing data triangulation and credibility of results. On the other hand, two studies were based on six and seven questionnairebased instruments to collect infor mation and, as it would be expected, response rates were low er than studies that used fewer instruments. Students fatigue to respond and time value should be taken into account.
Intrinsic motivation and autonomous forms of selfregula tion are the desired type of motivation in students, as they have been associated with deep learning, better performance and wellbeing, in comparison with extrinsic motivation and con trolled forms of selfregulation (i.e. under external control) [5,6,9]. Teacher behaviours and teaching styles can influence students motivation [8,19], either in classroom or in clinical environments. Students' own curiosity and interests are potent tools by which teachers can promote their desire to learn. In contrast, teachers that rely on external factors (e.g. rewards), risk students internal learning aspirations, compromising the quality of the process [8]. An autonomysupportive teaching style is characterised by providing options and opportunities for selfdirected decisions minimising external pressures [6,23].
The reviewed articles considered the autonomy supportive teaching style to be important for learning, as it aids students' selfmotivation and relatedness with significant others [1]. Therefore, many successes and failures in clinical education could be understood through selfdetermination theory. In http://jeehp.org J Educ Eval Health Prof 2015, 12: 8 • http://dx.doi.org/10.3352/jeehp.2015. 12.8 addition, intrinsic or extrinsic motivation are not permanent characteristics, thus, stressing the point about paying attention to the influences of learning environments [6].
Finally, a number of important limitations need to be con sidered. First, several sources of bibliographic data were used to identify eligible articles. Though important material was found, it was limited to the sources included and important papers could have been ignored. Second, journals searched were predominantly from the United Kingdom and USA, and in English. Even though Spanish articles were included in da tabase search, language and demographic criteria was also counted as limitations. Lastly, most of the reviewed articles were design as crosssectional studies. Prospective research is needed to examine if the satisfaction of the three psychologi cal needs in fact predicts changes in the internalization of be haviour and the fostering of intrinsic motivation towards aca demic activities.
It is not difficult to engage in an autonomysupportive teach ing style, it can be learned through practice and selfreflection. By providing an educational environment based on the self determination theory principles, clinical tutors may be suc cessful in their teaching. Therefore it is important that future research considers what educators and clinical tutors are actu ally doing to enhance student's motivation and how they can incorporate new teaching and learning strategies.