Influence of medical didactic training on the self-efficacy and motivation of clinical teachers

Introduction

Clinical teachers are required to navigate a dynamic landscape of conflicting interests, caught between the demands of patient care, a shortage of skilled staff, personal career objectives, work–life balance, and the expectations of medical students and junior doctors regarding their clinical training. Moreover, the didactic methods and attitudes needed for structured knowledge and skill transfer are not usually covered in medical school or specialist training, often making them inadequately or entirely unavailable to clinical teachers. The in-depth instruction and practical execution of advanced teaching skills can help manage these competing responsibilities more effectively [1].

In 2013, the modular course “Train the Trainer” (TTT) was designed by CAL (Chirurgische Arbeitsgemeinschaft Lehre, Deutsche Gesellschaft für Chirurgie (DGCH)) to professionalise the medical educational skills of clinical teachers [1]. This course is intended for medical teachers across various disciplines, regardless of their prior teaching experience.

Self-determination theory (SDT) is a theoretical framework that explains human behaviour by focussing on human motivation and the extent to which our actions are intrinsically motivated and self-determined [2, 3]. Self-efficacy is defined as the confidence in one’s ability to carry out actions successfully, thereby achieving a desired outcome [4]. Within the SDT framework, intrinsic motivation emerges when three innate psychological needs are met: competence, autonomy, and relatedness or social integration [2, 3]. An environment in which these needs are adequately fulfilled stimulates human growth, evolution, integration, and personal well-being; motives that prompt actions driven by intrinsic motivation and form self-determined (or self-regulated) behaviour patterns.

The concepts of self-efficacy and motivation have significant impact on teaching and learning processes in an academic as well as a medical context. By quantifying these factors in relation to participation in the TTT course, we aim to determine how the training can influence these parameters. Several aspects of the teaching and learning dynamics are addressed below.

Effective teaching: Motivated teachers aspire to introduce innovative concepts and refine their teaching methods on a regular basis [5]. Teachers with high self-efficacy focus on the existing knowledge and skills of learners [6], resulting in higher commitment and more effective instruction [7, 8]. This, in turn, elicits increased effort from students, fostering their learning success and advancing their academic performance [9, 10].

Competence: Self-efficacy expectations are strongly linked to the fundamental need for competence. By displaying one’s capabilities or demonstrating one’s own effectiveness in achieving personal goals, thereby providing a sense of control, a strong sense of competence enhances self-efficacy [2]. In turn, high levels of self-efficacy lead to individuals’ actively seeking out situations in which to gather more evidence of their own competence, creating a positive feedback loop.

Professional development: Motivated teachers are eager to expand their knowledge and skills [5] and therefore often participate in continuing education programmes. This behaviour enhances their competence – both objective expertise and perceived sense of development and mastery – thereby amplifying the positive impact not only on their professional skills, but also their self-efficacy.

Role modelling: Teachers in any context serve as role models for their students. The attitude they demonstrate while teaching can inspire students to further develop their skills and recognise their abilities [11], increasing their own intrinsic motivation [12] and self-confidence.

Resilience: High levels of self-efficacy, in particular, are crucial in strengthening one’s resilience [13]. Believing in one’s capabilities to overcome challenges contributes notably to their resolution, aids in problem-solving, and increases resistance to stress and external demands amidst a field of competing interests [1, 14, 15].

Job satisfaction: High degrees of motivation and self-efficacy are reflected in a strong sense of job satisfaction that ideally occurs not just while teaching, but during other routine tasks [16] and, ultimately, throughout the entire professional career. It correlates with enhanced performance [16], [17], [18] and promotes personal resilience, helping to prevent stress and exhaustion in employees. Notably, job satisfaction not only greatly affects personal well-being [3, 18]; it also has significant implications on micro- and macro-economic developments as well as on society as a whole [17, 19], [20], [21].

The TTT was designed to make effective teaching more accessible and integrate it into daily clinical practice without significant resource expenditure. However, this educational strategy does not solely look towards enhancing teaching methods and advancing course participants’ academic objectives; if the above-described effects are observable, the participants will reap multiple benefits, leading to better future navigation of their challenging environment.

This study aims to explore how participation in didactic training influences the self-efficacy and teaching motivation of clinical teachers. Additional effects of the course were evaluated by asking the participants about their prior didactic experiences, didactic methods they had implemented after the course, and the frequency of their feedback.

Methods

The TTT course runs for 7  hours distributed over 2 days, covering basic didactic principles and methods and utilising group work and simulations to demonstrate and implement them (Table 1). A significant portion of this course requires self-learning and practical application of contents. All methods taught in the course are designed to be easily integrated into clinical routine. As part of the course’s preparation and follow-up assignment, participants are asked to incorporate the methods they have learned into a course they have planned themselves.

Participants of this study were all individuals who took part in TTT courses held between June 2016 and October 2019. Their participation was voluntary, anonymous and not tied to their course results. General conditions were briefly explained before the questionnaires were handed out. Samples used in the original studies previously conducted to validate the psychometric parameters were employed as reference groups in our statistical analysis [4, 22].

Psychometric tools were employed to measure the participants’ self-efficacy across two areas. “Generalised self-efficacy” (GSE) gauges an individual’s confidence in their ability to address everyday challenges [4]. “Teacher self-efficacy” (TSE) specifically probes into teachers’ belief in their ability to meet distinct requirements of their profession [4] (Table 2).

To determine participants’ motivation regarding their teaching activities, the Physician Teaching Motivation Questionnaire (PTMQ) [22] was integrated into the questionnaires. The PTMQ, built around self-determination theory (SDT), is specifically designed to measure various dimensions of clinical teachers’ motivation. It differentiates between intrinsic and extrinsic motivation, with further subdivisions for identified regulation, introjected regulation and external regulation. It also factors in career motivation and amotivation (Tables 2 and 4).

PRE-survey: Before the course, participants were given a 50-question anonymous PRE-questionnaire. This questionnaire enquired about their biographical information, prior teaching experience, and the regularity of their feedback to students. The survey included a variety of question types, such as multiple-choice, Likert scale, and free-text. It incorporated validated scales to measure generalised self-efficacy (GSES; 10 items, four-point Likert scale), teacher self-efficacy (TSES; nine items, four-point Likert scale) [4, 23, 24] and motivation (PTMQ; 18 items, five-point Likert scale) [22]. All questionnaires used in this study can be found in the Supplementary Material.

POST1-survey: After the course, participants were requested to assess it using 25 course-related anonymous questions (multiple choice, Likert scale, free text), referred to as POST1.

POST2-survey: Participants received a 44-question follow-up questionnaire by mail at least 12 months after completing the course. They were asked to give demographic information, details on their current didactic tasks, and their application of methods learned on the course, including the frequency of their feedback (multiple choice, Likert scale, free text). Additionally, a second assessment of generalised and teacher self-efficacy [4, 23, 24] as well as teaching motivation [22] was made using the parameters previously applied in the PRE-survey.

Participants’ responses were recorded as ratings on the Likert scale, each represented by their numerical value. Multiple-choice answers were assigned corresponding numerical codes. Free-text responses underwent analysis and grouping. Individual item values from the Likert scale resulted in scores for GSE, TSE, and motivation, which were analysed as continuous interval-scaled variables. Forms returned with incomplete answers to GSE, TSE, or PTMQ scales were excluded from further analysis. Statistical testing was performed using BiAS version 11.12 (epsilon-Verlag 2022, Goethe University Frankfurt). We would like to thank Prof. Dr. E. Herrmann of the Institute for Biostatistics, Goethe University Frankfurt, for her assistance with the statistical analysis of our data.

After collection of the questionnaires had been completed, PRE and POST2 questionnaires were matched based on participants’ biographical information while preserving anonymity. A select number of forms that could not be assigned based on these criteria was excluded from matched analysis, resulting in a sample size of 51 matched pairs of PRE and POST2 questionnaires.

GSE, TSE, and PTMQ scores were analysed for changes pre- and post-course using a paired t-test. Similarly, scores from the PRE sample were compared to those from a specified reference group for each parameter using a two-sample t-test, employing Welch’s t-test in instances of unequal variances. The original samples used to validate the psychometric parameters were used as reference groups [4, 22].

To evaluate alterations in the frequency of participants’ providing feedback before and after completing the course, the five response options (“never”, “rarely”, “occasionally”, “frequently,” and “always”) were consolidated into two categories (“frequently” and “rarely”). Subsequently, the collected data were analysed using McNemar’s test for paired samples with a sample size of n=48.

Results

From June 2016 to October 2019, 20 TTT courses were conducted at six medical faculties in Germany. During the PRE-survey, data were collected from a total of 241 participants, 193 of which were doctors (80.1 %), 38 other medical staff (15.8 %), and nine from non-medical professional groups employed by the faculty (3.7 %). The participants’ ages varied between 22 and 58 years, with a median age of 37 years. The POST1 evaluation form was completed by 233 participants immediately after the course. A total of 182 questionnaires were distributed from 12 months (median 19 months) after course completion; the response rate was 39 % (n=61).

Self-efficacy

The comparison of samples before and after the course did not reveal significant changes in generalised self-efficacy (n=50, p=0.1926). However, a statistically significant increase in teacher self-efficacy was observed (n=48, p=0.0025) (Figures 1 and 2).

Figure 1:

Generalised self-efficacy of TTT participants before and after taking the course (n=51, X corresponds to the mean, the box corresponds to the first to third quartile, the whiskers 5 % and 95 % quantile, individual points outliers).

Figure 2:

Teacher self-efficacy of TTT participants before and after taking the course (n=51, X corresponds to the mean, the box corresponds to the first to third quartile, the whiskers 5 % and 95 % quantile, individual points outliers).

Before taking the course, participants demonstrated a significantly higher generalised self-efficacy compared to the chosen reference group (n=236 and n=299, respectively; p=0.0085; Figure 3). There was no significant difference in teacher self-efficacy between the two groups (n=216 and n=292, respectively, p=0.1429; Figure 3).

Figure 3:

Generalised and teacher self-efficacy of participants before taking the course vs. the reference group (mean values and standard deviation).

Teaching motivation

The comparison of samples before and after the course revealed a statistically significant increase in identified regulation (n=50, p=0.0000) and career-related motivation (n=50, p=0.0044). Meanwhile, there was a statistically significant decrease in introjected regulation (n=50, p=0.0048). No substantial differences were found for the other parameters.

Significant differences were observed in the parameters of intrinsic motivation and amotivation between the reference groups and course participants in the PRE-survey. Participants’ intrinsic motivation was significantly higher (n=217 and n=229, respectively; p=0.0000), and their amotivation significantly lower (n=218 and n=229, respectively; p=0.0025, Figure 4).

Figure 4:

Motivation dimensions (Likert scale points) of course participants before and after completing the course as well as the reference group as seen in the original study [22].

Discussion

In the field of teaching, self-efficacy and motivation are central concepts, and various examples for their application can be found in literature. However, the majority of such studies are conducted in the area of primary and secondary education; studies referring to higher education mostly focus on students, and those set in a clinical context usually examine the doctor–patient dynamic. This study specifically concentrates on teachers in a clinical setting.

As the TTT course is held at university hospitals, the majority of its participants, and thereby our study sample, are situated in a clinical context amongst a multitude of competing demands (as mentioned above). Seeing as teaching in such an environment is especially challenging, the potential benefits offered by didactic interventions, specifically the TTT, are immense. Investigating its impact – a first for this course – provides a valuable foundation not only for designing and refining didactic courses in a medical context but also for future studies in this expanding field of research.

Limitations

The study’s primary constraint involves confounders affecting participant results, particularly in case of extended periods between course participation and POST2 survey. Psychometric parameters such as self-efficacy and teaching motivation in particular are influenced not only by course participation but also by further acquisition of skills in both a professional and private context. To mitigate these influences, future studies should adopt prospective controlled trials.

The study sample consists of participants in an educational training course, creating a selection bias regarding teaching motivation. Doctors not involved in teaching or not taking part in didactic training would likely show different baseline values for teaching motivation. The inclusion of a control group could again have provided an advantageous balance. There is also a potential observation bias in the survey due to the nature of the study’s inquiry. Despite this unavoidable bias, efforts to minimise it were made by ensuring the survey’s anonymity.

Dybowski et al.’s [8] study conceived the Physician Teaching Self-Efficacy Questionnaire (PTSQ), which was designed specifically for clinical teachers, thus more precisely reflecting the “teacher self-efficacy” parameter. Although it was not employed for the ongoing study due to comparability issues, it is recommended for future research.

Conclusions

The concepts of self-efficacy and self-determination theory are well-established in education, sociology, and psychology. Significant research has been conducted on the influence of self-efficacy among schoolteachers, students and patients. However, teachers in a clinical setting remain an overlooked research group, with limited studies dedicated to their self-efficacy and teaching motivation [8, 30, 31]. Given the potential benefits, particularly in the restructuring of medical undergraduate and speciality training [32–34], it is essential to expand research in this area.

The “Train the Trainer” course holds potential not just for skill acquisition but also for strengthening participants’ self-efficacy and motivation to teach. This can be observed through its graduates’ increased identification with the role of a clinical teacher and growing confidence in handling associated challenges. Furthermore, while intrinsic motivation remained almost unchanged, a noticeable internalisation and integration of the imparted values was shown. The results’ validity is somewhat limited due to variable factors in the duration between course completion and follow-up survey, which may have affected self-efficacy and motivation. Future controlled studies are needed to quantify this effect.

In the ongoing and future development of the TTT and similar formats, focus should be given to the hands-on exercises of the course that potentially have a positive impact on self-efficacy [30]. These segments were highly favoured by participants and considered the most effective. Nonetheless, theoretical elements of the course should not be neglected as they support the process of internalisation and serve as food for thought. In addition, the current version of the TTT emphasises the application of “constructive alignment” by including the development of SMART learning objectives and the selection of suitable assessment methods.