Educators’ consideration of learner motivation in ophthalmology education in medical school: Influences on teaching practice and course design

Abstract

Background

Ophthalmology education in medical school has historically neglected the impact of autonomous motivation on student learning and wellbeing. This study aimed to understand ophthalmology educators’ consideration and application of student motivation in ophthalmology medical education.

Material and methods

Lead ophthalmology educators from Australian and New Zealand medical schools participated in an online semi-structured in-depth interview. Interview transcripts were analysed using thematic analysis. Codes were generated and aligned into overarching themes.

Findings

Six educators participated in the study. Five main themes arose from the transcripts: the lack of explicit consideration of student motivation, implicit consideration of motivation in curriculum design and in teaching practices, the impact of innovation on motivation and the relationship between teacher and student motivation. Participants also commented on trends in ophthalmology education including generalists’ confidence in managing ophthalmic disease, the role of fundoscopy in medical education and time pressure on ophthalmology in medical schools.

Conclusion

There has only been an implicit instead of explicit consideration of motivation in ophthalmology education in medical school, which leaves an unfulfilled potential for teaching practices to impact the affective along with cognitive and metacognitive aspects of learning. This study highlights the need for motivation to be explicitly incorporated into the development of teaching practices and curriculum reform.

Keywords:

• Medical education
• motivation
• ophthalmology
• self-determination theory
• curriculum design

Introduction

Proficiency in diagnosing and managing ophthalmic conditions is an essential skill for medical graduates. Approximately 2–19% of patient presentations in general practice are due to underlying ophthalmic disease, with a greater percentage likely to present to hospital emergency departments (Vernon 1988; Fan et al. 2007; Helena et al. 2014). However, ophthalmology teaching in medical schools has been underemphasised by medical schools across Australia. In a study by Fan et al. (2007), Australasian medical schools saw reductions or even the absence of ophthalmic specific teaching, with great variation in curriculum outcomes. A recent study by Scott et al. (2022) showed continued substantial variation in ophthalmology curriculum between Australian medical schools, even when compared with past national evaluations (Stark et al. 1992; Fan et al. 2007; Zhang et al. 2018; Scott et al. 2022). This trend has also been noted in UK and Canada, where medical schools have seen a decrease or even absence of ophthalmology teaching in medical schools (Quillen et al. 2005; Baylis et al. 2011; Hill et al. 2017; Gostimir et al. 2018). This underexposure to ophthalmic education in medical school is an evident concern of students and Junior Medical Officers (JMOs) (Li et al. 2016; Zhang et al. 2018), and has resulted in low levels of confidence (Tan et al. 1997; Sim et al. 2008) and accuracy (Statham et al. 2008) in diagnosing and managing ophthalmic conditions.

Practice points

• Reform in ophthalmology teaching in medical school has primarily focused on cognitive and metacognitive aspects of learning, often neglecting the impact of student motivation.

• Student motivation was not explicitly considered by educators, but was implicitly consider by acknowledging its positive impact on the effectiveness of educational practices and curriculum designs.

• Educators recognised the positive impact of teacher motivation and innovation on fostering student motivation.

• Educators should receive training on how strategies to foster autonomous motivation can be implemented in their teaching practices and the medical school ophthalmology curriculum.

• Given the positive impact of autonomous motivation on student learning outcomes, deliberate efforts should be made to improve student motivation in ophthalmology education in medical school.

This problem has spurred a redesign of ophthalmic education in many medical schools. Educators have recognised the time constraints of a medical degree and have opted to focus on initiatives that optimise the efficiency of ophthalmology training instead of simply increasing teaching hours (Succar et al. 2020). Self-directed and problem-based learning in ophthalmology education of medical students have been shown to enhance competency and preparedness (Sahoo 2016; Wu and Greenberg 2016; Atta and Alghamdi 2018). In addition, ophthalmology teaching that incorporates peer assisted learning activities (Sahoo et al. 2015), team-based learning activities (Huang et al. 2016), virtual reality simulations (Wu and Greenberg 2016), virtual clinics with case-based learning (Succar and Grigg 2010; Succar et al. 2013; Succar and Grigg 2019), and eLearning modules (Petrarca et al. 2018) have also been shown to improve student performance and satisfaction. Additionally, there has been a focus to standardise ophthalmology curricula in Australian medical schools to provide high quality education to all medical students (Stark et al. 1992; Fan et al. 2007; Zhang et al. 2018; Scott et al. 2022).

However, studies in ophthalmology education methods and curricula often neglect deeper inquiry into all aspects of the learning process and how these impact on student outcomes. The process of learning is understood to occur in three dimensions: the cognitive (what to learn), metacognitive (how to learn) and affective (why we learn) (Vermunt 1996; Bransford et al. 2000). Whilst recent developments in ophthalmology education often address the cognitive and metacognitive aspects of learning, the affective component is often neglected. Central to affective learning is student motivation, an area that has shown great promise in improving learning outcomes and wellbeing (Kusurkar et al. 2011; Kusurkar et al. 2011; ten Cate et al. 2011; Kusurkar et al. 2012). Motivation is defined as the energy or intention to move oneself or others to act (Deci and Ryan 2000; Ryan and Deci 2000b, 2000a).

Self-Determination Theory of Motivation (SDT) is a comprehensive conceptual model for motivation and has been effectively applied to health education (Kusurkar et al. 2011; Kusurkar et al. 2011; ten Cate et al. 2011; Kusurkar et al. 2012). SDT, empirically developed by Edward Deci and Richard Ryan, outlines that human behaviour is dependent on the quality and not just the quantity of motivation (Deci and Ryan 2000; Ryan and Deci 2000b; Deci and Ryan 2008). According to SDT, motivation can range from amotivation, or the lack of motivation, to controlled motivation and finally autonomous motivation. Behaviour that results from controlled motivation is often a result of external factors do not align with one’s sense of self (Ryan and Deci 2000b; Deci and Ryan 2008; ten Cate et al. 2011). Autonomous motivation describes an individual who identifies with the value of an activity, integrating it into their sense of self (Ryan and Deci 2000b; Deci and Ryan 2008; ten Cate et al. 2011).

Increased autonomous motivation has been shown to result in deeper understanding of course material, promote reflective learning and result in greater educational outcomes (Kusurkar et al. 2011; Kusurkar et al. 2011; ten Cate et al. 2011; Kusurkar et al. 2012). Additionally, productivity and higher cognitive processes were significantly boosted in medical school tutorial groups with higher autonomous motivation (Dolmans et al. 1998). Students with higher autonomous motivation have also been shown to have greater academic performance and sense of wellbeing than those with predominantly controlled motivation (Ryan and Deci 2000b; ten Cate et al. 2011). In a study of medical student motivations and educational outcomes, Sobral (2004) showed benefits to learning behaviour in students with higher levels of autonomous regulation. Autonomously motivated students were also more likely to engage in deep learning and pursue further studies, whilst the opposite was true for students with amotivation. In addition, students who were autonomously motivated achieved higher academic grades in preclinical years, were less likely to drop out and showed greater intention to continue studies after graduation (Sobral 2004). The benefits of fostering autonomous motivation is also evident in other areas of health education (Orsini et al. 2016), including dentistry (Orsini et al. 2018; Orsini et al. 2019) and nursing (Bengtsson and Ohlsson 2010; Hosseini et al. 2022).

Autonomous motivation is most likely to be developed by fulfilling three basic psychological needs: autonomy, competence and relatedness (Deci and Ryan 1985; Ryan and Deci 2000b, 2000a; ten Cate et al. 2011). Autonomy is the degree to which people feel free to make their own choices, competence is defined as the perception of capability within a person, whilst relatedness is the feeling of belonging and being valued as part of a group. Non-modifiable factors may also contribute to autonomous motivation, including age, gender, ethnicity, socioeconomic status, educational background and year of the curriculum (Kusurkar et al. 2011). Structuring the educational environment and curricular activities to fulfil the three basic psychological needs of students fosters autonomous motivation (Kusurkar et al. 2011; Kusurkar et al. 2011; ten Cate et al. 2011; Kusurkar et al. 2012).

Given the immense positive impact of fostering autonomous motivation in students, it is essential that medical education addresses the affective, cognitive and metacognitive aspects of learning equally. This is especially important in ophthalmology education, due to the concerning demand for improved outcomes and confidence in medical graduates managing ophthalmic disease. However, we must first understand how educators apply motivational strategies in the context of ophthalmology education in medical school. This can form the basis for recommendations to further integrate SDT into teaching practices and curriculum designs employed in ophthalmology education. To describe the role of student motivation in guiding ophthalmology education in medical schools, this study aims to explore ophthalmology educators’ consideration and application of student motivation in ophthalmology medical education.

Methods

In this descriptive qualitative study, ophthalmology educators engaged in a semi-structured in-depth interview to explore how motivation is perceived by teachers, and the impact that motivation has on teaching practices and curriculum design. A qualitative study design was chosen to provide rich and informative data, where researchers and participants have the freedom to highlight experiences that build understanding of the research topic (Wu and Volker 2009; Cleland 2017). Additionally, a post-positivist epistemology was employed, where participants’ meanings and experiences are focused on to gain insight into their external reality, which may support the development of conjectural knowledge about reality (Ryan 2006; Bisel and Adame).

Participants

Participants were staff involved in ophthalmology education in medical schools across Australia and New Zealand. To be included in the study, universities must have had a compulsory ophthalmology teaching component within their medical school curriculum, including a theoretical component and a clinical component. Participants were required to be ophthalmology academic leads in their respective universities and were to have a teaching role within the ophthalmology medical school curriculum. Medical schools were excluded from the study if ophthalmology teaching was solely run by other disciplines such as general practice or emergency medicine. These inclusion and exclusion criteria ensured that participants were integral in developing and disseminating ophthalmology education programs in medical schools.

Sampling

Purposive sampling was used in this study, and recruitment was voluntary. All 23 medical schools across Australia and New Zealand were invited to participate in this study. Universities were contacted through email and phone. Staff who were identified as being eligible were contacted individually to obtain consent for participation.

Information power (Malterud et al. 2016) was used to determine data sufficiency in our sample. The five dimensions of information power include the study aim, sample specificity, use of established theory, quality of dialogue, and analysis strategy. Throughout the data collection and analysis process, the adequacy of the sample size was continuously evaluated. Our study aim was narrow, the sample was densely specific, SDT was used as a theoretical framework, quality of interview dialogue was strong, and a cross case analysis was performed. Hence, the attained information power of our sample was high, and data analysis could be ceased at 6 participants.

Data collection

Interview questions were developed according to the seven-step process described by Artino et al. (2014). This included conducting a systematic review (unpublished) and descriptive analysis of the literature on the application of SDT in medical education and current educational approaches and advances in ophthalmology education in medical schools (Sharma et al. 2015). The review findings identified a sparsity of existing studies investigating SDT in the context of ophthalmology education in medical school. However, there was valuable data to support the application of SDT in medical education in speciality areas other than ophthalmology. These findings along with observations of student motivations in ophthalmology education and the potential applications of SDT in this context were discussed in focus groups that included all six authors. In general, focus group members observed a lack of deliberate consideration of student motivation, and a poor understanding of SDT principles by most ophthalmology educators. Hence interview questions were developed to examine ophthalmology educators’ considerations of student motivation, their observations of students’ motivation in response to their teaching methods and to further examine their views on potential applications of SDT in ophthalmology education. We ensured SDT principles and use cases were not prerequisite knowledge for interviewees.

A pilot study of potential interview questions was undertaken by DDCSD, HR and SC with two local ophthalmologists and one medical educator using draft interview questions. As a result of this, final interview questions were written with a focus on a more fundamental inquiry of educator’s consideration of motivation, and to formatted to be more open-ended. All interviews were recorded and transcribed, with all identifying data, including university and participant demographics later removed to ensure confidentiality (Johnson and Christensen 2019). Questions used for guidance of semi-structured interviews are listed in Supplementary List S1.

Data analysis

Interview transcripts were analysed using reflexive thematic analysis (Braun and Clarke 2021). This was done with an inductive, data driven approach (Clarke and Braun 2013; Kiger and Varpio 2020). The process for reflexive thematic analysis, as described by Braun and Clarke (2021), involves by six phases, and are outlined in Table 1. Importantly, these phases were carried out iteratively and recursively, using a constant comparative method.

Table 1. Six step process for thematic analysis as outlined by Braun and Clarke (2006).

Step	Description
Step 1: Familiarisation with the data	DDCSD transcribed audio interviews and actively read through transcripts.
Step 2: Generating initial codes	DDCSD coded data according to pertinent issues raised by participants. All authors reviewed these codes.
Step 3: Generating initial themes	DDCSD examined coded data to identify meaningful patterns or themes, which was discussed with all authors.
Step 4: Developing and reviewing themes	DDCSD, HR and SC checked candidate themes to ensure that coded data were placed appropriately to each theme, and that themes accurately reflect the entire dataset. The entire dataset was re-read, and codes and themes were revised if needed.
Step 5: Refining, defining and naming themes	DDCSD and SC analysed individual themes to identify its essence and create names that appropriately define each theme.
Step 6: Producing the report	DDCSD was involved in analysing the themes that emerged from the data using SDT as the theoretical lens. DDCSD wrote the manuscript to best reflect the analytic process and communicate a clear, logical and narrative account of results. DDCSD, SC and HR were involved in, reviewing and editing the results of this thematic analysis.

DDCSD, SC and HR are the initials of the authors of this paper.

The first step of the reflexive thematic analysis process involved familiarisation of the data. DDCSD carried out and transcribed all interviews. DDCSD was involved in active reading of interview transcripts to encourage immersion with the data, and initial relations within and between transcripts were noted. The second step involved the generation of codes, where DDCSD succinctly labelled important characteristics of the data with four rounds of coding. Codes were generated to represent only the most basic element of information and were reviewed by SC and HR to ensure accuracy of coding. In the third step of reflexive thematic analysis, DDCSD examined the coded data, looking for patterns of meaning to emerge. This allowed for initial candidate themes to emerge from the data organically without an imposed theoretical framework. These were discussed with DDCSD, HR and SC. Initial themes were developed and reviewed in the fourth step of reflexive thematic analysis by DDCSD, HR and SC. All authors ensured that candidate themes were representative of the dataset, which involved certain themes being split, combined or discarded.

The fifth step of reflexive thematic analysis involved refining, defining and naming themes. Each candidate theme was analysed with their meaning and story scrutinised by DDSCD and SC, to ensure each theme accurately reflected the narratives of the data set. This allowed each theme to be named by DDCSD to capture its true essence. These names were reviewed and refined by DDCSD, HR and SC. Writing up these themes were part of the sixth step of reflexive thematic analysis. This was done to best reflect the original dataset and most accurately preserve the voices of participants. Themes were analysed through the lens of SDT in this final stage of analysis, once themes were organically generated and named. This analysis is presented in the discussion, and is contextualised within the existing SDT literature. DDCSD wrote the manuscript, and all authors reviewed and edited subsequent iterations.

Analysis was carried out with the NVivo software (QRS NUB*IST Vivo).

Trustworthiness

A detailed record of data analysis was maintained by DDCSD and reviewed by all authors to support the trustworthiness of interpretations (Lincoln et al. 1985; Nowell et al. 2017). Credibility was maintained by researcher triangulation between DDCSD, HR and SC. Constant debriefing of the research process was carried out via meetings with all contributing authors, and the justification of all findings with quotes was ensured (Sandbergh 1997; Nowell et al. 2017). Dependability was addressed by DDCSD in maintaining a detailed description of the research process this study, which was reviewed by all authors and included in the manuscript (Nowell et al. 2017). Aims and methodology of the study were developed by DDCSD and reviewed by all authors after thorough systematic literature review as previously detailed, which addresses reflexivity (Stenfors‐Hayes et al. 2013).

Ethics

This study was approved by the Human Ethics and Research (HERC) committee of UWA.

Findings

A total of six medical schools met the inclusion criteria and agreed to participate in this study. Five medical schools were in Australia, and one was located in New Zealand. Two of the participating universities taught medicine as an undergraduate program (MBBS), with the other four universities teaching medicine as a graduate entry program (MD). A total of six interviews were carried out with ophthalmology educators from each medical school. All six educators were ophthalmology discipline leads in their respective medical schools.

Five major themes around student motivation were identified. These were a lack of explicit consideration of student motivation, implicit motivation in curriculum design, implicit motivation in teaching practices, relationship between teacher and student motivation and the impact innovation and motivation. Themes are supported by accompanying quotes displayed in Table 2. Additionally, certain trends in ophthalmology education were highlighted by educators.

Table 2. Major themes on medical student motivation in ophthalmology education.

Category	Meaning	Quote
Theme 1: Lack of explicit consideration of student motivation
Motivation not considered in curriculum design	Curriculum components were not chosen or designed to foster autonomous motivation	1. ‘When we developed our curriculum, it’s really about making them comfortable approaching the eye of a patient and teaching them how to do that. I'm afraid motivation was not really a factor we considered’. (Educator 2)2. ‘When designing the curriculum, we’re focused on minimum standards, which is the ICO. So really, motivation doesn’t really play a part in that’. (Educator 5)
Motivation not considered in assessment design	Assessment methods were not chosen or designed to foster autonomous motivation	3. ‘I haven’t dedicated a lot of time to be honest, to looking into new assessment methods that may make students more motivated to learn’. (Educator 3)
Learner centred	Culture shift where educators consider students learning needs, even though motivation was not explicitly one of these.	4. ‘So the way we structured the course was to attempt to put the student in the centre and develop topics according to their learning and emotional needs. However, I wouldn’t say it was motivation per se that we were prioritising’. (Educator 1)
Theme 2: Implicit consideration of motivation in curriculum design
Problem based learning	Interactive problem-based learning preferred over exclusively didactic teaching	6. ‘Students should be able to deductively work their way through a problem. We find that this mimics the clinical environment, and most students are actually more motivated to learn by solving problems than by simply being talked at. So, we have moved towards more problem-based learning to complement our lectures and tutorials’. (Educator 4)
Flipped classroom	Engage in content prior to class to allow for application of knowledge in face-to-face sessions	7. ‘What I do is I put all the slides for tutorials and lectures online, and I ask them to read those slides ahead of time. Students then come in to face to face teaching sessions with some context, and they feel more competent in that way’. (Educator 4)
Clear outcomes and information	Educators set out clear outcomes and logically organised course content.	8. ‘I have pushed to make the layout of our content as clear as possible. To me, the clearer it is, the more easily students will process it and remember it and feel confident in the material. When information is haphazard students simply will not be motivated to learn’. (Educator 1)
Rationalising assessments	Ensuring the appropriate number of assessments	9. ‘Some students don’t like some of our log-book style assessments, because they feel pressured that they have to see a certain number of patients which might not be feasible in the limited clinic time they have. So, we have limited the amount of logbooks assessments and made them more flexible to address this’. (Educator 5)
Rationalising content	Prioritising course content to ensure students are not overwhelmed	10. ‘Ophthalmology historically has been taught by subspecialty and in a lot of detail. But I think that’s off putting, it is too much volume for students. I don’t think it’s been taught with the general practitioner or the emergency doctor in mind as much as it should have. So, we have tried to focus on the most common and serious conditions in our teaching to not over-burden students with information’. (Educator 1)
Theme 3: Implicit consideration of motivation in teaching practices
Student feedback	Student feedback was the primary way educators implicitly gauged student motivation.	5. ‘We changed our teaching methods because we have feedback from the students. They tell us that some sessions don’t inspire them, and some encourage their engagement. So, this feedback does guide us in some way’. (Educator 5)
Vicarious learning	Inclusion of analogies and real-world stories as a memory cue and as a motivational tool	11. ‘If I were to describe how to do ophthalmoscopy versus tell them a really outlandish story about ophthalmoscopy that will get them to laugh and enjoy the class and teach them the skill, the later always motivates them more’. (Educator 4)
Building relevance	Educators using perspective to convey relevance for future practice	12. ‘I don’t think students know just how many eyes they’re going to be seeing in general practice or in ED. I try to begin the rotation by stressing that in reality if you’re a GP or you’re an emergency physician and in many other specialties whether it’s endocrinology, neurology, ENT, maxillofacial surgery or paediatrics, all of these guys are going to have some element of exposure to eye disease. So, I guess students lack that perspective, which is not their fault, but I try to broaden that’. (Educator 3)
Active non-clinical participation	Encouraging active engagement in the classroom	13. ‘I love the freedom us teachers have in the actual teaching workshops. We’ve been running these workshops now for almost 15 years and we always get very positive feedback from the students because it is very hands on, we always show case the latest technology, and the teachers are more relaxed and have time to engage with students’. (Educator 3)
Active clinical participation	Students actively seeing patients in clinics or discussing patients with consultants to encourage active thinking	14. ‘I try and make it a point that every student is actively involved in seeing every patient on the slit lamp. In my office, we have a video attachment to the slit lamp, which is very useful. And I try and make sure that we talk through some cases and discuss pathology, so we get them as involved as possible. I think at the end of the day, there’s no substitute for seeing patients. And I think that’s where the clinics are important. We try our best to get them involved in the consult’. (Educator 2)
Interest	Developing genuine fascination with the subject matter	15. ‘What we’ve done in our lectures is we’ve said, “Okay, what are the small, interesting things that we can show students that motivates them and inspires them to want to know more?” Once you have that initial spark, they are more likely to pursue information in a self-directed way’. (Educator 4)
Relatedness	Ensuring students feel part of the team	16. ‘I find that teamwork with students is very rewarding for both parties. Students feel that they have responsibility in the clinical workspace which often spurs them on to be more active and self-directed learners’. (Educator 6)
Support from teachers	Supportive and nurturing teaching styles	17. ‘And also, as a group, I like to think that all the registrars, are a good bunch to work with. They’re very friendly, very sociable, and I think the students enjoy being mentored by them. And that’s probably a way that we can actually encourage them and motivate them to feel excited about ophthalmology: to be supportive and personable to them’. (Educator 2)
Theme 4: Impact of innovation on motivation
Online teaching	Move towards online modes of teaching	24. ‘We have moved all our lectures to online lectures which is good because everyone’s very comfortable with that and it gives the lecturers a more freedom in terms of how or when they can present their lectures’. (Educator 2)
Virtual PBL	Virtual clinical scenarios to supplement clinical placements	25. ‘We are developing case-based scenarios on a smartphone app where it’s a step wise progression’. (Educator 1) 26. ‘It’s a virtual clinic in ophthalmology, and they go through the cases, and it goes through all the main presentations in clinic, and then also gives them a lot of clinical images that they see’. (Educator 5)
Virtual reality	VR to teach basic sciences	27. ‘We have created a virtual reality eyeball which we use for teaching, it will be extremely effective for anatomy and showing particular pathology’. (Educator 1)
Eye models	Realistic simulation models for clinical practice	28. ‘We have been able to get new eye models from Japan and you can actually change the size of the pupil. You can even place slides within the dummy, such that it mimics hyperopia or myopia, forcing students to change the focusing on the direct. These slides can also show a normal fundus or a whole bunch of pathology as well, like vein occlusions and macular disease. Students have found these new models very effective for introducing and practicing skills’. (Educator 2)
Devices	Showcasing novel devices and technology	29. ‘We have started using newer direct ophthalmoscopy devices which attach onto a phone so that people can take videos of the fundus. I usually teach students how to use a traditional ophthalmoscope and then show them these newer devices to inspire them’. (Educator 4) 30. ‘We show them how to use a new fundus camera device and also OCT scanner, and that gives a novel element to teaching. It does open a lot of eyes and makes them appreciate the cutting edge, or what the next generation of investigating modalities are like’. (Educator 5) 31. ‘Even just showing students pictures of fundus from devices that can attach onto a phone I find really interests students’. (Educator 3)
Theme 5: Relationship between teacher motivation and student motivation
Poor attitudes of teachers	Students’ motivation affected by poor teacher attitudes	18. ‘Some teachers are quite distant with their students, and themselves aren’t very motivated to teach. Students definitely find it harder to stay motivated when they are with teachers like this, so we have tried to address this and help work with teachers to be more engaged’. (Educator 6)
Teacher frustration	Teacher’s negative frustration emotional states hinders student motivation	19. ‘I'm known as the grumpy ophthalmologist that says, "Well, if you haven’t read the book, I can’t teach you anything.” I know students don’t respond very well to that, but it is the truth. Students distance themselves immediately when they see anger or frustration in their teachers, which is probably not healthy for their motivation’. (Educator 3)
Teacher interest	Teacher interest correlates to student motivation	20. ‘Enthusiasm of the teacher actually matters and it’s very intangible and we all know this to some level. Students are always more motivated if the teacher is showing that same motivation’. (Educator 1) 21. ‘We’ve got quite engaged, very experienced teachers that lead them, and they’re all ophthalmologists. And students thrive when they are taught by motivated staff’. (Educator 6) 22. ‘We actively make sure that the teachers that we have at the workshops are enthusiastic, engaged, and enjoy being there and enjoy teaching. And we assess it. So, because we’ve got about six or seven teachers per session, it becomes very quickly obvious if one of the teachers is just not interested, so we will address that by training them or replacing them. We take teacher motivation very seriously’. (Educator 5)
Teachers feeling supported	Universities actively supporting teachers to be motivated	23. ‘Being in a teaching role is rewarding for ophthalmologists, so the faculty try and support our teachers in terms of their own teaching careers in any way. Whether that be through resources we provide on effective teaching methods or flexibility of teaching schedules. When teachers and tutors are supported, it translates very well to the effectiveness of their teaching and student motivation’. (Educator 5)

Theme 1: Lack of explicit consideration of student motivation

The most prevalent theme that arose was the lack of explicit consideration of student motivation in ophthalmology education (quote 1–5). Explicit consideration of motivation describes educators who design curricula and teaching methods with the deliberate intent to foster autonomous motivation. Medical school ophthalmology curricula were often structured to address student’s cognitive needs by meeting certain curricula standards, such as those set by the International Council of Ophthalmology (ICO) (quote 2). Motivation was also not considered in designing assessments (quote 3). Whilst educators did not consider student motivation explicitly, there was an implicit preference towards teaching methods that improved student motivation. Most educators adopted a learner centred teaching approach, where students’ cognitive and affective needs were prioritised (quote 4). This implicit consideration of student motivation is explored further in Theme 2 and 3.

Theme 2: Implicit consideration of motivation in curriculum design

Educators attributed the effectiveness of certain educational practices or curriculum designs to positive responses in student motivation, which indicates an implicit consideration of motivation. Whilst educators did not choose curriculum components for the purpose of fostering student motivation, there was an implicit preference towards certain teaching practices that were recognised to have a positive impact on student motivation. Educators noted the improvement in student motivation when including problem-based learning and flipped classroom learning, with many having chosen to integrate this further within their curriculum (quote 6, 7). Setting clear outcomes and having a logical layout to course content was also recognised to improved students’ motivation to engage with the curriculum, and was applied to all aspects of content delivery (quote 8). Educators also recognised the negative impact of pressure on student motivation. Hence, course content and assessment quantity were rationalised in an attempt to minimise pressure (quote 9, 10).

Theme 3: Implicit consideration of motivation in teaching practices

Educators preferred certain teaching practices when engaging with students in the pre-clinical or clinical environments. Many of these preferences were informed by their impact on student motivation. For example, some teachers employed vicarious learning through stories and analogies that appealed to students’ affective component of learning, which in-turn fostered student motivation (quote 11). Active participation was also encouraged in clinical and non-clinical teaching scenarios as educators realised its effectiveness in increasing student motivation (quote 13,14). All educators realised the importance of building interest, relatedness and providing support in improving student motivation (quote 15–17). Additionally, through student feedback, educators often gauged the effectiveness of their teaching methods in fostering student motivation, which indicates a retrospective implicit consideration of motivation (quote 5).

Theme 4: Impact of innovation and motivation

Educators were asked to describe what they considered to be interesting, innovative, or creative teaching, or assessment, and how these practices impacted on student motivation. No educator could identify innovative assessment practices, however many educators reported trialling certain novel teaching practices resulting in improvements in student motivation. Online teaching was preferred by educators due to its convenience and independence that it provided students (quote 24).

A shift of teaching methods to employ virtual reality technology was also positively received by students. This included virtual case-based scenarios, virtual clinics and virtual reality eye models (quote 25–27). Novel simulation models effectively improved student motivation by improving students’ perceived competence (quote 28). Additionally, educators found student motivation to be fostered by showcasing novel investigation modalities in clinical teaching, including direct ophthalmoscope, phone attachments, OCT scanners and fundus cameras in teaching sessions and clinical placements (quote 29–31).

Theme 5: Relationship between teacher and student motivation

All educators noted the relationship between teacher motivation and student motivation. Hence many educators worked to foster teacher motivation as they have observed this to increase student motivation. For example, poor teacher attitudes and teacher frustration were observed to hinder student motivation (quote 18, 19). Enthusiasm and motivation of teachers were recognised to stimulate student motivation (quote 20–22). Many educators stressed the importance in supporting and nurturing teachers in order for them to maintain high levels of motivation (quote 23).

Discussion

This study provides understanding that motivation was not explicitly considered by educators when designing ophthalmology programs in medical school. However, educators did have an implicit sense of student motivation. This was primarily guided by feedback from students, which informed their choice of curriculum design and teaching practice. Innovation and teacher motivation were also found to be implicit drivers of student motivation. These findings are the first to illustrate ophthalmology educators’ consideration of motivational strategies.

Explicit and implicit consideration of motivation

The lack of explicit consideration of motivation noted in our study is reported in other areas of medical education (Kusurkar 2012; White et al. 2013). For example, a literature review by Kusurkar et al. (2012) found that motivation was not explicitly considered by educators in medical curriculum design and was not a driver for curriculum reform. As a result, student motivation is not cultivated and students are not nurtured to be autonomously motivated (Kusurkar et al. 2012). Aligning to Self-Determination Theory (SDT), high autonomous motivation in students has been found to be an independent predictor of student performance, educational outcomes and wellbeing (Mann 1999; Misch 2002; Kusurkar et al. 2011; Kusurkar et al. 2011; ten Cate et al. 2011; Kusurkar et al. 2012). Additionally, productivity and higher cognitive processes are also significantly boosted in students with higher autonomous motivation (Dolmans et al. 1998). Higher levels of autonomous motivation have a positive relationship with academic grades in pre-clinical and clinical years (Moulaert et al. 2004; Sobral 2004; Kusurkar et al. 2011). A failure of educators to explicitly integrate strategies to foster autonomous motivation in ophthalmology education in medical school, according to the principles of SDT, may discount the effectiveness of their curricula and teaching practices.

Motivation was only considered implicitly by educators in the present study. This was facilitated through direct observation and student feedback, which allowed educators to informally gauge the impact of teaching practices on student motivation levels. Motivation was viewed as a result of teaching methods, and not as an independent factor for impacting student performance. Kusurkar et al. (2012) also found this to be true, where motivation is assumed as an implicit by-product or outcome, and occasionally used to justify the effectiveness of a teaching practice. For example, integrated curricula and problem-based learning models have been shown to be effective curriculum designs, and also increase student motivation. This latter finding is now credited with the success of these models (Vidic and Weitlauf 2002; Dornan et al. 2006). Whilst implicitly gauging motivation may translate to fostering autonomous motivation in students, the explicit consideration of motivation on the principles of SDT may be more effective (Kusurkar et al. 2011; ten Cate et al. 2011).

Educators in the present study noted that showcasing technologically advanced ophthalmic imaging and diagnostic equipment may play a role in stimulating motivation. This may be explained by the development of students’ interest through the experience of novelty (Vansteenkiste et al. 2005; Kunanitthaworn et al. 2018). Educators favoured teaching through virtual reality and virtual patients, which may stimulate motivation through providing challenges to students that meet their level of advancement (Yavner et al. 2015; Berman et al. 2016). These online modules can also increase motivation by providing students the autonomy to choose activities that provide an appropriate cognitive challenge (Paas et al. 2005; Dankbaar et al. 2016).

The synergy between teacher motivation and student motivation reported in our study has also been previously described, but often underappreciated (Pelletier et al. 2002; Roth et al. 2007; Radel et al. 2010; Han and Yin 2016). The mechanism behind this relationship is multifactorial. Intrinsically motivated teachers are more likely to be supportive of students’ autonomy, which is a significant contributing factor to autonomous motivation (Pelletier et al. 2002; Radel et al. 2010). They are also more likely to engage in educational and curricular reform to foster student motivation (Han and Yin 2016). Hence, the importance educators placed on teacher support is warranted, as minimising pressure and cultivating a non-judgemental workspace for teachers boosts motivation (Williams and Deci 1998; Orsini et al. 2016).

Recommendations

The established benefits of student motivation on performance in the literature provides reason for educators to foster motivation alongside cognitive and metacognitive developments. The gaps between the findings of this study and suggestions outlined in previous studies on medical student motivation inform actionable recommendations to foster autonomous motivation in ophthalmology education in medical school. Importantly, these recommendations are relevant for all medical schools in the national and international context, as many of the challenges in ophthalmology education in Australian and New Zealand medical schools are also present in UK, USA and Canada (Stark et al. 1992; Quillen et al. 2005; Fan et al. 2007; Baylis et al. 2011; Hill et al. 2017; Gostimir et al. 2018; Zhang et al. 2018; Scott et al. 2022). Additionally, medical curricula generally allocate a disproportionate amount of time and resources to larger disciplines such as general medicine and general surgery (Quillen et al. 2005). Hence many smaller disciplines, such as otolaryngology, obstetrics and gynaecology, anaesthetics, paediatrics and emergency medicine much like ophthalmology, are prioritising time-effective teaching methods. Therefore, many of the recommendations offered in this study will also apply to these disciplines

Firstly, it is essential for educators to explicitly consider their impact on student motivation (Kusurkar et al. 2011; ten Cate et al. 2011). This can only be achieved if educators are first educated on the principles of SDT and students’ basic psychological needs of autonomy, competence and relatedness. Educators should also receive training on the strategies to foster autonomous motivation in students and the positive impact of these on academic performance and student well-being, as outlined in the SDT literature (Kusurkar et al. 2011; Kusurkar et al. 2011; ten Cate et al. 2011). This may encourage educators to actively choose teaching practices and design ophthalmology curriculum in order to stimulate autonomous motivation in their students.

Curriculum designers may consider models shown to increase autonomous motivation in students, such as PBL and integrated curricula (Vidic and Weitlauf 2002; Dornan et al. 2006). This should also be the case for lecturers and tutors, who may choose to develop an autonomy-supportive teaching style which includes acknowledging students’ preferences and needs, giving time and opportunity for autonomous work and providing constructive feedback (Reeve 2002; ten Cate et al. 2011). Teachers may also choose to integrate novelty and innovation into their teaching.

Most educators were unaware of the potential for assessments to impact student motivation. Appropriate assessments using realistic, innovative modalities that provide students with rich constructive feedback have been shown to increase autonomous motivation. The development of these assessments should be prioritised (Bransford et al. 2000; Larsen et al. 2008). Hartnett (2015) showed that appropriate assessment modalities play a key role in student motivation by affecting self-perceived autonomy and competence.

Finally, the important role of the implicit consideration of student motivation should not be underplayed. Educators should always look for feedback and allow for open discussion with students regarding aspects of the ophthalmology course, to ensure that their needs are met. This open communication also allows for students to appreciate important aspects and outcomes of the course.

Limitations

Ophthalmology educators from only six universities in Australia and New Zealand were interviewed. Therefore, the findings of this study are not a comprehensive review of ophthalmology teaching in Australian and New Zealand medical schools. Instead, we chose to deeply investigate each educator’s consideration and application of student motivation in medical education. Importantly, the findings in this study should still be considered in the context of medical schools internationally, in ophthalmology and other speciality disciplines looking to improve educational outcomes of their students. Additionally, there were no direct measures of the impact of teaching practices and curriculum design on students’ motivation. Educators also relied only on feedback and observation to gauge which interventions fostered motivation, which may introduce an element of recall bias. However, this was minimised as themes were generated by the iterative condensation of multiple codes as described by Braun and Clarke (2006), which increased the validity and reliability of the data presented.

Further research is needed to directly test the impact of innovations and changes in teaching practices on student motivation. Additionally, future research may choose to investigate if gains in student motivation occur when motivation is considered explicitly instead of implicitly in curriculum design.

Conclusion

Motivation has not been an explicit consideration in ophthalmology education, with the majority of emphasis currently being placed on the cognitive and metacognitive aspects of learning. There has only been an implicit consideration of motivation, where it is viewed as an outcome of teaching practices or developments. Given the positive impact of autonomous motivation on learning and student wellbeing, this study provides recommendations for motivation to be explicitly incorporated into the development of teaching practices and curriculum reform in teaching ophthalmology and other speciality disciplines in medical school.

Ethics statement

This study was approved by the Human Ethics and Research (HERC) committee of University of Western Australia with consideration of participant confidentiality managed.

Authors’ contributions

All authors have given their approval to submit this manuscript. Dr Deepaysh D.C.S. Dutt has been the main researcher in study design and data collection, analysis, interpretation, as well as writing of this manuscript. Dr Tabitha M. Scott, A/Prof Constantinos Petsoglou and Prof John Grigg contributed to the study design, data collection tool and drafting of the manuscript. Prof Sandra E. Carr and A/Prof Hessom Razavi contributed to the design, analysis, writing and review of each draft of this manuscript. All authors were involved in critically revising the manuscript.

Acknowledgements

We wish to thank the students who participated in this study and shared their experiences with us.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Deepaysh D. C. S. Dutt

Deepaysh D. C. S. Dutt, BSc, MD is a junior medical officer completing his Master of Health Professions Education at The University of Western Australia.

Sandra E. Carr

Sandra E. Carr, BSc, MPH, PhD, SFHEA, is Head, Discipline of Health Professions Education at The University of Western Australia.

Tabitha M. Scott

Tabitha M. Scott, BKin, MD, MMed(Ophth Sci), is a doctor, and completed her Master of Medicine in Ophthalmic Science at the University of Sydney with a focus on medical student education.

Constantinos Petsoglou

Constantinos Petsoglou, MBBS, MMed(Clin Epi), FRANZCO, is a consultant Ophthalmologist working as a Cornea Specialist at Sydney Eye Hospital. He is a senior lecturer in clinical ophthalmology at the University of Sydney and deputy director of NSW Tissue Banks.

John Grigg

John Grigg, MBBS, MD, FRANZCO, FRACS is Head of the Discipline of Ophthalmology at The University of Sydney’s Save Sight Institute. He also consults at Sydney Eye Hospital and The Children’s Hospital Westmead.

Hessom Razavi

Hessom Razavi, MBBS, BSc, MSc (Hons), FRCOphth, FRANZCO is an ophthalmic consultant at the Lions Eye Institute and the coordinator for ophthalmology teaching at The University of Western Australia.