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RES E AR C H A R T I C L E Open Access
Why should I prepare? a mixed method study
exploring the motives of medical undergraduate
students to prepare for clinical skills training
sessions
Marlien W Aalbers
†
, Juliette Hommes
†
, Jan-Joost Rethans, Tjaart Imbos, Arno MM Muijtjens
and Maarten G M Verwijnen
*
Abstract
Background: Although preparation for educational activities is considered beneficial for student learning, many
students do not perform preparatory assignments. This phenomenon has received little attention in the literature
although it might provide medical educators with the opportunity to enhance student learning. Therefore, we
explored why students prepare or not prepare.
Methods: An explorative mixed methods study was performed. In a qualitative study, 24 short group interviews with
medical undergraduate students (n=209) were conducted on why they prepared for skills training sessions. In a
subsequent quantitative study the resulting themes were used to construct a questionnaire. The questionnaire was
presented to all undergraduate medical students at Maastricht University and 847 students completed it. Scales were
constructed by a combination of exploratory factor analysis, reliability analysis, and content analysis. Between-class
differences in the scale scores were investigated using ANOVA.
Results: The qualitative study showed that students’ opinions on preparation are influenced by both personal factors,
categorized as ‘personal learning style’, ‘attitudes and beliefs’,and‘planning and organization’, as well as external
factors, including ‘preparatory advice’, ‘pressure, consequence, and checking of preparation’, ‘teacher-related
motivations’,and‘contents and schedule of the training sessions’. The quantitative study showed that ‘the objective
structured clinical examination’ and ‘facilitation of both understanding and memorizing the learning material’,werethe
two most motivating items. The two most demotivating aspects were ‘other students saying that preparation was not
useful’ and ‘indistinct preparatory advices’. Factor analyses yielded three scales: ‘urge to learn’, ‘expected difficulties’,and
‘lack of motivation‘. Between group differences were found between the three classes on the first two scales.
Conclusions: Students make an active and complex choice whether to prepare or not, based on multiple factors.
Practical implications for educational practice are discussed.
* Correspondence: m.verwijnen@maastrichtuniversity.nl
†
Equal contributors
Skillslab, Faculty of Health, Medicine and Life Sciences, Maastricht University,
Maastricht, The Netherlands
© 2013 Aalbers et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Aalbers et al. BMC Medical Education 2013, 13:27
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Background
Educational institutes rely on students to prepare for
classes, assigning study material or independent work con-
tinually. Teachers and educational institutes try to enhance
student preparation for example through providing study
guides [1]. It is assumed that preparation for educational
sessions is associated with improved academic achieve-
ment [2]; it is acknowledged to facilitate understanding [3]
and to increase participation in class [4-6], which is known
to enhance learning [7,8].
This is also acknowledged by students, who rate prepa-
ration as one of the most important factors for class partici-
pation [5]. However, we often observe that students do not
always do the assigned preparatory work. An internal (un-
published) study at Maastricht University Medical School
showed that 47% of first-year undergraduate students did
not consistently prepare. This is not only the case for me-
dical students: preparation rates amounted to 17% for
accounting [3] and macro-economics [9] students and to
approximately 30% to 50% for psychology students [10-12].
Remarkably, despite the fundamental importance of
preparation and the low compliance of students, this
problem has received very little attention in the literature.
This was also noted by Edmunds and Brown [13], who
stated that there is very little research on preparation,
considering its key role in small group learning. Yet, iden-
tification of the reasons for students to prepare or not pre-
pare is crucial, as this might help medical educators to
create the most optimal learning context [14].
To our knowledge, there are no studies available that
investigated why students do or do not prepare. However,
preparation can be viewed as an element of self-regulated
learning. It is assumed that students’ ability to regulate
their own learning is essential for successful learning. This
self-regulated learning behaviour is considered the prod-
uct of self-generated (personal) processes and external
influences [15-18]. Viewing preparation in the context of
self-regulated learning behaviour infers that preparation is
based on personal and external factors. Examples of
personal factors are students’ motivations, personal
learning styles and strategies to learn, and metacognitive
judgments (are the results worth the costs?). Environmen-
tal influences, such as the nature and structure of the
learning tasks, also influence students’ learning behaviour.
However, it is still unclear in what way and to what extent
these factors influence students’ motivation to prepare or
not. Therefore the first objective of this study was to ex-
plore why students do or do not prepare for educational
activities.
Furthermore, we were specifically interested to evaluate
whether there are differences between classes for the
factors determining students’ motivation, as it is known
that advancement in university is associated with changes
in learning: students in more advanced classes were more
likely to read assignments in advance than beginners [11].
Moreover, students’ self-regulated learning behaviour was
found to evolve as students progress through their de-
grees: senior students studied more and were more
engaged in activities beyond the advised guidelines and re-
lied less on others compared to first year students [19-23].
Therefore the second objective was to determine whether
students’ reasons to (not) prepare differ between classes.
To study these two objectives, we conducted a mixed
methods study. First we explored students’ motivations
(not) to prepare by a qualitative study. Based on the re-
sults of this qualitative study, we developed a question-
naire. This questionnaire was used in the quantitative
study, which is described in the second part of this article.
General overview of the methods
We conducted a mixed method study following a comple-
mentarity sequential approach [24]. First we explored why
students do and do not prepare by performing a qualita-
tive study. This was followed by quantitative study, aimed
at elucidating the importance of the reasons to (not) pre-
pare and at evaluating if there were differences between
students in different classes.
Context
The study was conducted at Maastricht University Medical
School, the Netherlands. This school offers a six-year
undergrad uat e-ent ry curriculum using problem based self
directed learning [25] as the central educational approach
(see also [26] for more information on problem-based
learning). The preclinical curriculum, comprised by the first
three classes, is organised in thematic modules of six to ten
weeks. Modules are offered only once a year as the modules
build onto one another. As such, students belong to a class
or year [1-3]. Preclinical teaching is mainly delivered in tu-
torial groups, complemented by lectures and a longitudinal
clinical skills programme. The clinical skills programme is
provided by the Skillslab and provides training in physical
diagnostic, therapeutic, laboratory, and communication
skills. Skills training is geared to the curriculum to ensure
that the training sessions deal with subjects that are
addressed in concurrent thematic modules. Skills trainings
are not compulsory. Students are not assigned to training
sessions, but mostly enrol themselves. As a result both
group composition and teacher may vary across sessions.
Preparatory advice is suggested by the faculty and is posted
on Blackboard. The advice comprises information about
objectives, contents, and methods of a training session (e.g.
involvement of (simulated) patients, practising on each
other, the need to undress), together with a list of reco-
mmended literature and (audio) visual materials. Skills per-
formance is assessed in an annual objective structured
clinical examination (OSCE). Skills-related theory is in-
cluded in the regular written end-of-module tests.
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Procedures
Ethical approval was obtained from the educatio nal
management board of the Faculty. Student’s participa-
tion was completely voluntary and anonymous, and lack
of participation did not have any consequences.
Methods I qualitative study
We conducted 24 short semi-structured group interviews.
Four questions were asked during these interviews to initi-
ate the discussion (Table 1).
The interviews were conducted during regular tutorial
groups to create an environment that was completely
separate from the Skillslab to minimise barriers to freely
discuss preparation. Tutorial groups were randomly
selected and all students that were present in the groups
were asked to participate. All 209 approached students
consented to participate.
Students from different classes were interviewed separ-
ately to prevent that the discussion would be dominated
by higher-class students. Both literature (e.g. [27]) and the
pilot interviews indicated that existing groups discussed
more issues than newly established groups. Therefore we
conducted the interviews in the penultimate week before
the end-of-module test when tutorial groups had been to-
gether for a number of weeks.
A student moderator conducted the interviews. A stu-
dent moderator was chosen instead of a staff member to
minimise the chance of students withholding negative
opinions. For the same reason, tutors left the room during
the interviews. The moderators received extensive written
and oral instructions. They tried to actively involve all
students in the discussion and gave no examples of answers
or summaries, since this could steer the discussion.
Interviews were audio taped and scheduled to last fif-
teen minutes. Two pilot sessions revealed that this de-
sign was feasible.
Participants
Twenty-four groups were randomly selected providing
approximately equal representation of students for each
of the three cla sses, with a total of 209 students (class 1:
n=75; class 2: n=61; class 3: n=72 students). Group size
varied from six to twe lve students. A sufficient number
of group interviews was conducted, since the saturation
point, i.e. the moment at which no new information
came up anymore, was reached after approximately ¾ of
the interviews in each class.
Analysis
The audio recordings of the interviews were transcribed.
Data were analysed by a thematic analysis approach
[28,29]. Three authors and one independent reviewer in-
dependently coded the transcripts using Atlas.ti software
[30]. Each reviewer defined “open” codes based on the
content and assigned them to the transcripts. Next, the
reviewers discussed the coding until they agreed on one
coding scheme and divided codes into motivating and de-
motivating items. They then jointly established coordinat-
ing or “core” categories. Subsequently, they assigned codes
to one or more categories if different aspects were
involved. For example, ‘teacher asks questions’ belongs to
the category of ‘teacher-related motivation’ but also to
‘pressure, consequences, and checking of preparation’.
Methods II quantitativ e study
We designed the Preparation Questionnaire based on the
results of the group interviews. Every (de)motivating item
that was mentioned in more than one group interview,
was translated into one question. Subsequently, the ques-
tionnaire was reviewed by four field experts and tested
through a pilot study among nine preclinical students
who were distributed evenly over classes 1 to 3. The
comments and suggestions of both students and experts
resulted in the final questionnaire, consisting of 39 items.
Twenty-one items were rated on a five point Likert scale
ranging from 1 ‘strongly demotivating’ to 5 ‘strongly mo-
tivating’ with 3 defined as ‘neutral’. Some items could only
demotivate or motivate students to prepare; for example
‘laziness’ can only demotivate. For these questions, the
five-point scale was modified into a three point Likert
scale. Seven items, which could only demotivate could be
rated from ‘strongly demotivating’ to ‘neutral’. Eleven
items, which could only motivate, could be rated from
‘neutral’ to ‘strongly motivating’.
The 39 questions were preceded by eight general ques-
tions regarding age, gender, and preparation frequency,
and perceived usefulness. The Questionnaire ended with
nine specific interventions. Students were asked to indi-
cate whether they thought that these interventions would
improve their motivation to prepare.
Participants
The questionnaire was distributed among all undergra-
duate students (classes 1-3) during the tutorial groups
(n=847). Exchange students and foreign scholarship
students were excluded. The students received both a
written and an oral instruction.
Table 1 Questions used by the moderator to guide the
discussion
1. What would be reasons for students to prepare for skill training
sessions?
2. What would be reasons for students not to prepare for skill training
sessions?
3. What do you think about the preparatory advice for skill training
sessions?
4. What should be changed to improve students’ preparation for skill
training sessions?
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Data analysis
All analyses were performed using SPSS [31]. Descriptive
statistics were reported as means and standard deviations.
Ap-value≤0.05 was considered statistically significant.
Cohen’s d was used as effect size for two-group com-
parisons, classifying effect sizes equal to .20, .50, and .80,
respectively as small (negligible practical importance),
medium (moderate practical importance), and large (cru-
cial practical importance) effects, respectively [32].
Scale construction
The Preparation Questionnaire (39 items) was validated
by constructing scales (subsets of related items), using a
combination of exploratory factor analysis (Principal
Components Analysis and Varimax rotation), reliability
analysis (calculating Cronbach’s alpha for a scale and the
change of alpha if an item is deleted from the scale), and
content analysis. Inspection of the scree-plot provided the
number of factors, and items with loadings <0.4, or a
loading difference (between highest and next-to-highest
loading) <0.1 were excluded. In a subsequent reliability
and content analysis items that did not contribute to the
reliability of a scale were removed. The process was
iterated until a subset of items was obtained showing a
consistent and interpretable factor structure, and a corres-
ponding set of reliable scales. In the analysis Cronbach’s
alpha was used as a measure of reliability (internal
consistency) of a scale. After the final set of scales was
constructed, corresponding scale scores (composite
scores) were obtained by calculating the mean score of all
items in the scale for each respondent.
Differing views on preparation between classes
Differences between classes were investigated by apply-
ing one-way ANOVA for each of the obtained scale
scores as dependent variable, and using class (years 1, 2,
and 3) as the independent variable. The Bonferroni rou-
tine was used as post-hoc test to test for significance of
pair wise differences of class means.
Results I qualitative study
We present the results according to the themes with illus-
trative quotations from the interviews depicted in italic.
Preparatory advice
Students said they prepared because they wanted to
know what to expect before and during the session. Spe-
cial practical exercises promoted preparation, especially
when the exercises were discussed. Inability to visualize
a certain skill and therefore inability to understand the
subject properly also resulted in less preparation. “I can
only understand it, if I’ve seen it.” Students indicated
that they would prepare more when preparatory advice
is short, specific, and easy accessible.
Contents and schedule of training session
“You can keep up with the training session even if you
have not prepared” is a reason why students consider
preparation unnecessary. Students said that the teacher
often reviewed the preparatory advice at the start of the
training session anyway. This rewarded students who
did not prepare. It was suggested that dependence on
the teacher should be reduced but at the same time
some students valued review of subject matter by the
teacher. “I like it better when the preparatory advice is
explained by an expert. That clarifies things for me.”
Reasons for preparing can be summarized as increased
efficiency: “If you have prepared, everything goes faster
and it’s easier to get to the point.” Students also said that
preparation depends on the type of training session: clin-
ical reasoning sessions invited less preparation than
sessions during which skills were performed.
Planning and organization
Students preferred to do their own planning so they
could choose a suitable time. The timing of a training
session in relation to the concurrent module was also
relevant: some students said to prepare more early dur-
ing a module while others prepared more close to a test.
Lack of time or planning also inhibited preparation. A
related factor was that some students give less priority
to skill training compared to other curricular activities.
Furthermore, students said they often forget they have a
training session or to prepare for it.
Pressure, consequences, and checking of preparation
Students indicated to be more motivated when their
preparation dire ctly affected other people. For example,
students said they prepared thoroughly for sessions in
which they performed rectal examination on teaching
associates. “We re cently learned about rectal examin-
ation. I wouldn’t like to be there without knowing where
to press”. Preparation can be promoted by pressure from
the teacher, for instance by testing students’ knowledge.
Conversely, a lack of stimulation by the teacher results
in less preparation.
Current assessment did not stimulate preparation.
“There are only a few questions about skills in the end-of
-module test...” Lack of evaluation of professional be-
haviour during skill sessions and lack of repercussions
demotivate: “No one will tell you to “leave the room” or
something like that if you have not prepared.” Students
thought that imposing more pressu re from teachers,
sanctions, or tests would improve preparation.
Teacher-related motivations
Other teacher-related motivations included low expec-
tations of students’ preparation by the teacher. “You are
much more motivated if you know you’ve got a training
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session with a teacher who really wants you to prepare
than if you have a teacher who says “Well, everybody is
probably unprepared”.” Teacher characteristics played a
role as well: “I’m quite an auditory person and I know that
there is a teacher that explains the material so well...
That’s just fantastic... I learn more from him than from a
book so I don’t read books so often since I know he will
explain it so well.”
Personal learning style
This category is defined as “how students learn, instead
of what they learn” [33]. Some students preferred study-
ing assigned preparatory work after a training session.
After not preparing for several sessions, a student was
likely to develop different learning strategies and thus
become habituated to not preparing. An example was
‘social loafing’ or ‘free riding’: “There are so many people
who read the information... They’ll tell me about it.”
One student suggested that this can be prevented by
peer teaching.
Students also mentioned that preparation helped them to
understand and learn. Having done preparatory reading
helps to memorize subject matter and enables students to
ask questions. Students indicated that availability of audio-
visual resources greatly enhanced preparation. “Seeing a
skill performed gets through much more easily than a de-
scription of a skill”.
Finally, only second-year students suggested to prepare
because they wanted to study independent ly “I like to
think for myself inste ad of everything being predigested”.
Attitudes and beliefs
Many reasons for preparing were related to professional-
ism. “One prepares because it’s for your own good”. They
thought that “you should adopt a professional attitude”
and that enrolling for a training session obliges you to
prepare. Moreover certain subjects were only dealt with
once resulting in a strong urge to prepare: “You won’t
get a second chance.” The perceived importance of skills
for future careers was also experienced as a stimulus to
prepare. Students did not only prepare because they
believed it is professional to do so, but also because it
makes training more enjoyable and more intere sting and
“because they didn’t want to fail in the training session.”
Some students did not prepare out of laziness, lack of
interest, or when fellow students said that it was no use to
prepare. Only first-year students, but not year 2 and year
3 students, mentioned that preparation was influenced by
their experiences with previous training sessions.
Results II quantitative study
The response rate was 100% (all questionnaires were
returned) comprising 85.0% (n=848) of all undergraduate
students. After exclusion of 39 questionnaires (4.6%) due
to incomplete answers to the general questions, 809 ques-
tionnaires were included in the data analysis (n=274,
n=275, and n=260 students in class 1, 2, and 3 respect-
ively). The mean age was 20.1 years (SD 1.3) and 279
participants were men (34.5%). These distributions were
similar to those of the total student population.
All students attended a skills training session at least
once. The majority of the students considered preparation
for a skills training valuable (mean 2.7; SD 0.5; range 1-3).
Although preparation was valued useful, the mean fre-
quency of preparation was 3.9 (SD 0.9; range 1 (almost
never) to 5 (almost always)).
Strongly motivating items for preparation were: the
OSCE (mean 4.4; SD 0.8), facilitation of both under-
standing and memorising the learning material (mean 4.3;
SD 0.7 and mean 4.4; SD 0.7 respectively). The most de-
motivating aspects on preparation consisted of: other
students saying that preparation is not useful (mean 2.2;
SD 0.8), indistinct preparatory advices (mean 2.3; SD 0.8),
and personal preference to study the learning material
afterwards (mean 2.6; SD 0.7).
Students indicated that six out of the nine specific
interventions that were proposed would improve their
preparation. These interventions were: more emphasis on
skills in the curriculum (indicated by 66.3% of all students),
more checking whether students prepared (60.4%), more
case based independent learning assignments (57.9%),
more testing of skills (58.3%), more sanctions if students
were not prepared (54.3%), and obligatory electronic inde-
pendent assignment (54.0%).
Aspects influencing students’ motivation to prepare
After several iterations of the factor -, reliability -, and
content analyses , a set of 21 items remained that showed
a consistent and interpretable three-scale structure. The
scales consist of 10, 6, and 5 items, with reliabilities
(Cronbach’s alpha) of 0.78, 0.58, and 0.60, respectively,
and explained 36.0% of the total variance. The questions
that made up the three scales are illustrated in Table 2.
The first scale ‘urge to learn’ comprised items linked to
the urge of students to obtain knowledge. Examples of
items contributing to this scale are: facilitation of memor-
izing the learning material, being able to ask questions,
and to deliver input in the training session. The second
scale was labelled ‘expected difficulties’ as the items reflec-
ted task and training related difficulties, such as new or
difficult subject matter or a teacher with high expec-
tations. The items of the third scale ‘lack of inner drive’
were related to indifference and passivity. Examples of
items contributing to this scale were: no repercussions
and ‘laziness’. The aspects ‘urge to learn’ and ‘expected dif-
ficulties’ motivated students to prepare (mean 3.9, SD 0.4;
respectively mean 3.8, SD 0.6). The aspect ‘lack of inner
drive’ demotivated students to prepare (mean 2.5; SD 0.4).
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Differing views on preparation between classes
Two out of three aspects influencing motivation to pre-
pare, show ed small to moderate differences between the
three preclinical classes in their extent to (de)motivate
preparation. The a spect ‘urge to learn’ motivated to pre-
pare less in year three compared to years one (p<0.001,
Cohens’ d=0.41) and two (p<0.001, Cohens’ d=0.43). In
contrast, ‘expected difficulties’, motivated second and
third year students more than year one student s
(p<0.001; Cohens’ d=0.44 respectively Cohens’ d=0.32).
No significant between-class differences were found in
students’‘lack of inner drive’ (p=0.087; F=2.45).
Discussion
Although the decision whether to prepare or not is part
of self-directed learning and although preparation is
acknowledged to be beneficial in the students learning
process, there is a lack of und erstanding why students
do not comply with the advised preparatory work.
Therefore, the current study evaluates motivations to
prepare or not to prepare as expressed by students. The
two parts of our mixed methods approach yielded com-
plementary results. First, our qualitative study identified
six themes and corresponding items were generated
(Preparation Questionnaire). Second, in the subsequent
quantitative study the question naire was validated and
scales were constructed, providing a measurement
model (scales) that enabled to investigate which aspects
motivated and demotivated the undergraduate students
most to (not) prepare for skills training sessions. Using
the resulting scales, between class differences were
found regarding the extent to which certain aspects (de)
motivated students to prepare.
Interpretation of the findings
The six themes that emerged from the qualitative study
can be clearly framed in the context of self regulated
learning [34]: preparation is influenced by both personal
factors, consisting of ‘personal learning style’, ‘attitudes
and beliefs’, as well as external factors, including categor-
ies such as ‘preparatory advice’, ‘pressure, consequence,
and checking of preparation’.
In the quantitative study, three scales were identified
representing motivation to (not) prepare. When looking at
the contents of the scales, it becomes clear that the scales
closely resemble Deci & Ryans’ self-determination theory
[35]. These authors described motivation not as antagon-
istic behaviour such as intrinsic versus extrinsic motiv-
ation, but as a continuum of motivations based on the
levels of internalization and self-determination within the
individual. Our first scale, ‘urge to learn’,comprisesitems
that resemble intrinsic motivation, e.g. ‘I think the training
is more interesting or more fun’, and identified regulation,
e.g. ‘I can memorize the subject material better’. The other
two scales represent the other end of self-determination
continuum composed by Deci and Ryan, mainly containing
items regarding ‘amotivation’ and ‘external regulation’.
Differences between students from the three classes in
their motivation to (not) prepare are in line with studies
indicating that students learn how to learn: senior stu-
dents study more, are more engaged in activities beyond
the advised guidelines, and rely less on others compared
to first year students [19-23]. In line with these studies,
the quantitative study shows that second and third year
students experience more motivation to prepare from
‘expected difficulties’ in the clinical skills trainings. Sur-
prisingly, third year students relied less on intrinsic motiv-
ation. This could be due to an overall difference in an
‘urge to learn’, representing less intrinsic or identified
regulation, between classes. However, it could also be
explained by a reduced need to prepare because year three
Table 2 Overview of the 21 items affecting motivation to
(not) prepare
Scale Mean sd
Urge to learn α = 0.78 3.92 0.43
◦ I'll know what to do 3.89 0.82
◦ I’ll know what to expect 4.02 0.77
◦ The subject treated in the training session has strong
cohesion with the module
4.19 0.74
◦ I memorize the subject material better through
preparation
4.35 0.70
◦ I think it’s more fun and interesting when I’m prepared 3.98 0.79
◦ It is easier to keep up with the training session 4.31 0.67
◦ Through preparation I’m able to ask questions during
the training session
3.79 0.76
◦ I’d like to contribute to the training session 3.49 0.67
◦ I have the feeling that I prepare ’for myself’ 4.24 0.69
◦ The training goes faster when I’m prepared 3.60 0.75
Expected difficulties α = 0.58 3.75 0.55
◦ The teacher has high expectations from students 3.78 1.00
◦ The subject treated in the training session is difficult 3.84 0.95
◦ During the training sessions, questions can be asked
to me
4.04 0.77
◦ The skills are hard to imagine from paper 3.30 1.06
◦ The subject treated in the training is unfamiliar to me 3.75 0.97
◦ An assignment with case-based discussion in the
training session
3.81 1.01
Lack of inner drive α = 0.60 2.52 0.40
◦ There are no consequences if I do not prepare 2.42 0.65
◦ I’m lazy 2.70 0.58
◦ I don’t feel like it 2.63 0.59
◦ Professionalism is not tested during training sessions 2.67 0.56
◦ I heard from other students that it wasn’t worth
preparing for a specific training
2.22 0.80
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students are more experienced in their clinical skills and
the focus of training in year three is shifted towards inte-
gration of knowledge and skills instead of learning new
skills which is the major aim in year one. The results seem
to indicate that students' reasons to prepare develop or
change when students progress through the curriculum.
However, it would require a longitudinal study to verify
whether the observed between-class differences are indeed
due to a development effect and not to a cohort effect.
Knowing this is useful for educational institutes because
they can take this into account when organizing clinical
skills programmes.
Surprisingly, both the qualitative and quantitative stud-
ies show that students are merely driven by external regu-
lation to prepare: only one reported motivation in the
qualitative study to (not) prepare was purely intrinsic
“Skills trainings are more fun and interesting when I pre-
pare”. Moreover, students reported that their preparation
would be improved by several externally regulated inter-
ventions such as more testing, more checking of prepar-
ation, and more sanctions for not preparing. Several
studies demonstrated that student motivation and prepar-
ation behaviour can be strongly influenced by external
factors such as upcoming tests [3,10,12]. Apparently, this
also holds true for students who are used to Problem-
Based Learning, a learning context in which students are
supposed to study in a self-directed manner according
to their own learning goals. This educational system
contrasts with the adaptations that students propose to
improve their motivation to prepare. This might be due to
a ‘misfit’ between students’ needs and the learning con-
text. Another explanation might be our implementation
of the Problem-Based Learning curriculum for our clinical
skills programme. For instance, the organization of
Skillslab sessions at Maastricht medical school appears to
run against the concepts of Problem-Based Learning, with
assigned preparation and teachers explaining subjects in
class. This is rather contrary to self-directed learning
where PBL stands for. Indeed, students indicated that in
order to prepare better, they would like training sessions
to be more ‘student-centred’ instead of ‘teacher-centred’,
suggesting that higher self-determination in trainings
would improve preparation. Van den Hurk et al. [36] also
stressed the importance of self-directed learning, demon-
strating that low self-regulation is associated with lower
and less effective preparation.
Another factor that illustrated students’ ambiguous atti-
tude towards self-directed and teacher-directed learning
was their opinion about teachers compensating for their
lack of preparation by reviewing subject matter. In the
majority of interviews this was very often mentioned as a
negative motivation, which made students feel that prep-
aration was a ‘waste of time’.Ontheotherhandsome
students indicated during the interviews to be motivated
by this factor. A similar bivalent attitude was seen in the
quantitative study with some of the students experiencing
reviewing the advised preparatory work as motivating,
while others experienced this as demotivating. This re-
sulted in an average neutral score. This might not only re-
sult from differences between students but also from
differences between teachers. For example, the amount of
time that is taken-up by the revision might be an import-
ant determinant of preparation. During the qualitative
study, students clearly indicated that lengthy revision of
the advised preparation material particularly decreased
their motivation to prepare because this revision caused
limited time to practice skills. Moreover, the way teachers
review the advised preparatory assignments might influ-
ence preparation with active involvement of students
being more stimulating than just summarizing the pre-
paratory material.
That students’ motivation to prepare is rather complex
was exemplified by the quantitative study, yielding three
scales with only 21-items remaining to be included, and
these three factors only explained 36.0% of the total vari-
ance. Another rea son for the low variance explained,
could be that there were other aspects, which were not
included in our questionnaire although it was based on
all motivations mentioned by students in the qualitative
study. Finally, complexity of preparation was reflected by
the discrepancy between perceived effectiveness and
preparation frequency: e ven though students valued pre-
paration as useful, only 26.0% of students indicated
that they almost always prepare for training sessions.
Students weigh the costs and benefits of preparation,
they “constantly e valuate the requirements for participa-
tion in activities and choose to either engage or to find
some other activity that better takes up their time” [37].
In other words, students’ meta-cognitive judgments,
which are a form of personal factors in self-regulated be-
haviour, are very strong determinants for preparation.
Limitations
First of all, this study is explorative in character and is
an attempt to help teachers understand what drives
students to prepare or not to prepare. In this mixed
methods study we have shown that there are various
reasons to prepare, but overa ll, students make an active
and deliberate choice. Referring to the lack of literature
on preparation, this study is one of the first to throw
light on the factors that influence preparation. There-
fore, we recommend replication of this study. Future re-
search should focus on development in motivations to
prepare over time, and should evaluate how proposed
interventions influences students’ motivation to prepare.
Second, in the qualitative study, the unconventional
short duration of the interviews may be considered a
disadvantage. The interviews were short because they
Aalbers et al. BMC Medical Education 2013, 13:27 Page 7 of 9
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were conducted during regular tutorials. The random se-
lection of the tutorials and the inclusion of a large num-
ber of students minimised the bias that can occur if
students are recruited. This was necessary as the main
objective of the first part of the study was to explore all
possible reasons (not) to prepare. Therefore, we wanted
to re cruit as many different students as possible in terms
of ability and interest in education. The pilot interviews
were not limited in duration. These pilot studies showed
that this approach was feasible and evoked active inter-
action between students and yielded sufficient data in 10
to 15 minutes. In the future it would be interesting to
evaluate certain aspects of preparation in depth such as
students’ meta-cognitive judge ments and subsequent
preparation through focus groups.
Third, in the quantitative part, the five and three point
Likert scales were constructed for this study, because the
group interviews showed that certain factors motivated
some students, but demotivated others. Therefore, the
scale had to include both ‘motivating’ and ‘demotivating’.
Much effort has been undertaken in order to assure that
this scale was clear to all students: a pilot was done with
full attention to the students’ interpretation of this scale,
all students received both oral and written instruction,
and researchers were available to provide additional ex-
planation if necessary.
Fourth, the study does not report to what extent
teachers’ behaviour is influenced by the opinion or atti-
tude of students with regard to preparation and especially
with regard to the depth of the preparation. For example,
do teachers review more of the advised preparatory ma-
terials when they notice that students didn’t prepare well
enough and how do the students appreciate this?
Finally, the results reflect the opinion or attitude of
students and not their actual behaviour. It would be
interesting to investigate what students really do with re-
gard to preparation and whether their behaviour is in line
with their opinion.
Implications for education
These findings offer a starting point from which learning
contexts can be optimized in order to enhance students’
preparation and their learning behaviour and perform-
ance. The complexity of students’ choices to prepare and
their development during their academic training impedes
recommendation of one universal intervention that would
enhance preparation by all students. This is supported by
the finding that none of the proposed interventions could
motivate more than two thirds of the students to possibly
prepare more in the future for skills training sessions.
However, this diversity might also hold the solution: stu-
dent preparation might be enhanced by offering students
various options for preparation. On theoretical grounds,
this provision of choice is assumed to enhance feelings of
autonomy and in turn motivation and performance [35].
This was confirmed by a randomized study that showed
that providing students with a choice of homework not
only increased homework completion but also enhanced
test performance [38]. Furthermore, considering the im-
portance of self-directed learning both in terms of success-
ful learning and preparation compliance [36], measures
should be undertaken to encourage self-directed learning.
This could be achieved through optimization of the educa-
tional setting and by practical measures, such as peer
teaching and students testing each other’s knowledge, as
suggested by the students. Moreover, students highly
appreciated case-based independent work exercises and a
majority of students indicated that these independent work
exercises would increase their preparation. Therefore, this
might be a practical design for preparation assignments.
Conclusions
In conclusion, this study points out that students’ moti-
vation to prepare for skills training is a very complex
process that evolves over the academic years. Preparation
can be viewed as a form of self-regulated behaviour,
influenced by many environmental and personal factors.
Future research should explore whether providing students
with different choices enhances the efficacy of teaching and
student performance.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
The study was initiated by all authors and conducted by MWA and JH. JJR
and GMV advised on the design of the study. MWA, JH, GMV conducted the
analysis of the data. TjI and AMMM advised on data analysis. MWA and JH
wrote the first drafts of the article, which were revised by JJR, GMV, TjI, and
AMMM. All authors read and approved the final manuscript.
Authors’ information
Marlien Aalbers (PhD) and Juliette Hommes (MD) are both MD-PhD students
at Maastricht University. They completed the honours programme
concerning research. From the beginning of their study they were active
members of the student government, closely involved in the management,
development, and evaluation of the educational programme of the medical
faculty.
Jan-Joost Rethans (MD PhD) is a general practitioner by training and
responsible for the simulated and standardized patients programme of the
Skillslab, Maastricht University. His interests are educational research with
simulated and standardized patients as a specialty.
Arno Muijtjens (PhD) works as a psychometric consultant at the Department
of Educational Development and Research of the Maastricht Medical School.
He specializes in methodology and psychometric data analysis in
educational research, focussing on progress tests and computer-based
testing.
Tjaart Imbos (PhD) is a statistician and retired member of the Department of
Methodology and Statistics. He specialises in psychometrics and research
methodology. His research interest is Statistics Education Research.
Maarten Verwijnen (MD), is a general physician working in medical education
at Maastricht since his graduation in 1977; as one of the early staff members
of the Maastricht Medical School he was involved in the development of
problem based self directed learning of medical education in the Maastricht
Medical School. Since 1999 he is head of the skillslab.
Aalbers et al. BMC Medical Education 2013, 13:27 Page 8 of 9
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Acknowledgements
We would like to thank W.G. Aalbers, J.P.N. Grond, P.E. Monteban (MD) for
their help with the data analyses, M. Gorsira and J. van Dalen for revision of
the manuscript, and A. Scherpbier for the illuminating discussions and clear
advises.
Received: 24 November 2011 Accepted: 14 February 2013
Published: 22 February 2013
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doi:10.1186/1472-6920-13-27
Cite this article as: Aalbers et al.: Why should I prepare? a mixed
method study exploring the motives of medical undergraduate
students to prepare for clinical skills training sessions. BMC Medical
Education 2013 13:27.
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