Background Patient contact and clinical-based learning have been suggested as positive determinants of student motivation. However, few studies have been conducted on how this impacts dental student motivation. Based on the self-determination theory, this study aims to explore differences in the quality of motivation of dental student transition from preclinical (no previous patient contact) to clinical courses. Methods A longitudinal study was conducted with 95 Chilean students who completed the Academic Motivation Scale in two iterations over a one-year period. Results Paired t-test showed a significant increase in relative autonomous motivation as well as in amotivation. Discussions This suggests that while clinical contact supports student self-determination, an abrupt transition might be associated with maladjustment, which could lead to feelings of inadequacy and anxiety. Future research could usefully explore if early and gradual clinical experiences enhance student adaptation to the clinical context, thus increasing relative autonomous motivation and decreasing amotivation in the time

Creswell

Deci

Kusurkar

Lalumandier

Legault

Littlewood

Orsini

Sobral

Ten Cate

Vallerand

Whitford

English

AbstractBackgroundPatient contact and clinical-based learning have been suggested as positive determinants of student motivation. However, few studies have been conducted on how this impacts dental student motivation. Based on the self-determination theory, this study aims to explore differences in the quality of motivation of dental student transition from preclinical (no previous patient contact) to clinical courses.MethodsA longitudinal study was conducted with 95 Chilean students who completed the Academic Motivation Scale in two iterations over a one-year period.ResultsPaired t-test showed a significant increase in relative autonomous motivation as well as in amotivation.DiscussionsThis suggests that while clinical contact supports student self-determination, an abrupt transition might be associated with maladjustment, which could lead to feelings of inadequacy and anxiety. Future research could usefully explore if early and gradual clinical experiences enhance student adaptation to the clinical context, thus increasing relative autonomous motivation and decreasing amotivation in the time

Orsini, Cesar

Binnie, Vivian I.

Fuentes, Fernando

Ledezma, Priscilla

Jerez, Oscar

Elsevier - Publisher Connector 

Educ Med. 2016;17(4):193--196
www.elsevier.es/edumed
EducaciónMédica
BRIEF ORIGINAL
Implications  of motivation  differences  in
preclinical-clinical transition  of  dental  students:
A one-year  follow-up  study
Cesar Orsinia,d,∗, Vivian I. Binnieb, Fernando Fuentesc, Priscilla Ledezmac, Oscar Jerezd
a Medical  School,  University  of  Glasgow,  Glasgow,  UK
b Dental  School,  University  of  Glasgow,  Glasgow,  UK
c Dental  School,  University  San  Sebastian,  Santiago,  Chile
d Teaching  and  Learning  Centre,  Faculty  of  Economics  and  Business,  University  of  Chile,  Santiago,  Chile
Received 5  February  2016;  accepted  1  June  2016
Available  online  30  July  2016
KEYWORDS
Motivation;
Self-determination;
Dental  education;
Preclinical-clinical
transition;
Chile
Abstract
Background:  Patient  contact  and  clinical-based  learning  have  been  suggested  as  positive  deter-
minants of  student  motivation.  However,  few  studies  have  been  conducted  on  how  this  impacts
dental student  motivation.  Based  on  the  self-determination  theory,  this  study  aims  to  explore
differences  in  the  quality  of  motivation  of  dental  student  transition  from  preclinical  (no  previous
patient contact)  to  clinical  courses.
Methods:  A  longitudinal  study  was  conducted  with  95  Chilean  students  who  completed  the
Academic Motivation  Scale  in  two  iterations  over  a  one-year  period.
Results:  Paired  t-test  showed  a  signiﬁcant  increase  in  relative  autonomous  motivation  as  well
as in  amotivation.
Discussions:  This  suggests  that  while  clinical  contact  supports  student  self-determination,  an
abrupt transition  might  be  associated  with  maladjustment,  which  could  lead  to  feelings  of
inadequacy  and  anxiety.  Future  research  could  usefully  explore  if  early  and  gradual  clini-
cal experiences  enhance  student  adaptation  to  the  clinical  context,  thus  increasing  relative
autonomous  motivation  and  decreasing  amotivation  in  the  time.
© 2016  Elsevier  Espan˜a,  S.L.U.  This  is  an  open  access  article  under  the  CC  BY-NC-ND  license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).∗ Corresponding author.
E-mail address: cesar.orsini@gmail.com (C. Orsini).
http://dx.doi.org/10.1016/j.edumed.2016.06.007
1575-1813/© 2016 Elsevier Espan˜a, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
194  C.  Orsini  et  al.
PALABRAS  CLAVE
Motivación;
Autodeterminación;
Educación
odontológica;
Transición
preclínico-clínica;
Chile
Implicaciones  de  diferencias  motivacionales  en  la  transición  preclínico-clínica  de
estudiantes  de  odontología:  un  estudio  longitudinal  de  un  an˜o
Resumen
Antecedentes:  El  contacto  con  pacientes  y  la  ensen˜anza  clínica  han  sido  sen˜alados  como  deter-
minantes  positivos  de  la  motivación  de  estudiantes.  Sin  embargo,  es  limitada  la  evidencia  sobre
cómo estas  variables  impactan  en  la  motivación  en  estudiantes  de  odontología.  Basándonos  en
la teoría  de  la  autodeterminación,  el  objetivo  de  este  estudio  fue  explorar  las  diferencias
motivacionales  en  la  transición  preclínica  (sin  previo  contacto  con  pacientes)  a  la  clínica  en
estudiantes  de  odontología.
Métodos:  Se  realizó  un  estudio  longitudinal  en  el  cual  95  estudiantes  chilenos  respondieron  en
2 ocasiones  la  Escala  de  motivación  educativa  en  un  período  de  un  an˜o.
Resultados:  La  prueba  t  de  muestras  pareadas  mostró,  al  mismo  tiempo,  un  aumento  signiﬁca-
tivo de  motivación  autónoma  relativa  y  de  amotivación.
Discusiones:  Esto  sugiere  que,  mientras  el  contacto  clínico  beneﬁcia  la  autodeterminación  de
los estudiantes,  una  transición  abrupta  puede  llevar  a  estados  de  inadaptación  y  ansiedad.  Se
sugiere que  futuras  investigaciones  exploren  si  la  experiencia  clínica  temprana  beneﬁciaría  la
adaptación de  estudiantes,  aumentando  así  la  motivación  autónoma  relativa  y  disminuyendo
la amotivación  en  el  tiempo.
©  2016  Elsevier  Espan˜a,  S.L.U.  Este  es  un  art´ıculo  Open  Access  bajo  la  licencia  CC  BY-NC-ND
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
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The  dental  school  has  a  six-year  discipline-based  undergra-ntroduction
ecent  research  in  dental  education  has  suggested  a strong
ssociation  between  self-determined  forms  of  motivation
nd  positive  outcomes,  such  as  higher  self-concept,  posi-
ive  emotions,  and  deep  study  motives,1 with  similar  ﬁndings
eported  in  medical  education.2 However,  few  studies  have
xplored  which  determinants  impact  students’  quality  of
otivation.
These  studies  have  been  conducted  following  the  princi-
les  of  the  self-determination  theory  of  motivation  (SDT).3
DT  focuses  on  quality  types  of  motivation  and  makes  a  dis-
inction,  from  the  least  to  the  most  self-determined  types,
etween  (1)  amotivation  i.e.,  lacking  the  intention  to  act,
2)  controlled  motivation  (CM)  i.e.,  originating  from  exter-
al  sources  and  aimed  at  doing  something  because  it  leads
o  a  separable  outcome,  and  (3)  autonomous  motivation
AM)  i.e.,  originating  within  the  individual  and  engaging  in
ctivities  because  they  are  interesting,  valuable  or  enjoy-
ble.  As  reasons  for  engaging  in  activities  become  more
elf-determined,  outcomes  become  increasingly  positive.
or  a  comprehensive  review  of  self-determined  motivation
n  health  professions  education,  we  refer  the  reader  to  the
ork  of  Ten  Cate  et  al.4
It  has  been  suggested  that  supporting  students’
utonomous  forms  of  motivation  might  lead  to  positive  edu-
ational  outcomes,  which  in  turn  may  encourage  students
o  use  a  more  autonomy-supportive  style  when  relating  to
atients,  and  therefore  support  patients’  autonomous  moti-
ation  towards  their  healthcare.4 However,  little  attention
as  been  paid  in  dental  education  to  which  variables  are
ikely  to  inﬂuence  students  to  engage  in  academic  activities
ut  of  autonomous  motivation.Patient-related  factors  such  as  extent  of  patient  respon-
ibility  and  clinical  contact,  have  been  reported  to  increase
tudents’  perceptions  of  autonomy  and  relatedness,  and
d
s
totivation  for  learning.5 This  is  especially  relevant  to  dental
ducation,  where  students  start  treating  patients  (under
utor  supervision)  in  early  years.  Traditionally,  the  transi-
ion  from  preclinical  to  clinical-based  learning  has  occurred
uring  the  third  or  fourth  year,  and  beneﬁts  from  this
ransition  have  been  shown  for  students’  communication
kills,  self-awareness  and  socialization.6 Additionally,  pre-
ious  research  in  dental  education  has  supported  an  even
arlier  and  more  gradual  transition,7 mainly  because  of  the
eelings  of  inadequacy,  fear,  and  anxiety  that  an  abrupt
ransition  may  cause  at  the  same  time.8 This  has  grown  in
mportance  in  light  of  recent  ﬁndings  from  a  cross-sectional
tudy  suggesting  that  third  and  fourth  year  dental  stu-
ents,  despite  reporting  a  more  autonomous  than  controlled
otivation  proﬁle,  were  at  the  same  time  reporting  higher
motivation  scores  than  other  years  of  study.1
A  question  that  rises  from  this  is  how  clinical  contact
mpacts  students’  motivation.  Therefore,  the  aim  of  this
tudy  is  to  explore  the  differences  in  students’  quality  of
otivation  to  engage  in  academic  activities  in  the  transi-
ion  from  preclinical  to  clinical  courses.  To  the  extent  of
ur  knowledge,  this  is  the  ﬁrst  study  to  undertake  a  longitu-
inal  analysis  on  this  topic  and  thus  provides  an  important
pportunity  to  advance  the  understanding  of  motivation  and
ts  determinants  in  dental  education.
ethods
e  conducted  a  longitudinal  panel  design  study9 at  the  Den-
al  School  of  the  University  San  Sebastian  in  Santiago,  Chile.uate  curriculum,  where  the  ﬁrst  two  years  comprise  basic
ciences,  progressing  to  a  preclinical  third  year,  and  ﬁnally
o  clinical-based  fourth,  ﬁfth  and  sixth  years.
Motivation  in  preclinical-clinical  transition  195
Table  1  Preclinical  --  clinical  RAM  and  amotivation  means  (standard  deviations),  and  t-test  differences  with  95%  BCa  bootstrap
conﬁdence intervals.
Sample  Pre  clinical
RAM  mean
(SD)
Clinical
RAM  mean
(SD)
Pearson’s
correlation
Mean
difference
95%
difference
BCa  CI
t  p-value  Effect  size
(Cohen’s  d)
Total  −1.64
(11.10)
1.26
(14.50)
.699  −2.90  [−4.88,
−0.80]
−2.71  0.008  −0.22
Sample Pre  clinical
amotiva-
tion  mean
(SD)
Clinical
amotiva-
tion  mean
(SD)
Pearson’s
correlation
Mean
difference
95%
difference
BCa  CI
t  p-value  Effect  size
(Cohen’s  d)
Total  6.22  (4.86)  7.49  (5.33)  .554  −1.27  [−2.25,
−0.32]
−2.57  0.010  −0.25
Note: 95% bias corrected and accelerated conﬁdence intervals based on 1000 bootstrap samples. RAM, relative autonomous motivation.
R
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SStudents  were  invited  to  participate  voluntarily  in  two
iterations:  at  the  end  of  the  ﬁrst  semester  of  the  third  year
(no  prior  patient  contact)  and  one  year  after,  on  the  fourth
year,  where  they  had  experienced  a  full  semester  of  clinical-
based  learning.  An  ad-hoc  power  analysis  (alpha  level  of
0.05,  power  of  0.80  and  effect  size  of  0.3)  resulted  in  a
total  sample  size  of  71  students;  nevertheless  we  invited
the  entire  2014  third-year  and  2015  fourth-year  cohorts,  in
order  to  have  a  representative  sample  and  to  account  for
possible  non-responses  and  attrition.
Data  were  collected  on  demographics  and  students’  qua-
lity  of  motivation  for  attending  university.  The  latter  was
measured  through  the  Academic  Motivation  scale  (AMS),10
which  is  a  self-reported  instrument  composed  by  28  items,
where  students  rate  how  closely  a  list  of  reasons  for  study-
ing  at  university  reﬂects  their  own  motivation.  We  used
a  Chilean-Spanish  version,  which  had  been  previously  va-
lidated  with  a  dental  student  sample  (Cronbach’s  alpha
0.77).1
We  used  the  variables  of  amotivation  and  a  single  score
to  measure  AM  over  CM.  The  latter  is  known  as  relative
autonomous  motivation  and  provided  a  general  estimate  of
students’  degree  of  autonomous  motivation.2 This  was  cal-
culated  by  combining,  weighting,  and  adding  the  respective
AMS-items  that  form  AM  and  CM,  so  as  to  compute  a  Re-
lative  Autonomous  Motivation  index  (RAM).  A  positive  RAM
suggested  an  autonomous  or  self-determined  proﬁle,  which
is  considered  the  ‘good’  type  of  motivation,3 whereas  a ne-
gative  RAM  indicated  a  controlled  or  non  self-determined
proﬁle.  Previous  research  has  reported  reliable  scores  for
amotivation,  CM  and  AM  (Cronbach’s  alpha  0.83,  0.74,  and
0.75,  respectively),  and  the  successful  use  of  RAM  to  com-
bine  the  measures  of  CM  and  AM.2
After  checking  for  normal  distribution  of  differences
between  scores,  the  SPSS® software  version  20.0  was  used
to  computed  descriptive  statistics,  reliability,  and  paired
t-tests  with  BCa  Bootstrap  conﬁdence  intervals  and  effect
sizes,  in  order  to  test  for  differences  in  RAM  and  Amoti-
vation  in  the  preclinical-clinical  transition.  The  study  had
ethics  clearance  (0039  2015-03-08/03)  through  the  Dental
School’s  Ethics  Committee.
a
o
ﬁesults
 total  of  95  students  (74.2%  response  rate)  agreed  to  parti-
ipate,  with  an  average  age  of  22.7  years  (SD  =  2.19)  at  the
rst  iteration.  There  were  57  (60%)  females  and  38  (40%)
ales,  which  represented  the  normal  gender  distribution
ithin  the  dental  school.
The  mean  Cronbach  alpha  values  of  the  AMS  were  0.81
nd  0.80  at  the  ﬁrst  and  second  iteration,  respectively.  This
as  consistent  with  the  results  from  previous  research.1
Table  1  presents  the  results  obtained  from  the  paired
-test  amongst  the  preclinical  and  clinical  transition  for
AM  and  amotivation.  A  negative  mean  score  for  RAM  was
eported  in  the  preclinical  year,  suggesting  a  controlled
otivation  proﬁle.  By  contrast,  these  students  reported  a
ositive  mean  RAM  score  in  the  ﬁrst  clinical  year,  suggesting
 change  towards  an  autonomous  motivation  proﬁle.  This
ifference  was  signiﬁcant  (p  =  0.008),  with  a  small  effect
ize  (Cohen’s  d  = −0.22).  In  other  words,  the  transition  to
he  ﬁrst  clinical  year  accounted  for  a  22%  of  the  variance
n  RAM.  Interestingly,  when  comparing  amotivation  scores,
here  was  a  signiﬁcant  increase  from  preclinical  to  cli-
ical  courses  (p  =  0.010),  with  a  small  effect  size  (Cohen’s
 =  −0.25).
iscussion and conclusions
ur  results  show  positive  and  signiﬁcant  differences  on  RAM
hen  transitioning  from  a  preclinical  to  a  clinical  environ-
ent.  These  results  further  support  those  from  previous
esearch,11 which  argue  that  motivation  is  a  dynamic  state
hat  may  change  as  moving  from  preclinical  to  clinical
ontexts.  Additionally,  these  ﬁndings  might  be  explained
y  the  enhanced  perception  of  autonomy  and  relatedness
ssociated  with  the  clinical  learning  cycle,  both  of  which
DT  suggests  need  to  be  satisﬁed  in  order  to  enhance
utonomous  motivation.3
Amotivation  results  were  in  agreement  with  those
btained  in  a  recent  study,1 where  dental  students  in  their
rst  clinical  year  showed,  at  the  same  time,  an  autonomous
1o
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196  
ver  a  controlled  motivation  proﬁle  as  well  as  reporting  a
igniﬁcant  increase  in  amotivation.
These  results  might  seem  contradictory  at  ﬁrst,  but  SDT
ostulates  that  amotivation  is  neither  an  autonomous  nor  a
ontrolled  form  of  motivation;  it  is  the  lack  of  it.3 Therefore,
 possible  explanation  for  the  increase  in  RAM  and  amoti-
ation  at  the  same  time,  might  be  that,  despite  reporting
n  autonomous  motivation  proﬁle,  students  were  uncertain
here  to  put  their  efforts  because  of  unsubstantiated  feel-
ngs  or  inadequacy  to  the  clinical  context.12 In  other  words,
tudents  were  self-determined  when  engaging  in  activities
n  this  new,  challenging  and  exciting  clinical  environment,
ut  at  the  same  time  an  abrupt  transition  might  be  mak-
ng  them  not  to  know  what  to  expect  and  therefore  to  feel
aladjusted  and  experience  anxiety,  uncertainty  and  lack
f  conﬁdence.8 Moreover,  previous  research  in  health  pro-
essions  education  has  correlated  amotivation  with  negative
motions  and  behaviours.1
These  ﬁndings  have  important  implications  for  support-
ng  early  and  gradual  clinical  contact  experiences,  as  these
ave  been  previously  associated  with  improvement  and
uicker  development  of  interpersonal  and  clinical  skills,
etter  understanding  of  basic  sciences,  improvement  of
onﬁdence,  and  the  alleviation  of  feelings  of  inadequacy,
ncertainty  and  anxiety.6,8,13
Our  ﬁndings  may  be  somewhat  limited  by  the  educatio-
ally  important  but  still  small  effect  sizes,  and  are  not  to
e  generalized  as  they  come  from  one  sample  in  one  dental
chool.  Additionally,  it  was  not  possible  to  assess  the  effect
f  other  variables,  such  as  teachers’  autonomy-support  and
erceived  competence  and  relatedness,  which  might  con-
ribute  to  explain  larger  variance  in  the  results.
Future  research  should  consider  additional  variables,  a
onger  follow-up  period  design  and  the  inclusion  of  early
nd  gradual  clinical  experiences,  so  to  explore  if  students’
daptation  to  the  clinical  context  would  lead  to  an  increase
n  RAM  and  a  decrease  in  amotivation.
This  is  the  ﬁrst  study  to  provide  evidence  on  the  rele-
ance  of  the  preclinical-clinical  transition  for  students’
elf-determination,  and  it  may  very  well  serve  as  a good
tarting  point  for  more  studies  on  determinants  of  motiva-
ion  in  dental  education.unding
one.
1C.  Orsini  et  al.
onﬂict of interest
he  authors  of  this  article  declare  no  conﬂict  of  interest.
eferences
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Implications of motivation differences in preclinical-clinical transition of dental students: A one-year follow-up study 

Background:  Patient contact and clinical-based learning have been suggested as positive determinants of student motivation. However, few studies have been conducted on how this impacts dental student motivation. Based on the self-determination theory, this study aims to explore differences in the quality of motivation of dental student transition from preclinical (no previous patient contact) to clinical courses.   Methods:  A longitudinal study was conducted with 95 Chilean students who completed the Academic Motivation Scale in two iterations over a one-year period.   Results:  Paired t-test showed a significant increase in relative autonomous motivation as well as in amotivation.   Discussions:  This suggests that while clinical contact supports student self-determination, an abrupt transition might be associated with maladjustment, which could lead to feelings of inadequacy and anxiety. Future research could usefully explore if early and gradual clinical experiences enhance student adaptation to the clinical context, thus increasing relative autonomous motivation and decreasing amotivation in the time

University of East Anglia digital repository

Educ Med. 2016;17(4):193--196www.elsevier.es/edumedEducaciónMédicaBRIEF ORIGINALImplications  of motivation  differences  inpreclinical-clinical transition  of  dental  students:A one-year  follow-up  studyCesar Orsinia,d,∗, Vivian I. Binnieb, Fernando Fuentesc, Priscilla Ledezmac, Oscar Jerezda Medical  School,  University  of  Glasgow,  Glasgow,  UKb Dental  School,  University  of  Glasgow,  Glasgow,  UKc Dental  School,  University  San  Sebastian,  Santiago,  Chiled Teaching  and  Learning  Centre,  Faculty  of  Economics  and  Business,  University  of  Chile,  Santiago,  ChileReceived 5  February  2016;  accepted  1  June  2016Available  online  30  July  2016KEYWORDSMotivation;Self-determination;Dental  education;Preclinical-clinicaltransition;ChileAbstractBackground:  Patient  contact  and  clinical-based  learning  have  been  suggested  as  positive  deter-minants of  student  motivation.  However,  few  studies  have  been  conducted  on  how  this  impactsdental student  motivation.  Based  on  the  self-determination  theory,  this  study  aims  to  exploredifferences  in  the  quality  of  motivation  of  dental  student  transition  from  preclinical  (no  previouspatient contact)  to  clinical  courses.Methods:  A  longitudinal  study  was  conducted  with  95  Chilean  students  who  completed  theAcademic Motivation  Scale  in  two  iterations  over  a  one-year  period.Results:  Paired  t-test  showed  a  significant  increase  in  relative  autonomous  motivation  as  wellas in  amotivation.Discussions:  This  suggests  that  while  clinical  contact  supports  student  self-determination,  anabrupt transition  might  be  associated  with  maladjustment,  which  could  lead  to  feelings  ofinadequacy  and  anxiety.  Future  research  could  usefully  explore  if  early  and  gradual  clini-cal experiences  enhance  student  adaptation  to  the  clinical  context,  thus  increasing  relativeautonomous  motivation  and  decreasing  amotivation  in  the  time.© 2016  Elsevier  Espan˜a,  S.L.U.  This  is  an  open  access  article  under  the  CC  BY-NC-ND  license(http://creativecommons.org/licenses/by-nc-nd/4.0/).∗ Corresponding author.E-mail address: cesar.orsini@gmail.com (C. Orsini).http://dx.doi.org/10.1016/j.edumed.2016.06.0071575-1813/© 2016 Elsevier Espan˜a, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).194  C.  Orsini  et  al.PALABRAS  CLAVEMotivación;Autodeterminación;Educaciónodontológica;Transiciónpreclínico-clínica;ChileImplicaciones  de  diferencias  motivacionales  en  la  transición  preclínico-clínica  deestudiantes  de  odontología:  un  estudio  longitudinal  de  un  an˜oResumenAntecedentes:  El  contacto  con  pacientes  y  la  ensen˜anza  clínica  han  sido  sen˜alados  como  deter-minantes  positivos  de  la  motivación  de  estudiantes.  Sin  embargo,  es  limitada  la  evidencia  sobrecómo estas  variables  impactan  en  la  motivación  en  estudiantes  de  odontología.  Basándonos  enla teoría  de  la  autodeterminación,  el  objetivo  de  este  estudio  fue  explorar  las  diferenciasmotivacionales  en  la  transición  preclínica  (sin  previo  contacto  con  pacientes)  a  la  clínica  enestudiantes  de  odontología.Métodos:  Se  realizó  un  estudio  longitudinal  en  el  cual  95  estudiantes  chilenos  respondieron  en2 ocasiones  la  Escala  de  motivación  educativa  en  un  período  de  un  an˜o.Resultados:  La  prueba  t  de  muestras  pareadas  mostró,  al  mismo  tiempo,  un  aumento  significa-tivo de  motivación  autónoma  relativa  y  de  amotivación.Discusiones:  Esto  sugiere  que,  mientras  el  contacto  clínico  beneficia  la  autodeterminación  delos estudiantes,  una  transición  abrupta  puede  llevar  a  estados  de  inadaptación  y  ansiedad.  Sesugiere que  futuras  investigaciones  exploren  si  la  experiencia  clínica  temprana  beneficiaría  laadaptación de  estudiantes,  aumentando  así  la  motivación  autónoma  relativa  y  disminuyendola amotivación  en  el  tiempo.©  2016  Elsevier  Espan˜a,  S.L.U.  Este  es  un  art´ıculo  Open  Access  bajo  la  licencia  CC  BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).IRaatrempStb(nt(aasFiwactpvhlossmettdtsveftisdmaismtodoiMWtThe  dental  school  has  a  six-year  discipline-based  undergra-ntroductionecent  research  in  dental  education  has  suggested  a strongssociation  between  self-determined  forms  of  motivationnd  positive  outcomes,  such  as  higher  self-concept,  posi-ive  emotions,  and  deep  study  motives,1 with  similar  findingseported  in  medical  education.2 However,  few  studies  havexplored  which  determinants  impact  students’  quality  ofotivation.These  studies  have  been  conducted  following  the  princi-les  of  the  self-determination  theory  of  motivation  (SDT).3DT  focuses  on  quality  types  of  motivation  and  makes  a  dis-inction,  from  the  least  to  the  most  self-determined  types,etween  (1)  amotivation  i.e.,  lacking  the  intention  to  act,2)  controlled  motivation  (CM)  i.e.,  originating  from  exter-al  sources  and  aimed  at  doing  something  because  it  leadso  a  separable  outcome,  and  (3)  autonomous  motivationAM)  i.e.,  originating  within  the  individual  and  engaging  inctivities  because  they  are  interesting,  valuable  or  enjoy-ble.  As  reasons  for  engaging  in  activities  become  moreelf-determined,  outcomes  become  increasingly  positive.or  a  comprehensive  review  of  self-determined  motivationn  health  professions  education,  we  refer  the  reader  to  theork  of  Ten  Cate  et  al.4It  has  been  suggested  that  supporting  students’utonomous  forms  of  motivation  might  lead  to  positive  edu-ational  outcomes,  which  in  turn  may  encourage  studentso  use  a  more  autonomy-supportive  style  when  relating  toatients,  and  therefore  support  patients’  autonomous  moti-ation  towards  their  healthcare.4 However,  little  attentionas  been  paid  in  dental  education  to  which  variables  areikely  to  influence  students  to  engage  in  academic  activitiesut  of  autonomous  motivation.Patient-related  factors  such  as  extent  of  patient  respon-ibility  and  clinical  contact,  have  been  reported  to  increasetudents’  perceptions  of  autonomy  and  relatedness,  anddstotivation  for  learning.5 This  is  especially  relevant  to  dentalducation,  where  students  start  treating  patients  (underutor  supervision)  in  early  years.  Traditionally,  the  transi-ion  from  preclinical  to  clinical-based  learning  has  occurreduring  the  third  or  fourth  year,  and  benefits  from  thisransition  have  been  shown  for  students’  communicationkills,  self-awareness  and  socialization.6 Additionally,  pre-ious  research  in  dental  education  has  supported  an  evenarlier  and  more  gradual  transition,7 mainly  because  of  theeelings  of  inadequacy,  fear,  and  anxiety  that  an  abruptransition  may  cause  at  the  same  time.8 This  has  grown  inmportance  in  light  of  recent  findings  from  a  cross-sectionaltudy  suggesting  that  third  and  fourth  year  dental  stu-ents,  despite  reporting  a  more  autonomous  than  controlledotivation  profile,  were  at  the  same  time  reporting  highermotivation  scores  than  other  years  of  study.1A  question  that  rises  from  this  is  how  clinical  contactmpacts  students’  motivation.  Therefore,  the  aim  of  thistudy  is  to  explore  the  differences  in  students’  quality  ofotivation  to  engage  in  academic  activities  in  the  transi-ion  from  preclinical  to  clinical  courses.  To  the  extent  ofur  knowledge,  this  is  the  first  study  to  undertake  a  longitu-inal  analysis  on  this  topic  and  thus  provides  an  importantpportunity  to  advance  the  understanding  of  motivation  andts  determinants  in  dental  education.ethodse  conducted  a  longitudinal  panel  design  study9 at  the  Den-al  School  of  the  University  San  Sebastian  in  Santiago,  Chile.uate  curriculum,  where  the  first  two  years  comprise  basicciences,  progressing  to  a  preclinical  third  year,  and  finallyo  clinical-based  fourth,  fifth  and  sixth  years.Motivation  in  preclinical-clinical  transition  195Table  1  Preclinical  --  clinical  RAM  and  amotivation  means  (standard  deviations),  and  t-test  differences  with  95%  BCa  bootstrapconfidence intervals.Sample  Pre  clinicalRAM  mean(SD)ClinicalRAM  mean(SD)Pearson’scorrelationMeandifference95%differenceBCa  CIt  p-value  Effect  size(Cohen’s  d)Total  −1.64(11.10)1.26(14.50).699  −2.90  [−4.88,−0.80]−2.71  0.008  −0.22Sample Pre  clinicalamotiva-tion  mean(SD)Clinicalamotiva-tion  mean(SD)Pearson’scorrelationMeandifference95%differenceBCa  CIt  p-value  Effect  size(Cohen’s  d)Total  6.22  (4.86)  7.49  (5.33)  .554  −1.27  [−2.25,−0.32]−2.57  0.010  −0.25Note: 95% bias corrected and accelerated confidence intervals based on 1000 bootstrap samples. RAM, relative autonomous motivation.RAcfimwawtRrmpadstitndDOwmrtcbaSStudents  were  invited  to  participate  voluntarily  in  twoiterations:  at  the  end  of  the  first  semester  of  the  third  year(no  prior  patient  contact)  and  one  year  after,  on  the  fourthyear,  where  they  had  experienced  a  full  semester  of  clinical-based  learning.  An  ad-hoc  power  analysis  (alpha  level  of0.05,  power  of  0.80  and  effect  size  of  0.3)  resulted  in  atotal  sample  size  of  71  students;  nevertheless  we  invitedthe  entire  2014  third-year  and  2015  fourth-year  cohorts,  inorder  to  have  a  representative  sample  and  to  account  forpossible  non-responses  and  attrition.Data  were  collected  on  demographics  and  students’  qua-lity  of  motivation  for  attending  university.  The  latter  wasmeasured  through  the  Academic  Motivation  scale  (AMS),10which  is  a  self-reported  instrument  composed  by  28  items,where  students  rate  how  closely  a  list  of  reasons  for  study-ing  at  university  reflects  their  own  motivation.  We  useda  Chilean-Spanish  version,  which  had  been  previously  va-lidated  with  a  dental  student  sample  (Cronbach’s  alpha0.77).1We  used  the  variables  of  amotivation  and  a  single  scoreto  measure  AM  over  CM.  The  latter  is  known  as  relativeautonomous  motivation  and  provided  a  general  estimate  ofstudents’  degree  of  autonomous  motivation.2 This  was  cal-culated  by  combining,  weighting,  and  adding  the  respectiveAMS-items  that  form  AM  and  CM,  so  as  to  compute  a  Re-lative  Autonomous  Motivation  index  (RAM).  A  positive  RAMsuggested  an  autonomous  or  self-determined  profile,  whichis  considered  the  ‘good’  type  of  motivation,3 whereas  a ne-gative  RAM  indicated  a  controlled  or  non  self-determinedprofile.  Previous  research  has  reported  reliable  scores  foramotivation,  CM  and  AM  (Cronbach’s  alpha  0.83,  0.74,  and0.75,  respectively),  and  the  successful  use  of  RAM  to  com-bine  the  measures  of  CM  and  AM.2After  checking  for  normal  distribution  of  differencesbetween  scores,  the  SPSS® software  version  20.0  was  usedto  computed  descriptive  statistics,  reliability,  and  pairedt-tests  with  BCa  Bootstrap  confidence  intervals  and  effectsizes,  in  order  to  test  for  differences  in  RAM  and  Amoti-vation  in  the  preclinical-clinical  transition.  The  study  hadethics  clearance  (0039  2015-03-08/03)  through  the  DentalSchool’s  Ethics  Committee.aofiesults total  of  95  students  (74.2%  response  rate)  agreed  to  parti-ipate,  with  an  average  age  of  22.7  years  (SD  =  2.19)  at  therst  iteration.  There  were  57  (60%)  females  and  38  (40%)ales,  which  represented  the  normal  gender  distributionithin  the  dental  school.The  mean  Cronbach  alpha  values  of  the  AMS  were  0.81nd  0.80  at  the  first  and  second  iteration,  respectively.  Thisas  consistent  with  the  results  from  previous  research.1Table  1  presents  the  results  obtained  from  the  paired-test  amongst  the  preclinical  and  clinical  transition  forAM  and  amotivation.  A  negative  mean  score  for  RAM  waseported  in  the  preclinical  year,  suggesting  a  controlledotivation  profile.  By  contrast,  these  students  reported  aositive  mean  RAM  score  in  the  first  clinical  year,  suggesting change  towards  an  autonomous  motivation  profile.  Thisifference  was  significant  (p  =  0.008),  with  a  small  effectize  (Cohen’s  d  = −0.22).  In  other  words,  the  transition  tohe  first  clinical  year  accounted  for  a  22%  of  the  variancen  RAM.  Interestingly,  when  comparing  amotivation  scores,here  was  a  significant  increase  from  preclinical  to  cli-ical  courses  (p  =  0.010),  with  a  small  effect  size  (Cohen’s =  −0.25).iscussion and conclusionsur  results  show  positive  and  significant  differences  on  RAMhen  transitioning  from  a  preclinical  to  a  clinical  environ-ent.  These  results  further  support  those  from  previousesearch,11 which  argue  that  motivation  is  a  dynamic  statehat  may  change  as  moving  from  preclinical  to  clinicalontexts.  Additionally,  these  findings  might  be  explainedy  the  enhanced  perception  of  autonomy  and  relatednessssociated  with  the  clinical  learning  cycle,  both  of  whichDT  suggests  need  to  be  satisfied  in  order  to  enhanceutonomous  motivation.3Amotivation  results  were  in  agreement  with  thosebtained  in  a  recent  study,1 where  dental  students  in  theirrst  clinical  year  showed,  at  the  same  time,  an  autonomous1ospcavawisibimofeihqbcunbsoptlaaivsstFNCTR11196  ver  a  controlled  motivation  profile  as  well  as  reporting  aignificant  increase  in  amotivation.These  results  might  seem  contradictory  at  first,  but  SDTostulates  that  amotivation  is  neither  an  autonomous  nor  aontrolled  form  of  motivation;  it  is  the  lack  of  it.3 Therefore, possible  explanation  for  the  increase  in  RAM  and  amoti-ation  at  the  same  time,  might  be  that,  despite  reportingn  autonomous  motivation  profile,  students  were  uncertainhere  to  put  their  efforts  because  of  unsubstantiated  feel-ngs  or  inadequacy  to  the  clinical  context.12 In  other  words,tudents  were  self-determined  when  engaging  in  activitiesn  this  new,  challenging  and  exciting  clinical  environment,ut  at  the  same  time  an  abrupt  transition  might  be  mak-ng  them  not  to  know  what  to  expect  and  therefore  to  feelaladjusted  and  experience  anxiety,  uncertainty  and  lackf  confidence.8 Moreover,  previous  research  in  health  pro-essions  education  has  correlated  amotivation  with  negativemotions  and  behaviours.1These  findings  have  important  implications  for  support-ng  early  and  gradual  clinical  contact  experiences,  as  theseave  been  previously  associated  with  improvement  anduicker  development  of  interpersonal  and  clinical  skills,etter  understanding  of  basic  sciences,  improvement  ofonfidence,  and  the  alleviation  of  feelings  of  inadequacy,ncertainty  and  anxiety.6,8,13Our  findings  may  be  somewhat  limited  by  the  educatio-ally  important  but  still  small  effect  sizes,  and  are  not  toe  generalized  as  they  come  from  one  sample  in  one  dentalchool.  Additionally,  it  was  not  possible  to  assess  the  effectf  other  variables,  such  as  teachers’  autonomy-support  anderceived  competence  and  relatedness,  which  might  con-ribute  to  explain  larger  variance  in  the  results.Future  research  should  consider  additional  variables,  aonger  follow-up  period  design  and  the  inclusion  of  earlynd  gradual  clinical  experiences,  so  to  explore  if  students’daptation  to  the  clinical  context  would  lead  to  an  increasen  RAM  and  a  decrease  in  amotivation.This  is  the  first  study  to  provide  evidence  on  the  rele-ance  of  the  preclinical-clinical  transition  for  students’elf-determination,  and  it  may  very  well  serve  as  a goodtarting  point  for  more  studies  on  determinants  of  motiva-ion  in  dental  education.undingone.1C.  Orsini  et  al.onflict of interesthe  authors  of  this  article  declare  no  conflict  of  interest.eferences1. Orsini C, Binnie V, Evans P, Ledezma P, Fuentes F, Villegas M.Psychometric validation of the academic motivation scale in adental student sample. J Dent Educ. 2015;79:971--81.2. Kusurkar R, Ten Cate O, Vos C, Westers P, Croiset G. Howmotivation affects academic performance: a structural equa-tion modelling analysis. Adv Health Sci Educ Theory Pract.2013;18:57--69.3. Deci EL, Ryan RM. Self-determination theory: a macrotheory ofhuman motivation, development, and health. Can Psychol Can.2008;49:182--5.4. Ten Cate O, Kusurkar R, Williams G. How self-determinationtheory can assist our understanding of the teaching and learningprocesses in medical education. AMEE Guide No. 59. Med Teach.2011;33:961--73.5. Kusurkar R, Ten Cate O, van Asperen M, Croiset G. Motivation asan independent and a dependent variable in medical education:a review of the literature. Med Teach. 2011;33:242--62.6. Littlewood S, Ypinazar V, Margolis SA, Scherpbier A, SpencerJ, Dornan T. Early practical experience and the socialresponsiveness of clinical education: systematic review. BMJ.2005;331:387--91.7. Orsini C, Evans P, Binnie V, Ledezma P, Fuentes F. Encouragingintrinsic motivation in the clinical setting: teachers’ perspec-tives from the self-determination theory. Eur J Dent Educ.2016;20:102--11, http://dx.doi.org/10.1111/eje.121478. Whitford DL, Hubail AR. Cultural sensitivity or profes-sional acculturation in early clinical experience? Med Teach.2014;36:951--7.9. Creswell JW. Educational research: planning, conducting, andevaluating quantitative and qualitative research. Upper SaddlerRiver, NJ: Merrill; 2002.0. Vallerand RJ, Blais MR, Brière NM, Pelletier LG. Constructionand validation of the Academic Motivation Scale. Rev Can desSci du Comport. 1989;21:323--49.1. Sobral DT. What kind of motivation drives medical students’learning quests? Med Educ. 2004;38:950--7.2. Legault L, Green-Demers I, Pelletier L. Why do high schoolstudents lack motivation in the classroom? Toward an under-standing of academic amotivation and the role of social support.J Educ Psychol. 2006;98:567.3. Lalumandier JA, Victoroff KZ, Thuernagle O. Early clini-cal experience for first-year dental students. J Dent Educ.2004;68:1090--5.

Implications of motivation differences in preclinical-clinical transition of dental students: A one-year follow-up study

Cesar Orsini

Vivian I. Binnie

Fernando Fuentes

Priscilla Ledezma

Oscar Jerez

Crossref

Educación Médica

Background: Patient contact and clinical-based learning have been suggested as positive determinants of student motivation. However, few studies have been conducted on how this impacts dental student motivation. Based on the self-determination theory, this study aims to explore differences in the quality of motivation of dental student transition from preclinical (no previous patient contact) to clinical courses.
Methods: A longitudinal study was conducted with 95 Chilean students who completed the Academic Motivation Scale in two iterations over a one-year period.
Results: Paired t-test showed a significant increase in relative autonomous motivation as well as in amotivation.
Discussions: This suggests that while clinical contact supports student self-determination, an abrupt transition might be associated with maladjustment, which could lead to feelings of inadequacy and anxiety. Future research could usefully explore if early and gradual clinical experiences enhance student adaptation to the clinical context, thus increasing relative autonomous motivation and decreasing amotivation in the time

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Implications of motivation differences in preclinical-clinical transition of dental students:A one-year follow-up study

Implications of motivation differences in preclinical-clinical transition of dental students:A one-year follow-up study

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