Clinical learning (CL) is defined as a complex and authentic process in which students learn as part of a team, in direct contact with healthy or sick individuals or communities. ¹

Defined as the workplace for health professions students during clinical placements, the clinical learning environment (CLE) serves as a crucial arena where theoretical knowledge is applied to practice, clinical skills are acquired, and problem-solving abilities are developed. ^{2 , 3}

It is important to motivate medical students to actively engage in CL for their professional development and the delivery of high-quality healthcare.

Motivation in CL refers to the drive, enthusiasm, and willingness of students to actively participate, learn, and excel in their clinical experiences. It influences their engagement, persistence, and overall learning outcomes.

In 2004, Brophy defined motivation as a theoretical concept that explains the onset, direction, strength, and persistence of goal-directed behavior. ⁴ Motivation to learn is widely acknowledged as central to effective education. ^{5 – 7} It is seen as a key element in ensuring progress and learning improvement. ⁸

The significance of motivation in learning behavior and education is well-researched and established in general education, but less so in medical education. Much can be learned in medical education research from the wealth of literature on general education, where motivation is a predictor of learning, academic success, progression, and well-being. ⁹ The factors that influence medical student motivation during CL remain poorly understood.

Understanding the factors that drive motivation in CL can enhance educational strategies and ultimately contribute to better-prepared, competent healthcare professionals. ¹⁰

The complexity of motivation in clinical learning, influenced by internal, external, social, and environmental factors, necessitates a nuanced understanding among medical mentors. As crucial contributors to the CLE, mentors must recognize the intricate interplay of these motivators to tailor instructional methods effectively, creating an atmosphere that promotes sustained engagement and enthusiasm among students. ¹

Exploring motivation in CL can be challenging due to the various settings, features, and stakeholders involved. ¹¹

Despite the growing body of literature on motivation in clinical learning, studies from North African and specifically Tunisian contexts remain limited. The exploration of this subject within the Faculty of Medicine of Sousse offers significant insights into the manner in which contextual, cultural, and educational factors may influence students’ motivation in underrepresented settings.

Our study aimed to assess the perception of CLE, to measure motivation for clinical learning among FMS (Faculty of Medicine of Sousse) students’ and to find associated factors to motivation in clinical learning clerkships.

Clinical learning, an integral component of healthcare education, plays a pivotal role in preparing future healthcare professionals for the dynamic and challenging environments they will encounter in their careers. Motivation, a driving force that propels individuals toward their goals, is a crucial factor in the success of CL experiences.

Our study aimed to determine undergraduate medical students’ perception of CLE measure motivation for CL among medical students in the FMS and identify its associated factors.

The educational environment for learning is one of the most significant determinants of effective implementation of curriculum. Students’ perception of the educational environment is crucial for improving and modifying the quality of medical education.

Overall, respondents reported moderate scores related to CLE perception and revealed areas that could be improved. This indicates that students’ CLE perceptions were generally positive. These are consistent with previous studies’ results. ¹⁶

In our study, students obtained an average score of 4.66 ± 0.90 for motivation towards CL. This indicates a medium level of motivation among students.

The lowest mean motivation score among students was 3.99 for ‘control of learning beliefs’. This finding may indicate that students perceive a lack of control or influence over their CL experience. This could be due to factors such as the structure of the clinical curriculum, communication with tutors, or the overall learning environment.

Students should be given immediate feedback on their progress and should be valued as unique individuals, which enhances their control over learning. Therefore, CL tutors should adopt a “constructivist” approach to instruction in which students are empowered to construct their representations of reality through actively engaging them in the learning process and learning by doing. ¹⁷

In Dempsey and al’s study, medical students recorded the lowest average motivation score of 4.57 for “test anxiety,” whilst dental students scored the lowest in “intrinsic goal orientation” with an average of 5.05. ¹⁸

The top mean motivation score among students was 4.95 for ‘self-efficacy for learning and performance’. This suggests that students feel confident in their ability to succeed in CL situations. High self-efficacy is commonly linked to elevated motivation and persistence when confronted with challenges. As per Bandura, self-efficacy is a crucial motivational resource that influences human performance either directly or indirectly through the motivational process. ⁷ Multon, Brown, and Lent’s meta-analysis on self-efficacy beliefs and academic achievement revealed that self-efficacy accounts for 14%-32% of the variance in academic achievements. ¹⁹ Therefore, we deduce that encouraging students to reflect on their clinical experiences and self-assess their performance can promote metacognitive awareness and enhance self-efficacy.

Students scoring higher on the Intrinsic Goal Orientation subscale had excellent CL results 5.28 ± 1.18 (p = 0.011) and academic rankings (p = 0.039). Individuals’ intrinsic goal orientation, which denotes their innate drive to master a task or acquire knowledge, has continuously correlated with improved learning and academic performance. ²⁰ It was shown that intrinsically motivated students are more persistent in their studies. ²¹

The excellent CL outcomes achieved by students with higher intrinsic goal orientation scores are consistent with the broader literature on motivation and learning outcomes. A UK-based study discovered that distinct internal motivations encourage medical students’ learning. ²² The connection between intrinsic goal orientation and good academic rank emphasizes the significance of intrinsic motivation not just in clinical education but also in academic success more broadly. Students who pursue their education with intrinsic goals are more likely to exhibit a profound involvement with the subject matter and an elevated level of critical thinking. These factors collectively contribute to achieving higher academic rankings. ²³

In our study, we found that students with higher motivation scores on the extrinsic goal orientation subscale agreed or strongly agreed that tasks are relevant to learning goals 4.78 ± 1.34, revealing an interesting link between extrinsic motivation and perceived task relevance. Extrinsic goal orientation pertains to external motivators such as rewards, grades, or approval. This link suggests that students who are more externally motivated may perceive tasks as meaningful when they see a strong connection between those tasks and the achievement of external rewards or recognition. ²⁴ In this sense, Moll-Khosrawi discovered that acknowledging the impact of extrinsic motivation on perceived task relevance enables teachers to create learning activities that explicitly highlight the real-world applications of the content or demonstrate how completing certain tasks is linked to achieving external rewards. This approach permits educators to employ extrinsic motivation to increase student engagement and the perceived relevance of the course material. ²⁵

Medical students who agreed or strongly agreed that the CL mentors were well prepared to supervise had higher motivation scores on the extrinsic goal orientation subscale 5.05 ± 1.27. The presence of a positive correlation between students’ perceptions of mentor preparedness and higher extrinsic goal orientation scores implies that when students think that their mentors are well-prepared, they may be more motivated. This association aligns with the current literature on the significance of mentorship in medical education and how mentors’ traits can impact student engagement and motivation. ²⁶ Taylor et al.’s work demonstrated that when supervisors are aware of the learning objectives, they can identify students’ learning needs and provide relevant learning experiences. ²⁷ When students perceive their supervisors as a source of guidance, constructive feedback, and a supportive learning environment, it contributes to a positive CLE. ²⁸

Students who agreed or strongly agreed that they felt welcome and received in a positive the way the staff in the CL environment had significantly higher motivational scores for test anxiety 4.27 ± 1.55 (p = 0.039) than those who disagreed or strongly disagreed 3.64 ± 1.34 (p = 0.039). This suggests that feeling welcomed in the CL department has the potential to improve motivation scores for test anxiety. According to the Putwain et al. study, feeling welcome is associated with higher motivational scores for test anxiety and also suggests a nuanced relationship between anxiety and motivation. Although high levels of test anxiety can be seen as negative, it can also act as a motivating factor, encouraging students to put more time and effort into their studies. ²⁹

Considering this evidence, educational institutions must prioritize the establishment of a welcoming and supportive CL environment. ³⁰

Learning takes place in complex contexts, requiring practitioners to overcome various motivational, systemic, emotional, and social barriers to the application of knowledge. ³¹ Although effective performance in clinical settings requires the integration between theory and practice, there is a gap between theoretical knowledge as taught in the classroom and what the students experience in clinical settings.

We found that most motivation subscales are significantly associated with higher agreement about alignment between theoretical knowledge and practices. On the other hand, continuity between learning objectives and tasks or skills is significantly associated with almost all motivation subscales. This promotes a smooth transition from classroom learning to clinical practice. Hence, in real clinical situations, they can generalize from what they have learned in theory. ³²

To our knowledge, this is the first Tunisian study to deal with assessing medical student perception and motivation toward CL.

However, our work has some limitations. Firstly, data collection method adopted in this work via Google forms presents some disadvantages compared to a face-to-face interview such as distrust of the anonymity and confidentiality of data with an often-lower response rate which was noticed in this study. Additionally, we should acknowledge the potential existence of a selection bias, since 55% of our sample is composed of 5 ^th year student, which is partially explained by their higher impregnation by CLE. A further significant restriction of this study is the utilisation of a purely quantitative approach, predicated on predefined variables. While this method enabled the measurement of key dimensions of motivation, it may not fully capture the complexity and depth of factors influencing students’ motivation in clinical learning. It is recommended that qualitative or mixed-methods approaches be considered in future research, as they have the potential to provide richer insights into students' experiences, perceptions, and contextual influences.

Further research should be undertaken with the involvement of all four Tunisian medical faculties at multiple centers and larger sample size to thoroughly explore the phenomenon of medical student motivation at a national level.

When students perceive their supervisors as a source of guidance, constructive feedback, and a supportive learning environment, it contributes to a positive CLE.

Faculty of Medicine of Sousse Ethics Committee approved the study. The approval reference: CEFMSo_0002_2024.

Participation was voluntary and anonymous. Informed consent was obtained from all participants before they proceeded with the questionnaire.

The questionnaire was distributed through Google Forms to students’ institutional email addresses, which were provided by the faculty administration. At the beginning of the questionnaire, participants were presented with a clear explanation of the study’s purpose, objectives, and their rights, including the right to withdraw at any time without any consequences. They were then asked, Would you like to participate in this study? Only those who explicitly selected “Yes” were allowed to proceed with the questionnaire, ensuring that all participants actively provided their consent before participating.

As this consent was obtained electronically and explicitly through Google Forms. This study was performed in line with the principles of the Declaration of Helsinki.