Strategies for Optimizing Trainee Engagement and Motivation in Surgical Simulation Laboratory

Introduction

Simulation training has been hailed as a potential non-clinical source of surgical trainee education¹ for skill acquisition² and decrease learning curve for complex tasks.³ Despite this, self-directed utilization of surgical simulation labs by surgical trainees remains poor, which may preclude their utilization in surgical curricula.^2,4 Furthermore, mandating the attendance to simulation lab did not improve the attendance.^2,5

The success of any education system requiring deliberate practice, such as learning surgical skills, depends on learner engagement and motivation.^6,7 While learner motivation has been studied extensively in numerous educational arenas, it has been hitherto largely neglected as it pertains to surgical education. The objective of this review is to cultivate the understanding of motivational theories among surgical educators, and develop strategies to enhance trainee motivation for and engagement in surgical simulation training.

Why consider learner motivation?

From an educational standpoint, mandatory simulation sessions may fulfill training requirements in the short term, and may even be necessary for mundane, rote manual skills such as knot tying that rely solely on repetition for skill acquisition. However, mandating attendance does not guarantee learner engagement and may thwart it,^5,8,9 reducing the efficacy of the training sessions that a program has worked hard to provide. Perhaps the greatest risk of simply mandating training sessions is that use of this strategy alone fails to address how best to tap into and harness learner motivation to maximize learning during training sessions and ultimately skill transfer and retention.

Since the 1960s, abundant research in a broad range of learning environments has consistently shown several key motivational drivers to enhance the amount and quality of learning¹⁰ Unfortunately, many medical educators consider motivation a natural consequence of training,¹¹ and therefore do not focus much time and attention on this important aspect of the learning process. While numerous motivational theories exist, this review will elaborate on three that mostly relate to surgical simulation training.

Motivational Theories in Education

Expectancy-Value Theory

The expectancy-value theory of learning postulates that the effort a trainee is willing to expend on a task is related to the degree to which they believe they can succeed at the task and the value they ascribe to the outcome.¹² This drive is based on social cognitive variables, such as individuals’ perception of other peoples’ attitude and expectations and by their own interpretations of pervious achievement outcomes.^13–15 Aspects of task value can be further broken down into subcategories, such as attainment value (the importance of high performance in attaining praise, power, self-efficacy, etc); intrinsic value (enjoyment and interest in the task itself); utility value (the task serves as a means to an end, such as the need to achieve high performance in order to gain promotion or achieve career goals); and cost (the negative aspects of engaging in the task, such as anxiety or time).¹⁴ When further studying the links between expectancies and values and achievements, learners’ prediction for their competency and expectancy to succeed strongly predict their academic grades and their sense of value of a subject or task strongly predicted their intention to continue the task.^13–16

The simulation lab may be viewed as an ideal tool by which to engender a sense of valuing the skills learned in the lab among surgical trainees. Presumably, surgical residents are already innately drawn to performing procedural tasks, so one would think that little effort needs to be expended in justifying the intrinsic value of skills lab tasks for this population. The Fundamentals of Laparoscopic Surgery (FLS) trainer box was shown to improve the acquisition of laparoscopic skills.¹⁷ Yet in fact, many surgical residents do not always see the value of the skills learned in the simulation lab.¹⁸ An example of how trainees often do not appreciate the value of simulation training unless the clinical applications are obvious. Setting goals has been shown to motivate medical students to practice on simulators and improve their scores.¹⁹ Setting simulation lab performance goals for trainees may therefore enhance learning and motivation amongst surgical trainees also.

Self-Determination Theory

Self-Determination Theory (SDT) is probably the best-known motivational theory, both within education and the popular media. Originally developed by Ryan and Deci (1975),⁹ this theory proposes that motivation is divided into two types: extrinsic and intrinsic. Intrinsically motivated behavior stems from an inherent interest in performing a task, while extrinsically motivated behavior results from a desire to avoid punishment or receive a reward. SDT postulates that three core needs - autonomy, relatedness, and competence - must be fulfilled (to varying degrees based on the individual) for a task to be experienced as intrinsically motivating. In numerous educational environments, intrinsic motivation has been shown to be superior to extrinsic motivation in fostering deep learning strategies, enhancing learner engagement, and increasing long-term knowledge retention and overall performance.^20–22

As such, it can be expected that the positive learning effects of engendering intrinsic motivation would apply to simulation learning also. For surgical trainees, fostering a sense of learner autonomy can involve such simple measures as instructors giving learners options in the direction of their own learning or dedicated time regarding the way a skill is learned. Such techniques have been found to also improve learner self-esteem and coping mechanisms in the face of failure.²³

Relatedness can be understood as the feeling of being part of something bigger than oneself, be it a larger group identity (such as being a ‘surgeon’), or a purpose that is not purely self-rewarding (such as providing quality patient care). A sense of relatedness, or purpose, can be fostered in the skills lab by using highly respected surgeons as instructors, and anchoring skills learned to meaningful, real-life patient outcomes.⁹

Competence is defined as the belief that a task is achievable, and that the learner has the capacity to succeed if enough effort is expended.⁹ For example, a sense of learner competence can be fostered in the skills lab when instructors provide immediate positive feedback after a task is completed well or a new skill is acquired. Skills competitions, which publicly put trainees against each other and for which there is only one “winner” can instill a sense of competence and enhance intrinsic motivation for high performers, however, this is achieved at the expense of average and low performers and can therefore detrimentally impact the intrinsic motivation to learn among trainees who actually need the most practice (also see Achievement Goal Theory below). As such, the routine use of skills competitions as a motivational teaching tool is discouraged, and if they are to be used, participation should be completely voluntary.

Achievement Goal Theory

The goals of the learning environment (such as to achieve mastery or to document performance) can also influence and even completely change a learner’s personal goals and beliefs.²²

Mastery learning goals, or the desire for continuous personal improvement, stem from the belief that effort and outcomes co-vary. This contrasts with performance learning goals, which reward the outcome regardless of effort expended or gains achieved. Often, performance-oriented learning environments attach considerable judgments of ability and self-worth to learners’ performances, such that the best in class achieves praise while the lower performers are ignored or punished.²² As such, comparing learners’ performances and stress on the importance of doing better than others may result in test anxiety^4,23 and diminish the likelihood of engagement in a timely manner or after experiencing difficulty.²⁴

Performance-oriented learning environments (such as those that require trainees to compete, or make performance metrics public knowledge), tend to alienate all but the top performers, and can even discourage trainee participation in learning opportunities lest they be judged as inferior. In contrast, mastery-oriented learning environments foster an atmosphere in which it is safe to make mistakes with the expectation that learning is accomplished through them, and the goal is for all learners to achieve high quality skills (such as learning to tie a laparoscopic knot with appropriate tension that does not slip, rather than being the fastest). Such measures allow all learners to remain on the path to continuous self-improvement, whether they are necessarily “all-star” material. Use of mastery-oriented learning goals has been shown to result in the development of enhanced self-regulated learning, persistence in the face of failure, and improve quality of engagement in the learning process.^22,24

Suggested Instructional Strategies to Enhance Trainee Motivation

• Fostering a culture of autonomy-supportive learning, such as by empowering residents to participate in goal-setting, training schedules, task design, etc

• Championing mastery goals and teamwork, and de-emphasizing performance goals and interpersonal comparisons of performance among trainees.

• Providing a source of expert feedback and encouraging feedback-seeking

• Ensuring training goals are purpose-driven, such as emphasizing quality over speed and providing real-life examples of why proper completion of a task is important

• Adjusting task difficulties according to the trainee’s present ability level to avoid boredom or becoming overwhelmed

• Using task performance goals and metrics in the lab for the skills learned to foster trainee’s attainments value

• Fostering an environment that encourages learning from one’s mistakes rather than fearing judgment and reprisal as a consequence of them

Conclusion

For all human endeavors, the type and degree of motivation plays a significant role in the outcome. If one considers a typical action movie; the heroes, intrinsically motivated by their beliefs and a sense of inherent value in an outcome that is greater than themselves, will fight harder, tire less quickly, and persist longer in the face of challenges than the villains who are motivated by material rewards or fear of reprisal from superiors.

Developing training curricula that enhance intrinsic motivation can be expected to positively impact the effort trainees put forth for training, both in the moment and throughout their careers. As surgical educators, we are entrusted to train future surgeons who cannot only be considered “competent” at the end or training, but who will remain lifelong learners and continue to advance their knowledge and skills with the times. Simulation labs can offer such high-quality skills learning opportunities, but only if trainees are engaged and motivated to learn.

By harnessing educational strategies that enhance intrinsic motivation and mastery learning, surgical educators may be able to enhance resident engagement in and use of the educational opportunities offered in the simulation setting.

Acknowledgment

None.

Ethical approval

Due to the nature of the review article, ethical approval was not obtained.

Funding

This review did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declarations of interest

none.