The role of transfer motivation and self-efficacy on student satisfaction during early clinical experiences in South Korea: a cross-sectional study
Article information
Abstract
Purpose
This study aimed to identify the factors influencing premedical students’ satisfaction with early clinical experience and determine the mediating effect of self-efficacy on the relationship between learning motivation and satisfaction.
Methods
This cross-sectional study included 35 second-year premedical students who completed the early clinical experience course and responded to course evaluation questionnaires on self-efficacy, transfer motivation, and student satisfaction. The data were analyzed using descriptive statistics, Pearson’s correlation, Baron and Kenny’s hierarchical multiple regression analyses, and the Sobel test.
Results
Student satisfaction was significantly correlated with self-efficacy (r=0.724, p<0.01) and transfer motivation (r=0.538, p<0.01). Self-efficacy and transfer motivation were also highly correlated (r=0.789, p<0.01). Multiple regression analyses and Sobel test indicated that self-efficacy fully mediated the relationship between student satisfaction and transfer motivation (Z=2.704, p<0.01).
Conclusion
In this study, early clinical experience program increased premedical students’ self-efficacy and transfer motivation for clinical knowledge and confirmed that self-efficacy mediated student satisfaction. These findings demonstrate the positive effects of early clinical experience on the medical school curriculum and suggest the need for educational strategies to increase self-efficacy in learning.
Introduction
The 2 years of premedical education in Korean medical schools are critical in the journey of medical students as they progress toward becoming physicians. However, it has been highlighted that premedical education often lacks a connection to medical education and that basic medical science does not motivate students [1]. In the traditional 2+2+2 system (2 years of premedical education, 2 years of clinical medicine, and 2 years of clerkship), students in the pre-clerkship period are not exposed to patients. This system primarily focuses on lecture-based theoretical clinical medicine, resulting in a disconnect between basic and clinical medicine during the clerkship [2].
Recognizing this issue, the Korean Institute of Medical Education and Evaluation has made pre-clinical education an accreditation standard. Consequently, many medical schools in Korea have introduced programs such as “Early Clinical Experience,” “Early Clinical Exposure,” and “Introduction to Clinical Practice” that allow students to experience clinical practice during the premedical period [3]. Early clinical experience (ECE) aims to provide foundational clinical training, stimulate interest in primary care, increase motivation to learn, and enhance the relevance of undergraduate medical education [4,5].
Several studies have reported that ECE influences the attitudes of first-year medical students by helping them overcome stress, increasing their insight into and confidence in medicine, and providing social and emotional fulfillment [6]. In essence, ECE serves as a learning method to keep students engaged and motivated in their studies. It is also viewed positively in terms of learning transfer, as it offers medical students an experiential context for understanding basic medical content. Furthermore, it bridges the gap between basic and clinical knowledge by providing real-world hospital experience, thereby deepening students’ comprehension of both theory and practice [7].
The application of acquired knowledge, skills, and attitudes to practice is a crucial learning objective in medical education. Ayres [8] proposed a model of motivation for learning transfer, emphasizing the importance of the willingness to apply educational knowledge to clinical practice. According to this model, increasing motivation to learn is essential for enhancing learning transfer. Ayres [8] argued that motivation to learn is a key factor in behavioral change, asserting that effective learning can only occur when a “transfer mood” is established. Various studies have identified factors contributing to learning transfer motivation, including learner motivation, self-efficacy, instructor and peer support, and performer confidence [9,10].
Self-efficacy in learning refers to an individual’s belief in their ability to utilize acquired knowledge successfully in a learning task [11]. Previous research has demonstrated that self-efficacy influences learners’ strategies for selfregulation and planning academic performance and courses. Higher levels of self-efficacy correlate with a stronger professional self-concept, greater satisfaction, academic achievement, and heightened motivation to learn [12].
During the pre-clerkship period, practical training using standardized patients (SPs) is expected to facilitate the acquisition of clinical knowledge and skills, positively influencing learning satisfaction and self-efficacy in learning, thereby effectively enhancing the transfer motivation for applying acquired competencies in practice. However, to date, it has been challenging to find studies in medical education research that confirm the mediating effect of self-efficacy in learning on the relationship between satisfaction and transfer motivation during ECE, specifically among premedical students.
The purpose of this study was to analyze the factors influencing student satisfaction with ECE among premedical students, focusing on the theories of motivation for learning transfer and self-efficacy in learning. Specifically, we explored how students’ enthusiasm for learning and their willingness to apply acquired knowledge during the pre-clinical years relate to their overall satisfaction, and we examined the mediating effect of self-efficacy in this process.
The specific research questions were as follows: (1) What is the relationship between transfer motivation, self-efficacy in learning, and student satisfaction in ECE? (2) Does self-efficacy in learning mediate the relationship between transfer motivation and student satisfaction?
Methods
1. Research design
This cross-sectional study aimed to determine the mediating effect of self-efficacy in learning on the relationship between transfer motivation and student satisfaction among premedical students who completed the “Foundations of Clinical Medicine” course implemented as part of the ECE program.
2. Participants
This study involved 40 second-year premedical students from a single medical school who took the “Foundations of Clinical Medicine” course during the second semester of the 2023 academic year. The recruitment period for this study was from October 10, 2023, to November 3, 2023. Data from 35 students who participated in the end-ofcourse evaluation and completed the survey were analyzed.
3. Overview of “Foundations of Clinical Medicine”
The “Foundations of Clinical Medicine” course ran for 4 weeks, from October 10 to November 3, 2023, for second-year premedical students. Students were organized into groups of five or six, and a written clinical performance examination (CPX) was administered at the end of the fourth week. Specific details on contents and class times are listed in Table 1. The course has three main features: flipped learning, hospital environment experience, and SP practice.
“Foundations of Clinical Medicine” Course Contents and Times
The course utilized a flipped learning model. Students studied basic theoretical knowledge through videos before attending small group discussions based on cases or scenarios related to the videos. Clinical materials such as patient case histories, electrocardiograms, X-rays, computed tomography scans, and other resources were used to contextualize structures and functions, explain key symptoms and signs, and teach basic clinical examination techniques.
Students visited real patients and interacted with both medical and non-medical personnel across various hospital departments. These visits included outpatient examination rooms, administrative offices, the intensive care, radiology, and endoscopy units, and the operating room. The aim was to enhance understanding of healthcare systems and the roles of different professionals.
Students practiced basic skills such as taking vital signs, measuring blood pressure, and performing ultrasounds. They also practiced interviewing patients using SPs and evaluated them using CPX. At the end of the 3-week course, students kept reflection journals and shared their experiences with their peers. In the fourth week, written and practical exams were administered, with opportunities for re-learning and reassessment for those who did not pass.
4. Measurements
1) Self-efficacy in learning
The instrument developed by Ayres [8] and adapted by Park [13] was used to measure self-efficacy in learning. It comprises 10 items scored on a 7-point Likert scale, with 1 corresponding to ‘not at all’ and 7 corresponding to ‘very much’. The total possible score is 70, with higher scores indicating greater self-efficacy. The reliability of the instrument is indicated by a Cronbach’s α of 0.95 in the study by Park [13] and 0.91 in this study.
2) Transfer motivation in learning
The instrument developed by Ayres [8] and adapted by Park [13] was used to measure transfer motivation. Originally comprising 10 items, this study used nine items, excluding “I actively think about ways to use the knowledge I have learned” due to low internal consistency and correlation with other items. Each item is scored on the same 7-point Likert scale for a total of 63 points. Higher scores indicate greater motivation to learn. The reliability of the instrument is indicated by Cronbach’s α of 0.94 in the study by Park [13] and 0.90 in this study.
3) Student satisfaction
Student satisfaction scores were obtained from course evaluation conducted at the end of the “Foundations of Clinical Medicine.” The evaluation comprised 10 questions: one on overall satisfaction, three questions on exams, four on classroom teaching, and two open-ended questions on strengths and areas for improvement. For this study, the score from the question on overall satisfaction was used, measured on a 5-point Likert scale (5=very satisfied, 1=very dissatisfied).
5. Data analysis
The Kolmogorov-Smirnov normality test was conducted to assess the normality of the distributions for the self-efficacy and learning transfer motivation scales. Normality was confirmed at a significance level of p=0.05 or higher, allowing for parametric test analysis. Descriptive statistics, Pearson’s correlation, and hierarchical multiple regression analyses were performed on the data. And the Sobel test was performed to verify the significance of the mediating effect. Reliability analysis was conducted using Cronbach’s α coefficients to verify the internal consistency of the survey items. Data analysis was conducted using IBM SPSS Statistics ver. 28.0 (IBM Corp., Armonk, USA).
6. Ethical considerations
This study was approved by the Institutional Review Board of Asan Medical Center (No. AMC 2023-1245). Before the study, the researcher explained the purpose and objectives of the study, the rights of the research participants, and the intended use of personal information. Written informed consent was obtained from all participants.
Results
1. Descriptive statistics and correlation analysis
Descriptive statistics and correlation analysis of medical students’ satisfaction, self-efficacy in learning, and transfer motivation are presented in Table 2. To assess the normality of data distribution, we analyzed the skewness and kurtosis. The skewness values ranged from –0.73 to 0.12, and kurtosis values ranged from –0.72 to 0.81, both meeting the criteria of an absolute value of 2 or less for skewness and 7 or less for kurtosis. The mean student satisfaction score was 7.743 out of 10 (standard deviation [SD]=1.462). The mean self-efficacy in learning score was 60.34 out of 70 (SD=6.919), and the mean transfer motivation was 49.943 out of 63 (SD=9.320).
Correlation with Descriptive Statistics of Satisfaction, Self-efficacy, and Transfer Motivation
Correlation analysis revealed that student satisfaction had a statistically significant correlation with selfefficacy (r=0.724) and transfer motivation (r=0.538) (Table 2). Additionally, self-efficacy and transfer motivation were highly correlated (r=0.789, p<0.01).
2. Hierarchical multiple regression analysis
Following the method proposed by Baron and Kenny [14], this study conducted a hierarchical multiple regression analysis to test the mediating effect of selfefficacy in learning on the relationship between transfer motivation and student satisfaction with ECE.
Table 3 presents the results of the analysis. The regression model was statistically significant at all steps: steps 1 (F=54.510, p<0.001), 2 (F=13.472, p<0.001), and 3 (F=17.845, p<0.001), indicating a good regression model fit. The explanatory powers were 61.1%, 26.8%, and 49.8% in steps 1, 2, and 3, respectively. The Durbin-Watson statistic ranged from 1.68 to 2.14, which is close to 2, indicating that the assumption of independence of residuals was not problematic. The variance inflation factor ranged from 1.0 to 2.68, all well below the threshold of 10, confirming the absence of multicollinearity issues.
The Mediating Effect of Self-efficacy on the Relationship between Transfer Motivation and Student Satisfaction
In step 1, the regression coefficient significance test found that the independent variable, transfer motivation, had a significant effect on the parameter, self-efficacy in learning (β=0.789, p<0.001). The result indicates that higher transfer motivation is associated with higher self-efficacy in learning. In step 2, transfer motivation significantly affected student satisfaction (β=0.538, p<0.001). In step 3, the effect of transfer motivation on student satisfaction was not statistically significant (β =0.789, p=0.661). However, the mediating variable, selfefficacy, had a statistically significant effect on satisfaction (β=0.793, p<0.001). These results indicate that selfefficacy in learning fully mediates the relationship between transfer motivation and student satisfaction (Fig. 1).
Mediating Effect of Self-efficacy in Learning in the Relationship between Students Satisfaction and Transfer Motivation
Sobel’s test was conducted to examine the statistical significance of the mediating effect, which indicated that self-efficacy in learning significantly mediated the relationship between transfer motivation and student satisfaction (Z=2.704, p<0.01).
Discussion
Many medical schools in Korea have found that ECE is an effective way to prepare students for clerkships [15,16]. If the learning outcome of exposing students to clinical experiences during the preclinical period is to apply them effectively in an actual hospital environment, it is closely related to transfer motivation, which is the intention to apply the knowledge and skills gained in ECE to clinical practice. This study aimed to examine the impact of transfer motivation on student satisfaction and to test the mediating effect of self-efficacy in learning among premedical students participating in ECE.
First, a Pearson correlation analysis was conducted to examine the relationships between transfer motivation, self-efficacy, and student satisfaction. The results showed that student satisfaction was significantly positively correlated with transfer motivation and self-efficacy, and that transfer motivation and self-efficacy were also highly positively correlated.
This finding supports previous studies reporting that transfer motivation is significantly associated with learning satisfaction and self-efficacy [17,18]. It also aligns with studies indicating that ECE is related to students’ satisfaction and motivation to learn, and that it is beneficial when applied to medical practice [19-21]. Moreover, it echoes findings that students who are more satisfied with their classes tend to show increased motivation to learn, professionalism, and perceived usefulness of the experience [22]. These results suggest that students with higher levels of transfer motivation and self-efficacy are more satisfied with their ECEs. Therefore, enhancing self-efficacy in learning and transfer motivation should be a focus to maximize the effectiveness of ECE programs.
Second, we examined the mediating effect of selfefficacy in the relationship between transfer motivation and student satisfaction with ECE. The findings revealed that self-efficacy fully mediated the effect of transfer motivation on student satisfaction, which is the first report in this area. This full mediating effect indicates that higher transfer motivation leads to higher student satisfaction indirectly through self-efficacy. In other words, higher transfer motivation enhances self-efficacy, which in turn boosts student satisfaction. Previous studies with nursing students have reported a partial mediating effect of self-efficacy on the relationship between learning satisfaction and transfer motivation [23]. These findings suggest that strategies to increase self-efficacy in learning should be considered to enhance transfer motivation, thereby promoting positive changes through learning. Previous research on ECE has offered various perspectives on the content and skills learned in ECE programs. However, the present study is significant in that it analyzes the impact of a 4-week block of clinical experience on premedical students who have not yet taken a clinical course, focusing on behaviors and attitudes.
However, the limitations of this study are as follows: First, conducting a single analysis with 40 pre-medical students from one medical school makes it difficult to generalize the research results to all medical schools in the country. Second, long-term study is needed to understand how ECEs during the pre-medical period impact not only clerkships but also postgraduate education in the long run. Lastly, to ensure the validity of the study results, a comprehensive theoretical interpretation based on a framework addressing the relationships among transfer motivation, self-efficacy, and learning satisfaction is necessary.
In conclusion, this study confirmed that enhancing self-efficacy in learning is essential for achieving the learning outcome of transfer motivation. The significance of this research lies in its demonstration of the positive effects of ECE within the medical school curriculum. These results suggest that when aiming to increase learning satisfaction and enhance transfer motivation, it is important to consider strategies that boost learner selfefficacy in learning. For example, hospital environment experience, basic skills training, and practical sessions using SPs can be proposed as beneficial learning methods.
Notes
Acknowledgements
None.
Funding
This research was funded the University of Ulsan (Fund No., 2024-0449).
Conflicts of interest
No potential conflict of interest relevant to this article was reported.
Author contributions
Conception or design of the work: SJC, IKS; data collection, data analysis: SJC; interpretation, drafting the article: IKS, SJC; critical revision of the article: IKS, HYJ; and final approval of the version to be published: SJC, IKS, HYJ.