With this study we wanted to gain more insight in how trainees regulate their learning in practice. The analysis of the interviews revealed that self-regulation of learning occurred in a short and a long loop, of which only the latter was influenced by external regulation like mandatory assessments or assignments to formulate learning goals. Self-regulation and learning were driven by trainees’ strong intrinsic motivation to become good doctors, prompted by others and influenced by organizational and educational elements in the training context. To elucidate our findings we will discuss the two self-regulation loops from the perspective of learning theory and the three elements influencing self-regulation from the perspective of Self-Determination Theory (SDT) [44–46].
Learning theory: monitoring and assessment
The learning we found in the short and the long loop can be seen as informal learning. Since learning in both self-regulation loops occured in reaction to an incidental learning need, with the long loop also involving planned learning, the short and long self-regulation loops appear to fit the types of reactive and deliberative learning as described by Eraut [47–49]. Reactive learning, according to Eraut, happens spontaneously when an unexpected situation makes the learner aware that something must be learned. Deliberative learning is similar to reactive learning but differs in that it includes planning of learning activities.
Both loops involved self-monitoring. Although our study did not focus on reflection, the analysis revealed that trainees reflected on their actions both during and after consultations, suggesting that trainees' self-monitoring may refer to Schön's ‘reflection-in-action’ (short loop) and 'reflection-on-action’ (long loop) .
Learning orientations may influence the way trainees plan and organize their studying . Learning in both loops originating from practice situations is associated with situational orientation. Learning in the long loop initiated form external regulation, like mandatory assignments, may be associated with course specific orientation.
In both loops trainees based their self-assessments on their confidence in their ability to perform competently. The variation among trainees in the extent to which they asked their supervisor to confirm their self-assessed competence suggests that trainees should be encouraged to seek more external information to confirm their self-confidence by consulting external sources, such as supervisors and mentors [12, 22, 50]. This is important because self-assessment undertaken as an individually conducted internal activity has little accuracy, especially for those with the least proficiency . This implies an active and critical role from supervisors, as in a work-based learning environment it is important for supervisors to encourage trainees to engage in critical reflection and be a role model in this respect [52, 53]. Trainees in our study variably used external assessments for learning. This may be explained by the level of the mandatory assessments. In Miller's assessment pyramid, assessments range from the lowest 'knows' level, via the ‘knows how’ and ‘shows how’ levels to the highest ‘does’ level [27, 54]. The communication video assessments are aimed at the ‘does’ level and provide specific and easily applicable feedback. The knowledge progress tests, however, are aimed at the ‘knows’ and ‘knows how’ levels. Trainees see feedback from these tests as having limited relevance to their performance. Further research should investigate ways of promoting the effectiveness of external assessments as well as ways of assessing practice performance in both loops that provide external information to confirm trainees’ self-confidence or in any other way scaffold their competence.
In conclusion, it is important to know how learning in the short loop takes place. This learning may not be visible to others. Therefore supervisors can play an important role in guiding learning and assessment in the short loop as they are the ones close to trainees. Formal learning activities, like learning portfolios or assessments, give opportunities to encourage trainees in monitoring, employing learning activities and assessment . As already known medical practice offers a powerful setting for informal learning [23, 47, 48]. However, it should be noted that relying on informal learning may involve the risk of learning and maintaining inadequate competencies, habits or behaviours . This stresses the importance of critical reflection, aimed at one’s attitudes and frames of references on (implicit) habits, behaviours, professional acting and professional learning .
Influencing elements and the Self-Determination Theory
We found influencing elements on personal, interpersonal and contextual level. The Self-determination theory (SDT) helps us to explain them and identify potential relationships between them [44–46]. According to SDT, human behaviour is determined by motivation, varying along a continuum from lack of motivation via extrinsic motivation to intrinsic motivation [44, 45, 55]. People driven by high internal motivation are more likely to achieve their goals than people driven by high external motivation [44, 46, 55]. Furthermore, SDT describes that goal pursuit and attainment are strongly related to the extent to which people are able to satisfy three basic psychological needs: (a) the need for autonomy, (b) the need for competence and (c) the need for relatedness to others and to the social environment [44, 45, 55]. People are more likely to adopt activities that are valued by relevant social groups when they feel efficacious with respect to those activities (need for competence). Internalization is also facilitated when the context supports autonomy, allowing the learner to feel competent, related and autonomous (need for autonomy).Behaviours prompted, modelled or valued by significant others to whom someone feels (or wants to feel) attached or related (need for relatedness) are more likely to be internalized.The influencing elements we found (on personal, interpersonal and contextual level) are related to intrinsic motivation and to the need for competence, autonomy and relatedness. Trainees reported a strong internal motivation to become good doctors. This motivation was a strong driver of self-regulated learning when they identified shortcomings in their performance, thereby fulfilling their need for competence and autonomy. To gauge their competence trainees appeared to rely mostly on self-confidence. Self-confidence may be based on self-efficacy beliefs resulting from judgements of one’s ability to deal with different situations [56–58]. There is evidence that self-efficacy beliefs contribute significantly to motivation and performance . Trainees also sought to varying extent confirmation from supervisors, mentors and peers. However, external mandatory assessment, the knowledge tests in particular, played a less prominent role in trainees’ self-assessment of their competence. Apparently, external assessments fail to meet the psychological conditions that are conducive to enhancement of motivation. This suggests that supervisors and mentors should promote the use of assessments by actively alerting trainees to the relevance of this feedback for their performance in practice.
Trainees also reported the influence of others on their self-regulation and learning. Following SDT this may be explained in terms of fulfilment of the need for relatedness. Supervisors were found to be especially important as role models and as someone trainees could feel related to. These findings correspond with the literature on supervisor’s role in medical education [59, 60].
Finally, trainees reported the influence from the workplace. The contextual elements like patient encounters, working climate, organizational and educational features and time pressure, are also described in the literature about workplace based learning, where the quality of the workplace and its educational aspects influence opportunities for and the quality of learning [23, 52, 61–64]. According to SDT context is important in supporting feelings of relatedness, competence and autonomy.
In summary, SDT offers explanations of the way trainees’ self-regulation is driven by intrinsic motivation, depending on the extent to which trainees’ needs for competence, autonomy and relatedness are met. The context of training and the actors in it are important in supporting these needs.
Differences between first and third years trainees
We only found differences in the kind of problems trainees mentioned in the long loop. In the long loop first year trainees reported mainly problems with communication skills. An explanation may be that an adequate mastery of these skills is prerequisite for working in general practice. Third year trainees mentioned more complex problems in the long loop. May be they are more likely to have such problems assigned to them than first year trainees.
The absence of differences in the short loop may be explained by the wide variety of patient problems in general practice making it impossible for trainees, even at advanced stages of training, to know everything about all types of frequently presented patient problems.
First and third year trainees did not differ in the influencing elements.
Strengths and weaknesses of this study
The results of this study of trainees’ self-regulation showed that medical practice is indeed a powerful learning environment, but also highlighted the complexity of the components and relationships within this environment . A weakness of the study may be that the exclusive focus on trainees' self-regulation precluded in-depth examination of potentially important influencing elements like the relationship between trainee and supervisor and the role of peers. Another weakness may be the fact that we exclusively used interviews to gather data. Observation of actual practice and analyzing portfolios (regarding the long-loop) may refine viewpoints on self-regulation. Also, since the study was limited to trainees' perceptions, no conclusions can be drawn regarding the supervisors’ views on trainees’ self-regulation. A strength of this study is the phenomenological qualitative approach, which enabled in-depth exploration of trainees’ individual views and experiences and resulted in the discovery of patterns.
Further research should focus on learning in the short and long loop and on how formal learning (e.g. external assessments, learning portfolio’s), people (e.g. supervisor, mentors) and context (e.g. educational quality, working climate) can contribute to self-regulation and thereby to learning. Further research on behavioural measures relating to learning and supervision of trainees and supervisors may strengthen the results found in this study.