Medical undergraduate curricula have changed and grown in the past years to provide the best learning environment for students. These changes were mostly based on content concerns (what to learn) and dealt with transmission and procession (how to learn) of knowledge.^1,2 According to educational psychology, learning can be mapped on three dimensions, and all these dimensions have to be considered to create learner-oriented teaching and truly student-centred curricula.^3-5 However, recent curriculum changes only aimed at two dimensions of learning, namely the cognitive and metacognitive.⁵  The affective (motivational) dimension has been neglected and under-evaluated.⁶

To understand the motivational dimension of learning and its impact on medical students, a brief insight into one of the leading theories of motivation, which has proven good applicability in medical education, is necessary.^{7, 8}  The Self-determination theory (SDT), introduced by Deci and Ryan⁹ postulates that every human has an innate will to grow, which is hampered or supported by the satisfaction of the three basic psychological needs: Autonomy, competence and relatedness.^9,10 The extent to which the basic psychological needs are satisfied, determine the manifestation of different types of motivation.

In SDT, motivation is qualified on a spectrum- one of its ends is intrinsic motivation (activities are carried out due to inherent satisfaction), and the other end is amotivation (lack of motivation).^11,12 When activities are carried out on the basis of external sources, extrinsic motivation is present.¹² Based on the levels of self-determination and autonomy, extrinsic motivation is subdivided into different forms of behavioural regulations: external-, introjected-, identified- and integrated regulation.¹² These behavioural regulations differ in their levels of autonomy, in the following descending order: Integrated-, identified-, introjected- and extrinsic regulation.^13-15

"Autonomous self-regulation" is the behavioural regulation which is desired and leads to better individual performance. It is composed of intrinsic motivation and integrated regulation, whereas "controlled self-regulation" is composed of external and introjected regulation.^15,16 The integral relation of motivation and learning in an academic setting and for medical students has been compiled, identifying motivation as a determining factor for successful learning.^17,18 It has been demonstrated that autonomous self-regulation leads to better learning and well-being^{19, 20} as well as greater time investments for studies^21-23 less drop-out²⁰ and academic success.^24-26 Therefore, the goal of further curriculum developments should be the consideration of the motivational dimension of learning, as students' motivation might have a greater impact on individual outcomes than learning and teaching strategies.⁷ One step towards this goal is the identification of teaching approaches and formats that have stimulating effects on students' motivation.²⁷

So far, evidence about the motivational effects of different teaching approaches and instructional designs is scarce. 5 One teaching approach which has the potential (based on SDT) to influence students' motivation and has already been implemented in many medical curricula is simulation-based medical education (SBME).²⁸ Therefore, our study aimed to analyse the effects of SBME on student' motivation and to compare the motivational effects of SBME with those of classical teaching approaches. A cohort of 3rd-year medical students, who participated in a total of six SBME and classic seminars during the study period of one semester, was investigated. We aimed to assess the motivational levels of students towards participating in SBME and classical seminars and to explore changes of motivation after participation in each teaching format, especially after participation in SBME.

We hypothesised that students report higher levels of autonomous motivation towards participating in SBME than in the seminars and that autonomous motivation would increase after participation in SBME.

A total of 981 (6 assessments per undergraduate for the same teaching units) assessments of situational motivation (SIMS) were collected. Fourteen of the SIMS questionnaires were incomplete and therefore excluded from the analysis.  Table 1 gives an overview of the number of assessed Situational Motivation Scale (SIMS) questionnaires collected at each teaching unit and the chronological order in which the teaching units were attended.

Motivational levels for all teaching units and the ANOVA results are shown in Table 2. The teaching units are depicted in the attended chronological order. Overall, the students reported high levels of intrinsic, identified- and autonomous regulation (motivation) for each SBME as well as for each seminar. Levels of external-, introjected- and controlled regulation as well as amotivation were reported low for each teaching unit (Table 2).

Our results did not confirm our hypothesis that students report higher levels of autonomous motivation towards participating in SBME than in the seminars.  We analysed the effects of each of the six teaching units on students' motivation separately (first sub-analysis) by conducting a one-way ANOVA. There were no outliners, according to the inspection of a boxplot, and the data was normally distributed for each group (Shapiro-Wilk test, p>0.059). Homogeneity of variance was given, as assessed by Levene's test, p > 0.05.  The levels of autonomous motivation for each attended teaching unit did not differ statistically, F_{(5, 839)} = 0.66, p=0.657. Neither did the levels of the other reported motivational qualities (intrinsic, introjected, extrinsic, controlled, identified) differ significantly.

Our results indicate that the students had the same manifestations of motivation for participating in SBME or classical seminars. Previous seminars or SBME did not change the further levels of motivation: motivation did not increase nor decrease over the semester after attendance of each teaching unit, no matter which teaching units were compared (Table 2).

For the second sub-analysis (motivational qualities for all the SBME teaching units vs motivational qualities for all the seminars), the sum scores of the reported autonomous levels for all SBME and all seminars were calculated and compared.  The summed autonomous and controlled scores were comparable for both teaching formats (sum of SBME:  Mautonomous=5.61, SD=0.86; sum of seminar: Mautonomous=5.57; SD=0.85; sum of SBME: Mcontrolled =2.29, SD=0.89; sum of seminar: Mcontrolled=2.28, SD= 0.90).

There was no statistically difference between the sum of autonomous motivation reported for participation in all SBME or all classical seminars, t₍₈₄₃₎ =-0.72, p = 0.868. We also did not find any other significant differences for the other summed motivational qualities reported for all SBME and all seminars (Table 3).

Figure 1 shows the chronological sequence of the students' motivation towards participating in the simulation training. We could not detect any effect of participating in SBME on student motivation during the study period: The reported motivation levels did not increase or decrease after each simulation training.

Our second hypothesis, that students´ motivation would increase after participation in SBME, was not confirmed by our results. Autonomous motivation did not enhance after participating in the first SBME, t₍₂₆₄₎ = 1.035, p = 0.301, after participating in the second SBME, t₍₂₅₄₎ = -0.055, p = 0.956, or after the third training, t₍₂₅₀₎ = -0.881, p = 0.379.

Our cross-sectional study found that 3rd-year medical student's motivation towards participating in simulation-based medical education (SBME) and classical seminars did not differ. Participation in SBME had no effect on students' motivation and did not enhance or decrease any motivational quality. Evidence about the effects of SBME on student motivation is scarce. Only a few studies pointed out that SBME is valued by students 35 and in postgraduate surgery training, simulation training lead to increased motivation for further training.³⁶ Our hypotheses, that students' would have higher autonomous motivation towards participation in SBME than in classical seminars and that SBME would increase autonomous levels of student motivation, were based on the various benefits that SBME yields. SBME creates an ideal educational environment by bridging the gap between the classroom and clinical setting³⁷ and hereby enhances student-directed learning.^38,39Furthermore, SBME has the potential to increase autonomous motivation due to the specific perceived task value of training and perceived self-efficacy, as well as the feeling of competency during simulation training.^40,41

However, although we put maximal effort to enhance students' autonomy during SBME by creating a good learning environment and providing appropriate feedback and emotional support^{42, 43} we could not find a modifying effect of SBME on students' motivation. As the investigated students were familiar with the teaching formats, potential bias due to the unfamiliarity and inquisitive effects on motivation, which new teaching formats may have⁴⁰ can be ruled out. The students had not participated in too much simulation training before the study, and therefore, a certain state of boredom was prevented, which also could have had biased the results because boredom has shown to have a fading effect on intrinsic and identified regulation and thus autonomous motivation.⁴⁰

One limitation of our study is that we analysed one cohort of students, disregarding intra-individual variances. Nevertheless, to our best knowledge, we are the first to report situational motivation towards different teaching formats, assessed longitudinally over a period of time, focusing on the affective dimension of learning.⁸ Our results also have particular value in times of the global Covid-19 pandemic, which led to the closure of universities and forced curriculum adaptations, like digital teaching and disruption of SBME.^{44, 45}Medical educators fear the cease of student motivation due to these curriculum adaptations. Our results are reassuring because we showed that classical teachings, like seminars, have similar effects on student motivation. Therefore, even during the pandemic, the affective dimension of learning can be addressed.

Third-year students reported similar levels of different motivational qualities towards participation in classical seminars and SBME. SBME might not have enhancing effects on student motivation. Therefore, regarding the affective dimension of learning and considering costs and benefits, medical curricula should apply SBME reasonable, not only focusing on SBME as a fashionable and contemporary teaching format. Further research is needed to clarify how the theoretically predicted enhancing effects of SBME on autonomous motivation can be achieved.  During the pandemic, we won't have to fear a decrease in student motivation due to a replacement of SBME with digital teachings. Therefore, we should put maximum effort into creating suitable digital teaching formats, like seminars, as they have proven to have the same effect on the affective dimension of learning.