what is motivation in a research paper

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Essay 1.1 What Is Motivation, Where Does It Come from, and How Does It Work?

• Published: January 2023
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Motivation is the process that drives, selects, and directs goals and behaviors. Motivation typically arises out of the person’s needs, and it then comes to life through the person’s specific goals. In this essay, the authors examine the concept of “needs” as the crucible from which motivated behavior arises because all individuals are born with needs that jump-start the goal-oriented, motivated behaviors that are critical to survival and thriving. These are both physical needs (such as hunger and thirst) and psychological needs (such as the need for social relationships, optimal predictability, and competence). The aim of motivation is therefore to bring about a desired (need, goal) state. Motivation underlies and organizes all aspects of a person’s psychology. As it does so, motivation “glues” a person together as a functioning individual in their culture and context.

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Motivation Science

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Journal scope statement

Motivation Science is a multi-disciplinary journal that publishes significant contributions to the study of motivation, broadly conceived.

The journal publishes papers on diverse aspects of, and approaches to, the science of motivation, including work carried out in all subfields of psychology, cognitive science, economics, sociology, management science, organizational science, neuroscience and political science.

Primarily, Motivation Science features empirical papers on motivational topics, although theoretical papers and reviews of the literature will also be considered.

Equity, diversity, and inclusion

Motivation Science supports equity, diversity, and inclusion (EDI) in its practices. More information on these initiatives is available under EDI Efforts .

Call for papers

• Call for papers: General

Editor’s Choice

One article from each issue of Motivation Science will be highlighted as an “ Editor’s Choice ” article. Selection is based on the recommendations of the associate editors, the paper’s potential impact to the field, the distinction of expanding the contributors to, or the focus of, the science, or its discussion of an important future direction for science. Editor’s Choice articles are featured alongside articles from other APA published journals in a bi-weekly newsletter and are temporarily made freely available to newsletter subscribers.

Author and editor spotlights

Explore journal highlights : free article summaries, editor interviews and editorials, journal awards, mentorship opportunities, and more.

Prior to submission, please carefully read and follow the submission guidelines detailed below. Manuscripts that do not conform to the submission guidelines may be returned without review.

To submit to the Editorial Office of Guido H. E. Gendolla and Rex A. Wright, please submit manuscripts electronically through the Manuscript Submission Portal in Word Document format (.doc).

Guido H. E. Gendolla University of Geneva

Rex A. Wright University of Texas Dell School of Medicine & University of North Texas, United States

Prepare manuscripts according to the Publication Manual of the American Psychological Association using the 7 th edition. Manuscripts may be copyedited for bias-free language (see Chapter 5 of the Publication Manual ). APA Style and Grammar Guidelines for the 7 th edition are available.

Submit Manuscript

Motivation Science welcomes significant high-quality manuscripts reporting research on diverse aspects of, and approaches to, the science of motivation.

Manuscripts should fall into one of the following categories:

Original Research Articles

These are full-length manuscripts reporting empirical research that advances the comprehension of variables and processes that influence motivation and behavior. Research articles can report more than one empirical study but are not required to do so. Preference will be given to reports that present theory-driven research involving tests of clearly derived hypotheses and findings with straightforward and substantive implications. Replication studies are welcome if they provide conclusive results. There is no space limit for research articles, but manuscripts should typically range between 2,500 and 7,000 words, exclusive of references, figures, and tables.

Original Research Brief Reports

These are abbreviated manuscripts succinctly reporting empirical research that advances the comprehension of variables and processes that influence motivation and behavior. Original research brief reports should report one empirical study or a short series of studies with similar designs and methods. Preference will be given to reports that present theory-driven research involving tests of clearly derived hypotheses and findings with straightforward and substantive implications. Replication studies are welcome if they provide conclusive results. The space limit for brief reports is 2,500 words, exclusive of references, figures, and tables.

Conceptual Articles

These are full-length theoretical papers and literature reviews that can — but are not required to — apply meta-analytic techniques. Preference will be given to analyses and reviews that have straightforward and substantive implications. There is no space limit for conceptual articles, but manuscripts should typically rage between 2,500 and 7,000 words, exclusive of references, figures, and tables.

Conceptual Brief Reports

These are abbreviated theoretical papers and literature reviews that can — but are not required to — apply meta-analytic techniques. Preference will be given to analyses and reviews that have straightforward and substantive implications. Conceptual brief reports also can involve reactive commentary (e.g., to a research or conceptual article). The space limit for conceptual brief reports is 2,500 words, exclusive of references, figures, and tables.

Research Methods in Motivation Science Articles

These manuscripts are intended to draw attention to methodological developments relevant to the scientific study of motivation. They should aim to enhance the use of techniques and insights that advance motivation science and its application. Examples might include articles (1) that describe techniques for validating new research instruments, (2) that introduce new quantitative methods, or (3) that debate important methodological issues. Articles should be accessible to non-expert readers with doctoral level training and avoid use of unnecessary technical content. They also should make clear how their content advances theory and/or practice. Preference will be given to well-constructed and documented reports that have substantive implications. There is no space limit for Methods articles, but manuscripts should typically range between 2,500 and 7,000 words, exclusive of references, figures, and tables.

Out-of-the-Box Articles

These are brief contributions that might attract broad interest but do not fit neatly into preceding submission categories. Submissions will include no more than 2,500 words and can involve a variety of formats. Examples include short thought pieces, humor pieces, pieces concerned with history, and pieces concerned with contemporary issues. Contributions might involve personal profiles (e.g., of important figures), interviews, and even substantive fictional depictions.

Masked Review Policy

Masked review, which means that the identities of both authors and reviewers are masked, is optional for Motivation Science . Authors should note in their cover letters whether they have opted for masked or unmasked review.

Masked Review

Authors who desire masked review should make every effort to see that the manuscript itself contains no clues to their identities:

• Authors should never use first person ( I, my, we, our ) when referring to a study conducted by the author(s) or when doing so reveals the authors' identities (e.g., "in our previous work, Johnson et al. (1998) reported that..."). Instead, references to the authors' work should be in third person (e.g., "Johnson et al. (1998) reported that...").
• The authors' institutional affiliations should also be masked in the manuscript.
• Include the title of the manuscript along with all authors' names and institutional affiliations in the cover letter.
• The first page of the manuscript should omit the authors' names and affiliations but should include the title of the manuscript and the date it is submitted.
• Responsibility for masking the manuscript rests with the authors; manuscripts will be returned to the author if not appropriately masked. If the manuscript is accepted, authors will be asked to make changes in wording so that the paper is no longer masked.
• After masked review, please ensure that the final version for production includes a byline and full author note for typesetting.

Research Transparency and Openness

Motivation Science encourages both methodological and data transparency to ensure the reproducibility of research results. Thus, we ask authors to ensure their manuscripts meet certain standards aligned with APA Style Journal Article Reporting Standards (JARS). These items include:

• Sample Size and Stopping Rules : Authors must describe the sample size, power, and precision, including:

▪ Intended sample size

▪ Achieved sample size, if different from the intended sample size

▪ Determination of sample size, including:

◦ Power analysis, or methods used to determine precision of parameter estimates

◦ Explanation of any interim analyses and stopping rules employed

• Reporting the full methods  for empirical studies, including all manipulations, measures, and eventual data exclusions.
• Reporting in the author note when data stem from related research.  APA Style stipulates that authors must include any disclosures of data stemming from related research in the author note. The original findings, if published, should be referenced in an in-text citation.

▪ If data stem from related research, authors should report:

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Motivation: Introduction to the Theory, Concepts, and Research

• First Online: 03 May 2018

Cite this chapter

• Paulina Arango 4  

Part of the book series: Literacy Studies ((LITS,volume 15))

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2 Citations

Motivation is a psychological construct that refers to the disposition to act and direct behavior according to a goal. Like most of psychological processes, motivation develops throughout the life span and is influenced by both biological and environmental factors. The aim of this chapter is to summarize research on the development of motivation from infancy to adolescence, which can help understand the typical developmental trajectories of this ability and its relation to learning. We will start with a review of some of the most influential theories of motivation and the aspects each of them has emphasized. We will also explore how biology and experience interact in this development, paying special attention to factors such as: school, family, and peers, as well as characteristics of the child including self-esteem, cognitive development, and temperament. Finally, we will discuss the implications of understanding the developmental trajectories and the factors that have an impact on this development, for both teachers and parents.

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Understanding and Supporting Student Motivation for Learning

Motivation and Action: Introduction and Overview

Intrinsic Motivation

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Arango, P. (2018). Motivation: Introduction to the Theory, Concepts, and Research. In: Orellana García, P., Baldwin Lind, P. (eds) Reading Achievement and Motivation in Boys and Girls. Literacy Studies, vol 15. Springer, Cham. https://doi.org/10.1007/978-3-319-75948-7_1

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Tuesday 11 July 2017

Research proposal: motivation and background, motivation for your research.

1.    Introduction

2.    background, 3.    research questions.

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Contribution vs Motivation

Can somebody explain to me what is the difference between contribution and motivation in any research paper?

• publications
• terminology

Motivation : why is this an important problem? Why should anybody care about this?

For example:

X affects tens of thousands of consumers in the United States each year, and costs companies billions of dollars.

If we can solve X, we are one step closer to solving the biggest open problem in the field, Z.

Contribution : what is the new thing (result, approach, technique, whatever) that this paper describes, that advances the state of this field?

This paper describes a way to do X using Y, which is up to 200 times faster than the current state of the art.

• Can we then say motivation describes the problem statement? –  Mike Commented Oct 23, 2015 at 0:01
• 2 @user2999915 A problem statement could just be "Here is a problem X." That's not really motivation, unless you say "We really want to know how to do X because [insert motivation here]..." –  ff524 Commented Oct 23, 2015 at 0:03
• @Mike Problem statement = "This is the problem we want to solve". Problem motivation = "The problem is relevant, because many people need to do X", contribution = "We solve these aspects of the problem". –  allo Commented May 26, 2021 at 16:15

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How to Write the Rationale of the Study in Research (Examples)

What is the Rationale of the Study?

The rationale of the study is the justification for taking on a given study. It explains the reason the study was conducted or should be conducted. This means the study rationale should explain to the reader or examiner why the study is/was necessary. It is also sometimes called the “purpose” or “justification” of a study. While this is not difficult to grasp in itself, you might wonder how the rationale of the study is different from your research question or from the statement of the problem of your study, and how it fits into the rest of your thesis or research paper. 

The rationale of the study links the background of the study to your specific research question and justifies the need for the latter on the basis of the former. In brief, you first provide and discuss existing data on the topic, and then you tell the reader, based on the background evidence you just presented, where you identified gaps or issues and why you think it is important to address those. The problem statement, lastly, is the formulation of the specific research question you choose to investigate, following logically from your rationale, and the approach you are planning to use to do that.

Table of Contents:

How to write a rationale for a research paper , how do you justify the need for a research study.

• Study Rationale Example: Where Does It Go In Your Paper?

The basis for writing a research rationale is preliminary data or a clear description of an observation. If you are doing basic/theoretical research, then a literature review will help you identify gaps in current knowledge. In applied/practical research, you base your rationale on an existing issue with a certain process (e.g., vaccine proof registration) or practice (e.g., patient treatment) that is well documented and needs to be addressed. By presenting the reader with earlier evidence or observations, you can (and have to) convince them that you are not just repeating what other people have already done or said and that your ideas are not coming out of thin air. 

Once you have explained where you are coming from, you should justify the need for doing additional research–this is essentially the rationale of your study. Finally, when you have convinced the reader of the purpose of your work, you can end your introduction section with the statement of the problem of your research that contains clear aims and objectives and also briefly describes (and justifies) your methodological approach. 

When is the Rationale for Research Written?

The author can present the study rationale both before and after the research is conducted. 

• Before conducting research : The study rationale is a central component of the research proposal . It represents the plan of your work, constructed before the study is actually executed.
• Once research has been conducted : After the study is completed, the rationale is presented in a research article or  PhD dissertation  to explain why you focused on this specific research question. When writing the study rationale for this purpose, the author should link the rationale of the research to the aims and outcomes of the study.

What to Include in the Study Rationale

Although every study rationale is different and discusses different specific elements of a study’s method or approach, there are some elements that should be included to write a good rationale. Make sure to touch on the following:

• A summary of conclusions from your review of the relevant literature
• What is currently unknown (gaps in knowledge)
• Inconclusive or contested results  from previous studies on the same or similar topic
• The necessity to improve or build on previous research, such as to improve methodology or utilize newer techniques and/or technologies

There are different types of limitations that you can use to justify the need for your study. In applied/practical research, the justification for investigating something is always that an existing process/practice has a problem or is not satisfactory. Let’s say, for example, that people in a certain country/city/community commonly complain about hospital care on weekends (not enough staff, not enough attention, no decisions being made), but you looked into it and realized that nobody ever investigated whether these perceived problems are actually based on objective shortages/non-availabilities of care or whether the lower numbers of patients who are treated during weekends are commensurate with the provided services.

In this case, “lack of data” is your justification for digging deeper into the problem. Or, if it is obvious that there is a shortage of staff and provided services on weekends, you could decide to investigate which of the usual procedures are skipped during weekends as a result and what the negative consequences are. 

In basic/theoretical research, lack of knowledge is of course a common and accepted justification for additional research—but make sure that it is not your only motivation. “Nobody has ever done this” is only a convincing reason for a study if you explain to the reader why you think we should know more about this specific phenomenon. If there is earlier research but you think it has limitations, then those can usually be classified into “methodological”, “contextual”, and “conceptual” limitations. To identify such limitations, you can ask specific questions and let those questions guide you when you explain to the reader why your study was necessary:

Methodological limitations

• Did earlier studies try but failed to measure/identify a specific phenomenon?
• Was earlier research based on incorrect conceptualizations of variables?
• Were earlier studies based on questionable operationalizations of key concepts?
• Did earlier studies use questionable or inappropriate research designs?

Contextual limitations

• Have recent changes in the studied problem made previous studies irrelevant?
• Are you studying a new/particular context that previous findings do not apply to?

Conceptual limitations

• Do previous findings only make sense within a specific framework or ideology?

Study Rationale Examples

Let’s look at an example from one of our earlier articles on the statement of the problem to clarify how your rationale fits into your introduction section. This is a very short introduction for a practical research study on the challenges of online learning. Your introduction might be much longer (especially the context/background section), and this example does not contain any sources (which you will have to provide for all claims you make and all earlier studies you cite)—but please pay attention to how the background presentation , rationale, and problem statement blend into each other in a logical way so that the reader can follow and has no reason to question your motivation or the foundation of your research.

Background presentation

Since the beginning of the Covid pandemic, most educational institutions around the world have transitioned to a fully online study model, at least during peak times of infections and social distancing measures. This transition has not been easy and even two years into the pandemic, problems with online teaching and studying persist (reference needed) . 

While the increasing gap between those with access to technology and equipment and those without access has been determined to be one of the main challenges (reference needed) , others claim that online learning offers more opportunities for many students by breaking down barriers of location and distance (reference needed) .  

Rationale of the study

Since teachers and students cannot wait for circumstances to go back to normal, the measures that schools and universities have implemented during the last two years, their advantages and disadvantages, and the impact of those measures on students’ progress, satisfaction, and well-being need to be understood so that improvements can be made and demographics that have been left behind can receive the support they need as soon as possible.

Statement of the problem

To identify what changes in the learning environment were considered the most challenging and how those changes relate to a variety of student outcome measures, we conducted surveys and interviews among teachers and students at ten institutions of higher education in four different major cities, two in the US (New York and Chicago), one in South Korea (Seoul), and one in the UK (London). Responses were analyzed with a focus on different student demographics and how they might have been affected differently by the current situation.

How long is a study rationale?

In a research article bound for journal publication, your rationale should not be longer than a few sentences (no longer than one brief paragraph). A  dissertation or thesis  usually allows for a longer description; depending on the length and nature of your document, this could be up to a couple of paragraphs in length. A completely novel or unconventional approach might warrant a longer and more detailed justification than an approach that slightly deviates from well-established methods and approaches.

Consider Using Professional Academic Editing Services

Now that you know how to write the rationale of the study for a research proposal or paper, you should make use of Wordvice AI’s free AI Grammar Checker , or receive professional academic proofreading services from Wordvice, including research paper editing services and manuscript editing services to polish your submitted research documents.

You can also find many more articles, for example on writing the other parts of your research paper , on choosing a title , or on making sure you understand and adhere to the author instructions before you submit to a journal, on the Wordvice academic resources pages.

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Home Market Research

Motivational Research: Techniques, Strengths, and Weaknesses

Motivational research is to identify and understand the aspects of the consumer that they do not fully comprehend. It makes the assumption that there are hidden or unconscious motivations influencing consumer behavior.

Motivational research gradually got linked with traditional marketing research, influencing and expanding the inventory of marketing research and research procedures. Its popularity peaked in the latter half of the 1950s and early 1960s.

So, in this blog, we will describe motivational research, its techniques, strengths, and weaknesses.

What is Motivational Research?

Motivational Research is the currently famous phrase for using psychiatric and psychological procedures to understand better why individuals react the way they do to products, advertisements, and other marketing scenarios.

Motivational research is consumer research that has grown in popularity in recent years. It is an endeavor to uncover and explain why customer behavior differs and why they behave in a specific manner.

Thus, it prompts the consumer’s inhibited (conscious) and repressed (unconscious) motives. In denial, the consumer is aware of his intentions but refuses to reveal them to others for fear of humiliation, punishment, or ostracism.

However, information regarding the motivating reason remains in the conscious mind. Because the individual will not accept the presence of a motive even to himself, repression suggests a more profound rejection of knowledge about an explanation.

LEARN ABOUT: Behavioral Research

Techniques of Motivational Research

Customers need to efficiently or accurately express their emotional feelings on direct questioning. As a result, Clinical Psychological methods/techniques are applied in motivational research for the psychoanalytical research of consumers.

All marketing activities require motivational research. The motivational study employs the following techniques:

01. Observation Technique

Consumer motivations can be deduced from their communication and actions. The researcher uses this strategy to observe consumer behavior without revealing their name. This procedure does not include any interviews.

Under this technique, the researcher may obtain relevant data or information individually using mechanical aids. This technique is appropriate for researching the purchasing process of consumers.

02. Depth Interview Technique

The researcher uses this strategy to conduct an intense interview.

The researcher questions respondents individually for several hours in the form of an interview. Interviewers are taught to develop rapport and not to steer the conversation too much. Respondents are urged to open up about their activities or interests and a specific issue or brand under investigation.

Interview transcripts are then thoroughly examined, along with comments on respondents’ moods and gestures they may have used to express attitudes or motives.

Such studies are appropriate for giving the market a head start on potential appeals.

03. Self Reports Technique

In this technique, the researcher merely verbally inquires about the respondent’s intentions, objectives, and needs or through a questionnaire.

The researcher may administer many tests using pencil and paper under this method of motivation study to elicit replies from the participants regarding their wants, desires, opinions, interests, reactions, etc.

The information is next quantified, which involves giving it a score to determine the degree to which a given need or motivation exists.

This technique has two measure restrictions:

• First, people must be conscious of their actions’ causes or motivations.
• Second, respondents might explain their words or actions. Respondents could be reluctant to disclose their genuine intentions and might be prone to providing socially acceptable answers.

04. Projective Techniques

Projective techniques aim to expose an individual’s genuine emotions and intentions.

Various cloaked tests with unclear stimuli, including unfinished sentences, cartoons, untitled images, other person characterization, etc., make up projective techniques .

Projective techniques operate on the fundamental presumption that participants are oblivious to the fact that they are expressing their emotions. These tactics need to give respondents a chance to explain their answers.

Some important projective techniques are as under:

• Thematic Apperception Test (T.A.T)
• Word Association
• Sentence Completion
• Third Person Technique
• The Paired Pictures Test.

Strengths and weaknesses of motivational research

Like anything and everything else in this world, motivational research has some of its strengths and weaknesses. Some of them are given below:

Strength: 

Some of the strengths of motivational research include the following:

• In-depth insights into consumer behavior and motivations
• Assists marketers in tailoring their products and marketing messages better to fit the wants and wishes of their customers.
• Can assist businesses in identifying unmet consumer requirements and product development prospects
• Can give helpful information for market segmentation and target marketing
• It can increase the success of marketing campaigns by identifying important motivators and drivers of consumer behavior.

Weaknesses:

Measuring the influence of motivational studies on consumer behavior and corporate outcomes can take time and effort. Some of the weaknesses of motivational research are as follows:

• It can be time-consuming and costly, especially compared to other market research types.
• It is based on self-reported data, which might be skewed and inaccurate.
• It is often based on tiny, non-representative samples, which limits the conclusion’s generalizability.
• It might be challenging to transform ideas from motivational research into tangible activities or marketing and product development initiatives.

LEARN ABOUT: Market research vs marketing research

Motivational research is a type of market research that tries to find out what drives, wants, and needs people really have. In-depth interviews, focus groups, and observation are all common ways to research what motivates people.

Overall, motivational research can be useful for businesses that want to learn more about their customers and make better marketing plans.

QuestionPro is survey software that can be used to research what motivates people. The platform has various features and tools that help researchers design, run, and analyze surveys for motivational research.

QuestionPro lets people create surveys with different kinds of questions, like multiple choice, open-ended, and rating scales. It also lets you change how surveys look and feel and target specific groups of respondents.

QuestionPro also has various tools for analyzing and reporting data that can help researchers make sense of the information they collect and come to useful conclusions. Overall, QuestionPro can be a useful tool for doing motivational research.

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MOTIVATION: CONCEPT, THEORIES AND PRACTICAL IMPLICATIONS

Management researchers have long believed that organisational goals are unattainable without effective use of motivational concepts. One key element of leadership is the ability to get others to do something, creating an influence. This paper is designed to help familiarise readers with the concepts related to motivation. Some popular theories will be reviewed and discussed. A leader must be able to motivate others to achieve goals, accomplish tasks, and complete objectives. Motivation is one key indicator of behaviour. We behave in a way that will satisfy motive based on a need. However, we don’t always have the luxury of knowing what our needs or motives are. Knowing potential areas of motivation, like the ones discussed in this module, can provide guidance in working with and discussing concerns with others.

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This paper examines the concepts, theories, and techniques of motivation, which are important aspects of managerial and administrative people in business and industry. The performance of any organization depends on the efficiency of individuals, and that could be achieved when they are motivated with their works. Motivation is the inner force or drive of individuals constituted through feelings, experience, realization of job, work, and behavior of management that directs them to accomplish their work assignments. Definitions pertaining to motivation also disclosed that this force is directed to satisfy or fulfill needs, wants, expectations, and desires This force could be made favorable by making change of needs and wants satisfying factors that are widely known as means of motivation. The motivational means might broadly be of two types financial and non-financial By adapting the means of motivation, company can create motivational and well-disciplined work environment that are essential for the present complex business world.

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Motivation is the most important tool for modern organizations. Motivation actually crates drive that leads to the achievement of the individual as well as the organization’s objectives. Now a days many management experts have focused their studies in this field. Moreover not only business organizations, other types of organizations need motivation to obtain their desired goals. It is vital element in the field of education too, as we know very well that a teacher persuade and create drive the students to learn new things and lesson. The present study focuses on concept of motivation, importance of motivation and techniques of motivation at work places.Academic Voices, Vol. 3, No. 1, 2013, Pages 13-18 DOI: http://dx.doi.org/10.3126/av.v3i1.9980

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One of the major responsibilities of managers in an organization is to identify potential capacities of the personnel and to bring about conditions for their growth and realization of these capacities which in turn, serves the basic goal of promoting productivity. In other words, gaining knowledge about motivational factors for improving performance and productivity of the organization is of great importance. Also, such this knowledge can greatly help to improve the application of human resources in organizations, prevent employees' resistance against change, reduce limitations in the output, and prevent conflict among personnel, a process which consequently results in a profitable organization. Motivation is about human life and realization of goals. Human beings live and work happily and hopefully when they feel alive and perceive a meaningful relationship between their work and life.

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Motivation research: definition and techniques.

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It is amply clear from the chapter CONSUMER BEHAVIOUR that the identification of consumer motives is a complex business. The difficulties involved in discovering directly the precise motivating factors that shape buying behaviour led some marketing psychologists to devise oblique techniques for exposing hidden motives.

For many years before World War II, researchers in the fields of psychology, psychiatry, sociology and social- anthropology had been conducting research into the behaviour of consumers, particularly probing of sub-conscious mind. Marketing research, today, can be conveniently divided into two parts ‘quantitative’ and ‘qualitative’.

The former concentrates on finding the answers to the questions: ‘What’ ‘Who’ ‘How many” Where’ and ‘When’ the consumer wants a product or service? On the other hand, qualitative research focuses its attention mainly on ‘Why he wants a product or service?

Put in other words, consumer ability to buy is not that important; what is more important are motives behind such buying.

In course of time, motivation research became integrated with traditional marketing research and influenced and expanded the inventory of marketing research and research techniques. It reached its high peak of popularity in the latter half of 1950s and early 1960s.

What is Motivation Research?

Motivation research is a form of consumer research which has gained ground over the recent years. Motivation Research is the currently popular term used to describe the application of psychiatric and psychological techniques to obtain a better understanding of why people respond as they do to products, ads and various other marketing situations.

It is an attempt to discover and explain why the consumer behaviour differs; why he or she behaves in a particular way?

What appeals and sales programmes will best influence his or her decision to act or buy or not to act or not to buy?

It concentrates on emotional or hidden stimuli to consumer action.

Thus, motivation research is an attempt to uncover the consumer’s suppressed (conscious) and repressed (unconscious) motives. In suppression, the consumer remains aware of his motives but does not care to admit their existence to others for the fear of ridicule, punishment or being ostracized.

Information about the motivating factor remains in the conscious mind, however. Repression implies a more serious rejection of knowledge about a motive because; the individual will not admit motive’s existence even to himself.

It is a careful probing beyond the surface “why” offered by consumers to explain their actions. As a branch of marketing research, it aims to discover the real reasons for their purchasing preferences via sample questionnaires, interviews and the like.

The theme of above definitions is that motivation research is to discover underlying motives, desires, instincts and emotions which provoke human behaviour and, in market research, true reasons why people buy or do not buy certain goods as distinct from the reasons they express or even imagine they act upon. The distinguishing feature of motivation research is probing “beneath the skin”, or “below the surface”.

Today, the most challenging task of marketing research is to predict how people will react and why they react in a particular way in a given situation. “How they react”? Can be answered with ease and confidence. Say, how the consumers receive the new product, package advertising message and the like where surveys cross tabulations and analysis can help to find the answers. However, more difficult task is one of finding out “why people” react in a particular way? By merely asking consumers why they like or dislike a product or an advertisement or a package, one cannot get satisfactory answers.

The answers differ widely and are misleading very often. These answers are misleading not because people are dishonest, but merely because they do not know really why? Wrong or unbelievable answers are given because of two possible reasons:

1. Conscious or unconscious attempt to rationalize their behaviour and

2. Preference for not disclosing their real reasons for ranking.

Conventional research does not answer this but motivation research does. It is the psycho-analysis that helps in overcoming the inability or the reluctance of people to tell why they like or dislike a product or a service. This is known as penetrating below the surface to reach sub-consciousness.

The relations between a consumer and a product are partly conscious and partly sub- conscious. The ‘price’ of a motor car, for example, is conscious relationship.

A person no doubt is worried and particular about kilometers per litre, cost per kilometer, boot-space acceleration and the like but his product preference of sub-conscious type is ‘sex symbol’.

Car is an extension of man’s personality which is known by motivation research. Precisely, motivation research is the art of finding out why? Without asking why?

The best example of understanding is one of choosing a girl as a house­wife. Ask a sober looking young man as to what type of woman he wants to marry; the answer may be “the quiet, home-loving more concerned about the food she cooks for me than the clothes, ornaments and make-up aids she wants”.

Observe him at parties and get-togethers and you will find that he is after a woman attractively clothed with gleaning make-up appealing to his hidden motives. Thus, motivation research is something that goes beneath the line. Thus, it is an attempt to market below the line.

Techniques of Motivation Research :

The techniques used in motivation research are of two types namely, Projective Techniques and Depth Interviews.

Projective Techniques :

These projective techniques represent the test conducted to establish the personalities of the respondents and their reactions to product media advertisement package product design and the like.

They project or reflect the subject’s thought about what he or she sees, feels, perceives thus producing the reactions.

These tests are derived from clinical psychology and work on the postulation that if an individual is placed in an ambiguous situation, he is guided by his own perceptions to describe the situation.

They often provide, an insight into the motives that lie below the level of consciousness and when the respondent is likely to rationalize his motives consciously or unconsciously; his responses tend to reflect his own attitudes and beliefs by indirection and discretion; they are his own perceptions and interpretations to the situation to which he is exposed.

There are five most commonly administered tests of this kind namely :

1. Thematic Appreciation Test.

2. Sentence Completion Test.

3. Word Association Test.

4. Paired Picture Test and

5. Third Person Test.

1. Thematic Appreciation Test (TAT):

Under this test, the respondent is presented with a picture or series of pictures of a scene or scenes involving people and objects associated with goods or services in questions. These are unstructured, doubtful in action and very often neutral giving no expression or motions. The respondent is to study the picture or the pictures and construct a story.

His narrations or readings are interpreted by a skilled analyst. Thus, the picture may be of a young man scribbling on a piece of a paper. Here, the respondent is to read as to whether the person in picture is writing. If so what? For whom? And why? And so on.

2. Sentence Completion Test (SCT):

Sentence completion tests are designed to discover emotional responses of the respondent. It is the easiest, most useful and reliable test to get the correct information in an indirect manner. The respondent is asked to complete the sentence given.

For instance, the questions may be, in case of ladies:

1. I like instant coffee because……………

2. I use talcum powder because…………..

3. I use electric kitchen gadgets because………………….

4. I do not use pain-killers like aspirin because……………..

5. I do not like red, brown and black colours because…………………….. In case of men, these questions may be

(a) I liked filter tipped cigarettes because………………….

(b) I gave up smoking because…………………

(c) I love natural proteins because………………..

(d) I prefer cold coffee because………………

(e) I do not use foam beds because……………….

The way the questions are asked, do not reflect right or wrong answers. However, the emotional values and tensions are reflected in the answers so given.

3. Word Association Test (WAT):

Word association test is similar to that of sentence completion test. The only difference is that instead of an incomplete sentence, a list of words ranging from twenty-five to seventy-five is given. This is the oldest and the simplest kind of test.

The respondent is to match the word. That is, the word suggested by the researcher is to be associated by the respondent by the most fitting word he thinks. This is widely used to measure the effect of the brand names and advertising messages.

Here, it is not possible to give all the seventy-five words. On illustrative basis, let us have fifteen words:

1. Perfume………..

2. Tooth paste

3. Hair oil………..

4. Shampoo……………………….

5. Shoes…………

6. Two-wheelers…………

7. Four-wheelers…………

8. Tyre………………………

9. Glass wares………….

10. Ink………..

11. Pencils…………

12. Fridges…………………….

13. Cupboards…………

14. Television………………….

15. Video cassettes………………

Thus, a respondent may give his preferences as ‘Colgate’ or ‘Promise’ or ‘Close-up’ or ‘Forhans’ in case of tooth paste. On the basis of such answers, it is possible to determine a scale of preference.

4. Paired Picture Test (PPT):

This is another very appealing and easy to administer test. Paired picture test means that the respondent is given a pair of pictures almost identical in all respects except in one. For instance, the researcher may be interested in knowing the reaction of respondents to a new brand of refrigerator.

The pair of pictures may show a woman opening refrigerator which is moderately priced with a usual brand; another picture of the same woman opening the refrigerator door of another brand.

Looking to these two pictures, the respondent is to give his own feelings or reactions. Though the same pair is shown to so many respondents, the reactions differ from person to person. Instead of using the usual figures, cartoons may be introduced. The analyst gets here the inner feelings of an individual for this analysis purpose.

5. Third Person Test (TPT):

The format of this test is that the respondent is given a photograph of a third person—may be a friend, a colleague, a neighbour, a star, a player, a professional and the like The point involved is that the researcher is interested in knowing what the third person thinks of an issue as heard through the respondent.

It is assumed that the respondent’s answer will reveal his own inner feelings more clearly through the third person than otherwise it would have been possible.

The best example of this kind the test conducted on American house-wives in connection with ‘instant coffee’. Prior to the test, the attitude of house-wives was “It does not taste good”, with the test being conducted, the real attitude was “A lady using instant coffee is lazy, spend-thrift and not a good house­wife”. This amply clears the fact how the test revealed the naked truth.

In addition to these tests of usual type, the researchers do use other qualitative techniques such as role-playing, psycho-drama, graphology and the like.

Related Articles:

• Motivation Research: Strengths and Weaknesses
• Different Studies of Marketing Research

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• Published: 23 August 2024

Different motivation, different achievements: the relationship of motivation and dedication to academic pursuits with final grades among Jewish and Arab undergraduates studying together

• Efrat Gill 1   na1 ,
• Oz Guterman 1   na1 &
• Ari Neuman   ORCID: orcid.org/0000-0002-1416-5522 2   na1  

Humanities and Social Sciences Communications volume  11 , Article number:  1079 ( 2024 ) Cite this article

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Much research has indicated disparities between majority and minority groups in academic achievements. In Israel, differences have been recorded between the ethnic majority of students of Jewish origin and the ethnic minority of students of Arab origin. One possible reason for these findings might be differences in motivation, influenced by the respective cultures of the Jewish ethnic majority and Arab ethnic minority. The present research examined the relationship between differences in academic achievements of 73 students of Jewish origin and 74 students of Arab origin studying together and patterns of motivation and dedication to academic pursuits. The findings indicate considerable differences between the two populations in final grades and in motivational patterns and dedication to academic pursuits. In addition, in each of the research populations, different motivations were associated with a higher level of grades.

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In many societies, academic education is considered key to social mobility and is especially important for minority groups (Alsulami, 2018 ; Baskakova et al., 2017 ; Bautista et al., 2023 ; Dominguez-Whitehead, 2017 ). In a review of studies that examined the effect of academic education on the social status of minority groups, Arar and Mustafa ( 2011 ) found that academic education strengthened minority groups by enabling better integration into the labor market, thereby enabling the minority groups better economic, social, and political status. Given the importance of this factor, it is alarming to see data on the gaps between the majority and minority groups in academic achievement. This gap does not exist in all minority groups and there are even cases in which minority groups have higher academic achievements. However, in cases where there is a gap, it is an obstacle to the progress of minority groups (Pérez-Martín and Villardón-Gallego, 2023 ).

Gaps in education and academic success between majority and minority groups at all levels of education have been widely documented in the literature. According to Martin et al. ( 2017 ), this is one of the most difficult and frustrating problems for policymakers. For example, the data on the gaps between students of African American and of white origin in the United States over the last three decades indicated significant differences in grades in favor of the latter (Bowen and Bok, 1998 ; Charles et al., 2009 ; Hung et al., 2020 ). At the college level, students of Latin American and African American origin in the United States had lower academic achievements (average grade and graduation scores) and took a longer time to graduate compared with students of white or Asian origin (Bowen et al., 2009 ; Kugelmass and Ready, 2011 ).

The gap between academic achievements of majority and minority groups in Israel

In Israel, too, there are gaps between the ethnic majority and minority groups, such as, for example, students of Jewish and Arab origin. Arar and Mustafa ( 2011 ) contended that the characteristics of students of Arab origin in Israel’s higher education system were similar to those of other minority groups in the world.

Lufi and Parish-Plass ( 2010 ) argued that the differences between Jewish-origin and Arab-origin students in academic achievements were reflected in a number of academic and educational indicators. Feniger et al. ( 2013 ) found that after completing high school, about 69% of Jewish-origin students eligible for a matriculation certificate continued on to higher education, compared with only 51% of Arab-origin students. Moreover, 74% of the Jewish-origin students completed their studies at the end of the qualifying period, compared with 62% of the Arab-origin students. In other words, about half (51%) of the Jewish-origin students entitled to a matriculation certificate completed a bachelor’s degree, compared with about one-third (32%) of the Arab-origin students. In addition to their relatively low rates of enrollment in academic institutions, the dropout rate among Arab-origin students has been shown to be higher, approximately 16.6% within two years of entering, compared with 12% among Jewish-origin students (Mustafa, 2007 ). Examination of the data on gaps in education over several years revealed an upward trend in the level of education among the Arab population in the last decades, however, the gap between Jews and Arabs remained (Guterman and Gill, 2023 ; Central Bureau of Statistics, 2020 ). These differences were also found to be associated with cultural disparities. The Arab society in Israel is characterized by a higher level of collectivism compared to Jewish society, and these differences were found to be linked to the academic achievements of students, among other factors. (Guterman et al., 2024a ). The Arab society in Israel is generally more traditional, placing a greater emphasis on belonging to the extended family. In this regard, family identity is, on average, more significant for Arab-origin students, and there is a tendency in Arab society in Israel towards more collectivist motivations (Guterman et al., 2024b ).

Differences in motivation and dedication to academic pursuits and cultural differences between Jews and Arabs in Israel

One of the explanations for these gaps between students of Jewish and Arab origin in academic achievements may be motivational differences. Several studies examined the level of motivation of high-school students of Jewish and Arab origin and showed that the desire to pursue academic degrees was higher among students of Arab origin (e.g., Feniger et al., 2021 ; Khattab, 2005 ). However, the effect of different types of motivation on the academic success of the two groups was not examined.

One of the possible explanations for the differences between students of Jewish and Arab origin in Israel in level of motivation and dedication to academic pursuits lies in the cultural differences between these population groups in terms of collectivism and individualism. As explained, previous research has found that students of Arab origin have a higher tendency toward collectivism than students of Jewish origin do (e.g., Amzaleg and Masry-Herzallah, 2022 ).

Research on motivation and dedication to academic pursuits

Several academic models and theories are dedicated to examining the motivation and dedication that individuals exhibit toward their academic endeavors. Each of these theoretical frameworks offers different explanations for the gap in academic achievements between Jewish and Arab populations in Israel, as well as potential disparities between these two groups in motivation and dedication to academic pursuits. Achievement goal theory (AGT; Ames, 1992 ), one of the most widely used theoretical frameworks in the research of motivation to learn (Huang, 2012 ; Urdan and Kaplan, 2020 ), explains students’ purposes for studying. Elliot and Trash ( 2001 ) defined motivation for achievement, and especially motivation for academic achievement as the purpose for which a person engages in goal-driven activities (p. 140). A number of studies have shown the connection between achievement goals in an academic setting and students’ learning behaviors (see, e.g., Meece et al., 2006 ) and examined the characteristics of students who continue to succeed in challenging learning environments.

Earlier studies in the field distinguished between two types of goals: mastery goals, in which the purpose is to develop abilities, and performance goals, in which the purpose is to demonstrate mastery (Ames, 1992 ; Dweck and Leggett, 1988 ). Recent studies have added an approach-avoidance dimension, whereby approach goals arise from the motivation to succeed or the motivation to avoid failure, respectively. Huang ( 2012 ) argued that approach motivation is generally associated with higher academic achievement and avoidance motivation is associated with lower academic achievement.

The underlying factor of motivational orientations is the way in which students assign meaning to school and learning. Nicholls ( 1992 ) argues that mastery goals and performance goals stem from students’ theories about education and learning. These theories are shaped by cultural meanings associated with education in their respective communities and their personal experiences within educational contexts (Maehr and Nicholls, 1980 ). This perspective suggests that in schools within different cultural groups, students may have different theories regarding school and learning.

Significant cultural differences are evident between minority and majority groups. Generally, majority groups adhere to a distinct cultural group that is different from that of minority groups, allowing for the distinction between ‘majority culture’ and ‘minority culture.' Indeed, this viewpoint aligns with the findings that highlight disparities between these groups, in academic achievements. For example, the 2009 Program for International Student Assessment (PISA), identified significant achievement gaps between immigrant and non-immigrant students was identified across all domains in most OECD countries. Immigrant students generally exhibited lower proficiency levels compared to their non-immigrant counterparts: in reading in 23 countries, in mathematics in 24 countries, and in science in 25 out of 28 countries. Additionally, academic difficulties were more prevalent among second-generation immigrants compared to first-generation immigrants (OECD, 2012 ).

Disparities in academic achievements were found in Israel between the majority Jewish population and the Arab minority. The gap in achievements was evident in the results of the 2002 PISA exam. According to the exam results, students of Arab origin achieved lower scores than those of Jewish origin, ranking Israel 31st in mathematics, 30th in reading, and 33rd in science out of 42 countries assessed. Conversely, if only scores of Jewish-origin students were considered, Israel would have ranked 12th. It was found that ~60% of students of Arab origin in Israel struggle with reading comprehension, compared to 30% among students of Jewish origin. In the Arab sector, despite an improvement in academic achievements, the eligibility rates for matriculation certificates remain low; among students of Arab origin, the eligibility rate stood at 34%, compared to 51% among students of Jewish origin. Regarding the quality of the matriculation certificate, a higher percentage of Jewish-origin students met the university entry requirements—87%, compared to 73% among Arab-origin students. Additionally, the dropout rate among youth is significantly higher in the Arab sector (Mi-Ami, 2003 ).

Indeed, previous research on differences between Jewish and Arab students in terms of achievements indicated the important role of learning goals (Guterman et al., 2024a ). The study found that the level of approach-avoidance goals of the Arab students was indeed lower than those of the Jewish students. This finding suggests the possibility that the collectivist perceptions of this population might lead to less willingness to create challenges, thus creating more passive and less active coping.

Another common model of motivation is the expectancy-value theory (EVT), a motivational framework that describes the correlation between an individual’s expectation of success in a task and the perceived value attributed to that task. First introduced by Atkinson in 1957 EVT was further developed by Wigfield and Eccles ( 2000 ). This theory comprises two principal components: expectancy and value. Expectancy is an individual’s belief in their ability to achieve success in a task, addressing the question, “Can I effectively execute this task?” Expectancy beliefs are influenced by past accomplishments or failures, thus shaping one’s perception of their likelihood of success. Value refers to the perceived importance, utility, or enjoyment associated with a task, addressing the question, “Do I consider this task worthwhile?” Value is influenced by an individual’s prior experiences, beliefs, and personal objectives. EVT identifies four distinct types of values: intrinsic value (the enjoyment derived from the task), attainment value (the personal significance of achieving success in the task), utility value (the practical usefulness of the task), and cost (the negative aspects associated with engagement in the task).

EVT offers an interesting look at the differences between groups. However, unlike AGT, differences between Jews and Arabs have not yet been examined from the perspective of this theory. In our opinion, and in accordance with EVT, there are no expected differences between the groups in the degree of desire to succeed (value). In other words, even though it is possible that the desire to succeed stems from different motivations, such as a desire for personal achievement (individualism) or a desire for group achievements (collectivism), there is no reason to assume that the desire for success itself would be different.

In contrast, there may be differences in the belief of individuals in their ability to succeed (expectancy). An individualistic perception directs individuals to focus on their own abilities. Indeed, research has shown a correlation between individualism and self-efficacy (Earley, 1994 ). In this respect, according to EVT, students of Jewish origin, who come from a more individualistic society, can be expected to show more active strategies compared with students of Arab origin, whose society is more collectivist.

The present study

The present study focused on motivation and dedication to academic pursuits among students of Jewish and Arab origin who were studying together in a college in Israel. To this end, a questionnaire validated in previous research in Israel was used to examine academic motivational patterns (Eliassy, 1999 ). The students were enrolled at an institution in which approximately half of the students were Jews and the other half were Arabs. The research examined several hypotheses:

In keeping with previous research, including studies conducted with students in academic institutions in Israel (Guterman and Neuman, 2019 ), a gap will be found between the groups in student grades, where the students of Jewish origin will have higher final grades than their peers of Arab origin.

A positive correlation will be found between the level of motivation to study and the final grade point average.

In light of the character of Arab culture in Israel, which is typically more collectivist than Jewish culture (Lapidot-Lefler and Hosri, 2016 ; Sagy et al., 2001 ), the level of passive engagement in learning (which refers to the performance of assignments given by lecturers) will be higher among students of Arab origin compared with those of Jewish origin. As noted, this hypothesis is based on previous findings that suggested a greater reliance on sources of authority as a basis for personal action in Arabs compared with Jewish society in Israel (Lapidot-Lefler and Hosri, 2016 ; Sagy et al., 2001 ).

Participants

The research was conducted with 147 students, all enrolled at the same college in Israel. The sample was divided between 74 students of Arab origin and 73 students of Jewish origin (according to their self-reports, as explained later). To enable examination of differences between the groups, we matched them in terms of the gender and age of the participants.

At the time of the research, the students were in their second year of bachelor’s degree studies. There were 109 female students (74.15% of the sample) and 38 male students (25.85%). Differences between the samples in the distribution of genders were examined using Chi-square analysis; no significant differences were found between the groups of Arab and Jewish origin in terms of the distribution of men and women; Χ 2 (1) = 0.96, p  > 0.5 (among the Arab students: 55 women and 19 men; among the Jewish students: 54 women and 19 men).

The participants’ ages ranged from 18 to 57. The mean age was 24.78 with a standard deviation of 6.64. To examine the differences between the groups in this respect, an independent sample t -test was conducted. No significant differences were found, t (145) = 0.44, p  > 0.05 (Arabs: M  = 24.54, SD = 7.27; Jews: M  = 25.02, SD = 5.98).

The researchers invited social sciences students to participate in the research during their classes at Western Galilee College. They explained that participation was voluntary and were assured that the data would not affect their grades or be used for any purpose other than the research. After the students gave their consent to participate in the research, meetings were arranged to administer the different questionnaires included in the research. The students signed to indicate their consent to participate in the research as well as permission for the research team to examine their final grades. The grades were collected two and a half years after completion of the questionnaires, according to the approval of the Ethics Committee of the college. Seven students dropped out of studies and were therefore not included in the research.

Instruments

Motivational patterns questionnaire.

Eliassy ( 1999 ) developed a questionnaire of 24 items in which the respondents rank the degree to which the statements fit them on a scale of 1 (“not at all true”) to 4 (“true to a great degree”). The items refer to different aspects of studying that represent patterns of high and low motivation in terms of quality and test the degree to which the student expresses willingness to demonstrate each of them. The Hebrew version regarding motivational patterns includes five subscales: (a) persistence when encountering difficulties during studies (such as difficult questions in homework assignments, study material that is hard to understand, and the like). In the present study, the Cronbach’s alpha for this subscale was 0.71; (b) active involvement in studying, where the items examine the degree to which the student demonstrates interest in what is going on in class during lessons and their active participation in activities during lessons (that is, the degree to which the student engages in actions that reflect involvement, such as expressing an opinion, raising one’s hand, and the like). In the present study, the Cronbach’s alpha for this subscale was 0.84; (c) passive involvement in studying, where the items also examine the degree of interest expressed by the student in what is happening in class during lessons, but in this case referring to situations when they turn their attention to what is happening during the lesson but do not take any specific action. In the present study, the Cronbach’s alpha for this subscale was 0.82; (d) willingness to invest effort in studying (the degree to which the student is willing or chooses to put effort and time into studies, both in class and at home). In the present study, the Cronbach’s alpha for this subscale was 0.81; and (e) seeking challenges in studying (the extent to which the student prefers to engage in complex or simple assignments in studies, in terms of the level of difficulty and the personal challenge they pose to the individual). In the present study, the Cronbach’s alpha for this subscale was 0.77.

Academic achievements

The student’s final grades were collected from the college’s databases. The data were collected in accordance with the consent of the study participants and the approval of the Research Ethics Committee.

Demographic questionnaire

The respondents completed a demographic questionnaire that included questions about gender, study track, year of studies, age, and ethnic origin.

To test the hypotheses, several stages of analysis were conducted. First, the differences between Jewish and Arab students in all variables were analyzed. Second, the relationships between the research variables were examined, and finally, hierarchical regression was conducted to examine interactions between the variables in their contribution to explaining the variance in the final bachelor’s degree grades.

Differences between the students of Arab and Jewish origin in terms of the variables

To examine the differences between the students of Jewish origin and those of Arab origin in motivational patterns, a one-way MANOVA was performed. To examine the differences between the groups in final grades, a t -test was conducted.

The MANOVA regarding differences between the students of Jewish and Arab origin in motivational patterns showed a significant difference between the groups, F (5,141) = 4.01, p  < /−1. Eta 2  = 0.13. The results, means, and standard deviations of the motivational patterns by group are presented in Table 1 .

As the table shows, significant differences were found between the students of Jewish origin and their classmates of Arab origin in motivational patterns of willingness to invest effort in studies and seeking challenges in studies. In both these variables, the scores of the students of Jewish origin were higher, on average, than those of the students of Arab origin.

In addition, an independent sample t -test was conducted to examine whether there were differences between the students of Jewish and Arab origin in their final grades; it showed significant differences between the students in final grades, t (206) = 6.53, p  < 0.001. The average grades of the students of Jewish origin were higher than those of the students of Arab origin (Arabs: M  = 71.98, SD = 9.91; Jews: M  = 81.93, SD = 8.51).

Correlations among the research variables

To examine the correlations among the research variables and the between them and the final grades, Pearson correlations were calculated for each group. The correlations between the two motivational patterns and between these patterns and the final grade among students of Jewish origin and of Arab origin are presented in Tables 2 and 3 .

The tables show that among the students of Arab origin, there was a positive correlation between the final grade and passive involvement in studies. In comparison, among the students of Jewish origin, there was a positive correlation between final grade and active involvement in studies. In other words, among the students of Arab origin, the greater their passive involvement in studies was, the higher their final grades were, and among the students of Jewish origin, the greater their active involvement in studies, the higher their final grades were.

In contrast, in both groups, a negative correlation was found between involvement in studies (whether active or passive) and persistence when encountering difficulties with studies. In other words, in both groups, the less the student’s passive or active involvement in studies, the less their persistence when facing difficulty. In fact, in both groups, there was a positive correlation between the two types of involvement in studies (passive and active), where the greater the involvement of one type was, the greater the involvement of the other, as well; in other words, these variables were not independent. Furthermore, in both groups, a negative correlation was found between willingness to invest effort in studies and persistence when encountering academic difficulties. In other words, the greater the willingness to invest effort in studies, the lower the level of persistence when encountering difficulty. In both groups, a positive correlation was found between persistence when encountering academic difficulties and seeking challenges in studies: the greater the persistence when encountering difficulties, the greater, too, was the student’s search for challenges when studying.

In both groups, there was a positive correlation between passive involvement in studies and willingness to invest effort in studies. However, among the students of Jewish origin, there was also a positive correlation between active involvement and willingness to invest effort in studies, but among those of Arab origin such a correlation was not found. In other words, in both groups, the greater the passive involvement in studies, the greater the willingness to invest effort in studies, but only among those of Jewish origin did we also find that the greater the active involvement in studies, the greater the willingness to invest effort in studies.

In both groups, a negative correlation was found between passive involvement in studies and seeking challenges in studies, that is, the greater the passive involvement in studies, the less the search for challenges. Furthermore, among the students of Jewish origin, a negative correlation was also found between passive involvement in studies and willingness to invest effort in studies, that is, the greater the passive involvement in studies, the lower the willingness to invest effort. However, among the studies of Arab origin, no correlation was found between these two variables.

Regression analysis of explained variance of final grades among students of Jewish and Arab origin

To examine the contribution of the research variables to the explained variance in final grades, a separate regression analysis was performed for each of the groups. In both analyses, the first stage was to perform a multiple regression that included all the variables mentioned, even though some of them were not found to be associated with the final grade. The purpose of this analysis was to examine whether these variables might be found to contribute due to interaction with other variables. Next, a hierarchical regression was performed, where the variables that had been shown to correlate with the final grade, either as a main effect or an interaction, were entered. These regressions included three steps: (a) demographic characteristics (age and gender); (b) motivational patterns (persistence when encountering difficulties in studies, active involvement in studies, passive involvement in studies, willingness to invest effort in studies, and seeking challenges in studies); and (c) interaction of the motivational patterns with the demographic characteristics, to examine whether the contribution of the motivational patterns was dependent on the demographic characteristics of the student.

In the first two steps, the variables were force-entered; in the third step, which examined the contribution of the interactions to the explained variance, only those interactions that had been found to contribute to the explained variance significantly ( p  < 0.05) were entered. The regression regarding the students of Arab origin indicated that the level of explained variance was 30%; in comparison, the regression regarding students of Jewish origin indicated that the level of explained variance was 13%. The beta coefficients of the explained variance in each of the regressions are presented in Table 4 .

As the table shows, in the regression regarding the students of Arab origin, the results of the first step, which included only the demographic variables (age and gender), showed a significant contribution of 14% to the explained variance in final grades. In the regression regarding the students of Jewish origin, the same regression did not indicate a contribution to the explained variance in final grades. In the regression regarding the students of Arab origin, age was found to correlate positively with final grade: the older the student, the higher the grade. In the second step, when the five variables of the student’s motivational patterns (persistence when encountering difficulties in studies, active involvement in studies, passive involvement in studies, willingness to invest effort in studies, and seeking challenges in studies) were entered, both the regression regarding the students of Arab origin and that regarding students of Jewish origin indicated a significant contribution of 12% to the explained variance.

In the regression regarding students of Jewish origin, active involvement in studies correlated positively with the final grade (the greater the active involvement in studies, the higher the final grade). Furthermore, in the regression regarding Arab students, passive involvement in studies correlated positively with final grade (the greater the passive involvement in studies, the higher the final grade). In addition, among the students of Arab origin, a negative correlation was found between active involvement in studies and final grade (the greater the active involvement, the lower the final grade).

In the third step, when the interaction of willingness to invest effort in studies with age was entered, a significant contribution was found in the group of students of Arab origin. This interaction contributed an additional 4% to the explained variance in final grades among the Arab students. In the regression regarding students of Jewish origin, this interaction did not contribute significantly to explained variance in grades.

To reach a deeper understanding of the interactions, Aiken and West’s ( 1991 ) method was employed. Figure 1 presents a graphic description of the interaction of “willingness to invest effort in studies” with “age” among the students of Arab origin.

Relationship between willingness to invest effort in studies and final grades among older and younger students.

As shown, among the younger students of Arab origin, the willingness to invest effort in studies did not correlate significantly with final grades, β  = 0.20, p  > 0.5. In contrast, among the more mature students of Arab origin, a significant negative correlation was found between willingness to invest effort in studies and final grades, β  = –0.23, p  < 0.5. In other words, among these students, the greater their willingness to invest effort in studies, the lower their final grades were.

Consistent with the research hypotheses and the findings of previous research, a significant difference was found between the groups of students in final undergraduate grades. The students from the Jewish ethnic majority had higher grades than those from the Arab ethnic minority. In addition to this finding, which corroborates that of earlier studies, the results of the present study also indicated differences between the groups in terms of motivational patterns. The students of Jewish origin scored higher than those of Arab origin in seeking challenges and willingness to invest effort in learning.

These findings are consistent with the two models presented in the introduction with respect to seeking challenges. One possible explanation arises from the difference between the groups in achievements. The grades of the students of Arab origin were lower; therefore, it is reasonable that the studies were more difficult for them, and this may have posed a greater threat to them compared with their Jewish counterparts. As presented in the introduction, this finding is consistent with many research findings on the gap between Jews and Arabs in Israel in academic achievements (Ayalon et al., 2019 ; Blass, 2020 ; TIMSS, 2023 ; OECD, 2018 ; Zuzovsky, 2008 ).

These figures are not unique to Israel. Modern society is characterized by substantial migration both between and within countries, leading to the intersection of diverse languages, cultures, and identities. Consequently, numerous nations are comprised of different ethnic minorities that are distinguished by distinctive characteristics. This situation, occasionally intensified by successive waves of migration, gives rise to numerous social advantages alongside complex challenges. Among the latter, the socioeconomic assimilation of minority group members stands out prominently. Discrepancies between majority and minority population groups in educational accomplishments often serve as a notable contributor to the prevailing disparities in these realms (Lauri et al., 2022 ; OECD, 2019 ; U.S. Department of Education, National Center for Education Statistics, 2023 ).

In light of the greater difficulty, they may have been less able to seek challenges in their studies. In further research, it would be interesting to examine the level of threat that students experience and the relationship between this and the degree to which they seek challenges.

With regard to the willingness to invest effort in studies, the results were contrary to the research hypotheses. It was hypothesized that the need to cope with a greater academic challenge would lead to a greater willingness to invest in studies. However, the more complex task of coping for the Arab students may have created an opposite effect, that is, perhaps it led them to give up and created a negative feeling, expressed in less willingness to invest effort in studies. Another possible explanation of this finding might be based on the cultural differences between the groups. As discussed in the Introduction (Lapidot-Lefler and Hosri, 2016 ; Sagy et al., 2001 ), Arab society in Israel is more collectivist and places greater emphasis on authority figures than Jewish society does. Accordingly, it is possible that the students of Arab origin tended to invest more according to the social demands led by the authority figures of the lecturers, and were therefore less inclined to invest beyond the formal requirements. In further research, it would be interesting to examine these explanations by means of qualitative interviews with students from both sectors, which could shed light on the feelings created by facing difficulties and its impact on students’ willingness to invest effort in studies, as well as the way members of the two groups perceive the concept of investing in studies.

Another finding that emerged from the research was the positive correlation among the students of Arab origin between passive engagement in learning and final grades, compared to the positive correlation among the Jewish students between active engagement in learning and final grades. Possible explanations for this finding might also be drawn from the results of previous research that compared these two groups. Specifically, here too, the finding may stem from the different attitudes of the students of Jewish and Arab origin to authority figures. Students from the more traditional Arab society, which places greater emphasis on authority, might be less inclined to be active and take the initiative beyond the specific definitions of the system so that their main effort is expressed in passive learning. In contrast, students from less traditional Jewish society, which stresses authority less, may tend to base their efforts more on personal initiative and less on the demands of the system. It would be interesting for further research to include measures associated with cultural variables, such as conformism or the perception of authority figures, in order to examine these explanations.

Another finding of the present study was the lack of correlation between willingness to invest in studies and final grades among the younger students of Arab origin, and the negative correlation between these two variables among the older students of Arab origin. This might indicate a change in perceptions over time. As presented earlier, among students of Jewish origin, there was a positive correlation between willingness to invest effort in studies and final grades. One possible explanation of these findings is that these students, who were raised in modern Arab society, are less traditional and less influenced by the potential conflict between a collectivist society that places more emphasis on instructions of the system and less on personal effort and the competitive, individualistic society in which they study. This might explain the negative correlation found among the older, but not the younger students of Arab origin. In this case, too, further research that combines measures of the level of collectivism of students might be useful in examining this explanation of the present findings.

The findings of the present research are important, but the study nevertheless had some limitations. First, the types of motivation considered were derived from the literature and research instruments. There is an advantage to using instruments that have been tested in previous research as well as previous research findings, but this method also has an intrinsic shortcoming. For example, the present study did not include an examination of the fit of the division into types of motivation presented in the questionnaires with the taxonomy of types of motivation as perceived by these participants. In the future, it would be interesting to conduct a qualitative examination of how students perceive the types of motivation they feel, followed by a quantitative examination of the research questions of the present study, taking this taxonomy into account.

Second, because of the limited number of respondents, the research examined differences between the groups without considering their subgroups, which could have a strong impact on the findings. For example, the Arab ethnic minority in Israel is composed of several different groups, such as Muslims, Christians, and Druze, which have different characteristics. The Jewish population in Israel can also be divided into groups in different ways. It would be interesting for further research to examine the impact of belonging to these groups on the attitudes and perceptions of the respondents in the two groups. Third, the present research referred to undergraduate studies in a mixed institution, where about half of the respondents belonged to each group. Naturally, the results might be different in other institutions, with different proportions between the groups. It is essential to continue to study this important issue among different population groups, in order to obtain a fuller view of the findings.

Despite these limitations, the present research offers an important contribution. It deepens the understanding of the relationship between the types of motivation and the academic achievements of students. Moreover, the results indicated how this relationship might be influenced by the cultural and personal characteristics of the learners, thus providing a new perspective and enhancing the understanding of this field. Understanding differences between ethnic minority and majority groups also contributes, together with further research in the field, to the ability to help members of ethnic minorities integrate and advance socially, by means of evidence-based practice. From this perspective, research in this field may inform better-focused and well-founded assistance to groups that currently demonstrate lower achievements. Thus, it is hoped that the present research will serve as the basis for further studies that will broaden the understanding of this field.

For instance, targeted interventions aimed at low socioeconomic status (SES) populations can concentrate on defining diverse goals and ensuring alignment with these objectives. Such research illustrates that the challenge lies not only in skills but also in addressing a cultural gap concerning learning objectives. Given that learning goals correlate with academic achievements, efforts to uplift low-SES populations should emphasize not only technical aspects but also the perception of learning goals. Moreover, understanding the correlation between culture and learning goals paves the way for a more profound theoretical comprehension of this domain.

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Gill, E., Guterman, O. & Neuman, A. Different motivation, different achievements: the relationship of motivation and dedication to academic pursuits with final grades among Jewish and Arab undergraduates studying together. Humanit Soc Sci Commun 11 , 1079 (2024). https://doi.org/10.1057/s41599-024-03548-7

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Design and Effect of Neurosurgical Educational Software Using Gamification on Students' Learning and Motivation

Sedigheh hannani.

1 Department of Operating Room, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran

MAHDIEH SALEHI

Fardin amiri, nemam ali azadi.

2 Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran

Introduction:

Gamification is an innovative learning approach that, when combined with technology, aligns well with students' preferences. Recognizing the necessity of employing effective educational methods in surgical team training, this study aims to examine the impact of gamification-based educational software on students' learning and motivation in the surgical technology field.

This study was conducted as a quasi-experimental single-group pre-and post-test design in Iran in 2023. The study sample comprised 40 undergraduate students majoring in surgical technology, selected through a census method. The educational software is designed according to the nine principles of the model of Karl Kapp and Sharon Buller, using the mechanics, dynamics and aesthetics (MDA) framework. After implementation, the software's impact on students' learning and motivation was assessed. The students' learning levels before and after using the educational software were evaluated using a multiple-choice test. To measure students' motivation, a researcher-developed questionnaire was utilized.  The Shapiro-Wilk test was used to check the normality of the distribution of the studied variables. Through SPSS version 26, descriptive statistics such as frequency, percentage, mean, and standard deviation were analyzed along with inferential statistics, including paired t-tests.

Among the participants, 55% were female, and the sample had a mean age of 22.30±0.99 years. A significant difference was observed between the mean learning scores before and after using the educational software (10.43±4.38 vs. 21±4.11, p < 0.001). The motivation level of the students showed a significant increase.

Conclusion:

Based on the results of this study, gamification-based software has led to improved learning and increased motivation among students in surgical technology.

Introduction

Neurosurgery, specifically brain and nerve surgery, is one of the most challenging and delicate surgical procedures ( 1 ). Medical errors within the surgical team can lead to irreversible complications such as mortality, iatrogenic diseases, and long-term post-neurosurgical complications ( 2 ). Surgical teams involved in neurosurgical procedures require fundamental surgical skills and a profound understanding of neuroanatomy and clinical manifestations of diseases ( 3 ). Despite the rapid advancements in surgical technology, surgical team training has been progressing much slower ( 4 ). One of the most significant challenges in educating surgical technology students is providing effective training that ensures optimal clinical services ( 5 ). In the surgical environment, where conditions change every second, surgical technologists must be trained efficiently to tackle the upcoming challenges effectively ( 6 ). With the emergence and progress of new technologies, the learning needs of digital-era learners have also transformed, rendering traditional teaching methods less effective ( 7 ).

Integrating technology into the educational process proves instrumental in meeting the requirements of the new generation, and one of the most recent technologies involves incorporating gamification techniques into electronic learning environments ( 8 ).

The concept of gamification was first introduced by Nick Pelling in 2002 and has recently gained widespread popularity ( 9 ). Studies indicate that this instructional method has increased tenfold in the past five years ( 10 ). Gartner, the company, defines gamification as using game elements in non-game environments ( 11 ). Implementing gamification in e-learning engages learners, enhances motivation, and improves student learning outcomes ( 12 ). This active and innovative learning approach aligns well with the learning preferences of medical students ( 13 ).

Gamification offers numerous advantages for healthcare service providers, including increased knowledge and job skills, the ability to repeat learning experiences, utilization in adult education, facilitation of the teaching-learning process, feedback provision, enhanced interaction between educators and learners, creating opportunities for participation and engagement, and boosting learners' interest and motivation ( 14 ). Increasing motivation also enhances the overall learning outcomes of learners ( 15 ). Motivation refers to an individual's inclination towards success and engagement in an activity, where success depends on an individual's ability and effort ( 16 ). According to studies, traditional teaching strategies cannot solve learners' lack of motivation ( 17 ). By incorporating various game elements, gamification significantly impacts learners' motivation ( 18 ). While many elements are introduced in effective gamification design, PBL (points, badges, and leaderboards) remains the most popular ( 19 ). One of the foundational theories explaining how gamification works in creating motivation is the self-determination theory presented by Ryan and Deci in 2000 ( 20 ). This theory focuses on three major psychological factors that lead to enthusiasm and motivation for tasks: competence, which refers to an individual's ability and power to adapt to conditions and adjust their effort and skills according to the difficulty level of the challenge; relatedness, which deals with changes in an individual's behavior concerning others and within social contexts; and autonomy, which emphasizes an individual's right to choose and decide without external pressures and constraints ( 21 ).

A review of related literature demonstrates the positive outcomes of gamification in various fields of the medical sciences ( 14 ). For instance, gamification in neurosurgery education improved motivation and performance among surgical residents. Learners in gamified environments exhibited higher speed and fewer errors than the control group ( 22 ). Another study conducted on health, laboratory sciences, and medicine, students showed higher motivation and learning levels in psychology education using gamification methods ( 23 ). Examination of students' feedback and electronic learning management system data indicated that gamification is an appropriate strategy for enhancing motivation among nursing students, although further studies are needed ( 24 ). Also, one study indicates improved learning among surgical technology students using gamification-based educational applications in heart surgery courses ( 25 ). Although adult education gamification studies are increasing, many questions remain unanswered ( 26 ). For instance, there is still uncertainty regarding gamification's effectiveness in various contexts and subject areas, and its effect on motivational outcomes has not remained consistent over time ( 27 , 28 ). Therefore, due to the insufficient evidence and the lack of attention given to the motivational components and player types of surgical technology students, the current study aims to design and investigate the effect of gamification-based neurosurgery software on the learning and motivation of surgical technology students at the Iran University of Medical Sciences (Tehran, Iran).

The present study was a quasi-experimental single-group pre-post-test design. 

Participants

The study was conducted on 40 undergraduate students in the operating room department at the Iran University of Medical Sciences. A gamified educational intervention was conducted in 2023 between May and July. The sampling method used was census sampling.

Inclusion and Exclusion

The inclusion criteria for this study were undergraduate students of the 6th and 8th semesters of surgical technology in the second semester of the academic year 2022-2023 who had successfully passed the theoretical courses on neurosurgery (offered in the 5th semester), expressed willingness to participate in the study, had not previously received training in gamification, were not guest or transfer students, and had access to a personal computer or smartphone. The exclusion criterion for the study was the failure to complete the software stages and questionnaires.

Design and Development of Educational Software

In this study, we applied the nine principles of effective educational game design proposed by Karl Kapp and Sharon Boller ( 29 ) to design and develop educational software for teaching neurosurgery techniques. This web-based software is versatile, compatible with various mobile phones and computers, and can be run on any operating system and screen size.

The stages are as follows:

Stage 1: Introduction and Familiarization with Gamification Fundamentals

In this stage, a deep understanding of the principles and concepts of the gaming and gamification domain was achieved through research, literature review, studying library resources, and conducting research studies.

Stage 2: Playing and Evaluating Educational Games

In this stage, educational games within the field of medical sciences (both domestic and international) were studied and evaluated. Technical and graphic design, game implementation platforms, educational content, etc., were all considered.

Stage 3: Exploration of Educational Games

During this stage, efforts were made to evaluate software and platforms based on gamification in medical sciences, especially focusing on their components and frameworks. The aim was to use the results and experiences from previous studies in the software design.

Stage 4: Defining the Learning Foundation and Initiating the Educational Design Process

Setting Objectives

In this stage, educational objectives were defined, and questions and questionnaires tailored to these objectives were designed and sent to the expert panel for evaluation.

Analysis of Learners' Characteristics

In this stage, demographic profile forms were completed by the participants. Additionally, the Hexad player types questionnaire was used to analyze the players' personalities and the specific components that should be considered alongside general components in game design ( 30 ). The predominant personality traits among the students were Philanthropists, free-spiritedness, and achievement. The components that received more attention alongside the general components included:

• • Philanthropists: Assisting others and sharing knowledge; collecting medals; awareness of game objectives.
• • Free-spirited: exploration, unlocking, the right to choose, being amazed.
• • Achiever: challenges, certifications, learning opportunities, stages.
• • General: game guidance and teaching to learners; feedback; theme; time constraints; rewards; storytelling; replay ability; leaderboard.

Fifth Stage: Linking Learning with Game Design

During this stage, the precise content of the game design document was developed using the Mechanics, Dynamics, and Aesthetics (MDA) framework. This is framework, introduced by Hunicke and colleagues in 2004, is one of the most fundamental and widely accepted frameworks for game design. Mechanics refers to the game's rules and principles (such as challenges, chances, and feedback). Dynamics encompasses the events during gameplay, including narrative, emotions, and progression paths. Aesthetics involve the emotions and feelings a player can experience while playing the game. These elements are essential for understanding systemic thinking and the mutual effects of game elements in non-game contexts ( 31 ).

Type of Game: electronic and web-based that can be run on computers and smartphones.

Goal: The goal of the game is to become a professional surgeon's assistant in the field of neurosurgery by getting the highest score and successfully passing all the stages.

Dynamic: The main dynamic is solving the problem and answering the questions.

Game Mechanics or Rules

Game environment: In this game, by creating a user account, learners must be able to complete each stage of the game, which is set based on the syllabus topics. The game consists of 9 stages; at the beginning, only the first stage will open, to begin with, and to open each stage, players need to successfully complete the previous stages by at least capturing one light. On the left side, the game narrator guides the learners to make decisions in the game environment.

Perform the steps: To pass each stage, at least one light equal to 30% of the points of that stage must be obtained. Otherwise, learners have to play the stage again from the beginning. The game was designed so that if the players needed to leave the game in the middle of each stage, they could answer the questions after returning to the game. Learners received feedback immediately after answering each question, and the correct answer was displayed.

Type of questions: To answer each question, the question was displayed first, and after clicking on "show options", the options containing correct and incorrect answers were displayed. After selecting the desired option or options, if the learner wants to correct his answer, he will click "again". If the answer is approved by clicking on "confirm," the answer will be validated, and the score will be calculated. There was a time limit to answer the questions.

Game Elements Used

• • Point
• • Story
• • Time limitation
• • levels
• • leaderboard
• • Badge
• • Feedback
• • Replay
• • Competition
• • Avatar

Educational content: The educational content related to neurosurgery techniques for the brain, spinal cord, and peripheral nerves was developed by the sources outlined in the undergraduate surgical technology curriculum ( 3 , 6 , 32 , 33 ). The stages of the curriculum encompass basic and advanced concepts, including anatomy, pathology, diagnostic procedures, surgical readiness, instruments and equipment, peripheral nerve surgery, brain surgery, and spinal surgery. The content of the course materials, instructional videos, and specialized terminology were also compiled at this stage. The faculty of the operating room department approved the validity of the educational content.

Sixth Stage: Considering Points and Rewards

In this software, various elements were utilized as rewards, including badges (earned by obtaining 95% of the points in each stage), a three-star system (based on the percentage of correct answers to questions), a score table (for comparing scores), cash prizes (awarded to the top 4 scorers), and certificates (for all individuals who successfully completed the game stages).

Seventh Stage: Prototype Development

In this stage, the game design document and the research team's ideas were shared with the programming team. Together, they collaborated to create the initial version of the software, aligning the game concept with the development process.

Eighth Stage: Playtesting and Iteration

Playtesting refers to the actions taken to improve the game until it reaches the desired state. After creating the initial prototype, the design team thoroughly reviewed the software. The entire process, from start to finish, was meticulously examined, and any necessary modifications were made by both the programmers and the design team. Furthermore, the software was made available to five target users to uncover and rectify any errors or issues in the design that might have gone unnoticed by the designers and programmers.

Ninth Stage: Game Development and Implementation, Iteration, and Deployment

In this stage, one of the researchers visited the research environment and conducted an orientation session on how to use the software and address potential questions from students. Subsequently, an information group was formed on a virtual network (Telegram), accessible to all students, to facilitate necessary communications. It's worth noting that an instructional video on how to use the software and supplementary information were provided within the group for students to refer to if needed. Students were then requested to message the researcher if they were interested in participating, and they would receive the link immediately. Students were given a two-month timeframe to complete the software. During the intervention, the researcher acted as a facilitator, providing necessary guidance and addressing any issues that arose while using the software. Since this software was entirely electronic and the instruction was provided virtually, students were self-directed in progressing through the stages, affording them the utmost flexibility in terms of time and location. After receiving the link and registering on the website, the students first participated in a pre-test to assess their initial knowledge. A week after completing the stages, they were given a post-test for evaluation. The samples were given the researcher's motivation questionnaire once they had finished using the software.

Data Collection Tools

Player Type: The hexad scale was used to assess the player type, introduced by Marczewski and colleagues in 2016 ( 30 ). This questionnaire consists of 24 items and employs a 5-point Likert scale (ranging from "strongly agree" with a score of 5 to "strongly disagree" with a score of 1). The hexad scale categorizes players in gamified environments into six personality types: philanthropists, socializers, free spirits, achievers, players, and disruptors. Each player type is assigned four specific questions, and the category with the highest score indicates the dominant player's personality. 

Assessment of Learning:  The researcher-designed test comprised 30 multiple-choice questions based on the reference sources of the undergraduate surgical technology curriculum. The questions covered topics related to the stages of surgery, including anatomy, clinical manifestations, diagnostic procedures, surgical preparedness, tools and equipment, peripheral nerve surgery, brain surgery, and spinal surgery. Each correct answer received one point, while incorrect or unanswered questions were scored zero. The maximum attainable score was 30, and the minimum was 0. Pre-test questions were completed before the educational intervention, and post-test questions were completed one week after the intervention.

Assessment of Motivation: A researcher-designed motivation questionnaire consisting of 10 items was provided to the students. The motivation questionnaire used a 5-point Likert scale (ranging from 1 for "completely disagree" to 5 for "completely agree"). Scores between 10 and 30 indicated low motivation, 31 to 40 indicated moderate motivation, and 41 to 50 indicated high motivation. The researcher's motivation questionnaire was provided to the samples after they completed the software's steps to measure the software's impact on students' motivation.

Validity and Reliability

Player-type questionnaire: The reliability and validity of this questionnaire in Iran were confirmed by Abdollahzade and Jafari ( 34 ), who obtained a Cronbach's alpha coefficient of 0.72. This study assessed internal consistency and reliability using Cronbach's alpha coefficient. The reliability coefficients were determined to be 0.856 for this questionnaire.

Learning question:   To ensure content validity, the content coverage and relevance of the question to the primary objectives were drafted according to the initial blueprint and Content Validity Ratio (CVR) and Content Validity Index (CVI) indices approved by 10 experts in the fields of surgical technology, medical education, and e-learning. We asked an expert to rate each of the items as ‘‘essential’’, ‘‘useful but not essential’’, or ‘‘not essential’’. A weighted value was assigned to each rating. Responses from all panelists were pooled, and the number indicating ‘‘essential’’ for each item was determined. The value of the content validity ratio for 10 experts in the Lawshe table is considered to be at least 0.62. Items that did not reach this threshold were deleted from the final questionnaire. This ratio was in the range of 0.8 to 1 for the final questionnaire items for the CVR.  For the Content Validity Index (CVI), the three criteria of relevance, simplicity, and clarity were examined separately by experts in a four-part spectrum for each of the items (1: unrelated, 2: somewhat relevant, 3: relevant, and 4: completely relevant). The CVI score was calculated by summing the positive scores for each item ranked 3rd and 4th over the total number of experts. Acceptance of items based on CVI was higher than 0.79 ( 35 , 36 ). Construct validity was confirmed by verifying the formulation of questions and options for each question based on the Millman checklist. A Cronbach's alpha coefficient of 0.870 was obtained for this questionnaire.

Motivation Questionnaire: The content validity (CVR and CVI indices) of this questionnaire was confirmed by 10 experts in surgical technology, medical education, and e-learning. The value of the content validity ratio was in the range of 0.8 to 1 for the questionnaire items. The content validity index of all questionnaire items was above 0.79. Cronbach's alpha coefficient was determined to be 0.948 for the motivation questionnaire.

Statistical Analysis: The results of the Shapiro-Wilk test indicated that the distribution of the study variables is normal ( Table 1 ). Parametric tests were employed for data analysis. Data were analyzed using descriptive statistics such as frequency, percentage, mean, and standard deviation, as well as inferential statistics, including paired t-tests, in SPSS version 26. A significance level of less than 0.05 was considered. 

Shapiro-Wilk test to determine the normality of Variables

Based on the data collected from 40 research participants, 55% (22 individuals) were female, and 45% (18 individuals) were male. The average age of the sample was 22.30±0.99. As observed in Table 2 , the level of gaming personality traits among surgical technology students has been significantly high in the areas of altruism, freedom, and achievement.

Types of Player Personality Among Surgical Technology Students

As observed in Table 3 , there was a statistically significant difference in the mean scores obtained from the questions related to learning among surgical technology students before and after training (p < 0.001), with the mean scores approximately doubling.

Comparison of the Mean Scores Obtained from Questions Related to Learning Among Surgical Technology Students Before and After Training

As indicated in Table 4 , after the educational intervention, the level of motivation among surgical technology students was predominantly high (19 individuals, equivalent to 47%) and moderate (15 individuals, equivalent to 37.5%).

Motivation Level of Surgical Technology Students

The mean and percentage of students' responses to the motivation questionnaire are shown in Table 5 .

Mean and Percentage of Students' Responses to the Motivation Questionnaire

The results of this study demonstrate that game-based educational software has impacted the learning outcomes of surgical technology students, leading to increased learning. These findings align with the research conducted by Salehinia and colleagues (2023), where they designed, implemented, and evaluated a game-based educational application for cardiac surgery on surgical technology students. The results of this study have shown that with the advancement of technology, the use of innovative methods such as gamification in education leads to improved learning outcomes and enhances the effectiveness of education for surgical technology students ( 25 ). Furthermore, the results of this study align with the research conducted by Mosalanejad and colleagues (2018), which aimed to investigate the effectiveness of game-based education on the learning indices of nursing students. The findings of their study demonstrated that gamification, by creating an interactive and engaging environment, significantly impacts students' learning outcomes ( 37 ). Additionally, our study findings align with the research conducted by McAuliffe and colleagues (2020). Their study aimed to assess the feasibility and effectiveness of game-based education for general surgery residents, revealing that using this instructional method led to enhanced learning outcomes (increasing the average scores from 28 to 43) ( 38 ).

Furthermore, the study by Eslami and colleagues (2020), which aimed to design a game-based educational application for basic drug information targeted at pharmacy students, demonstrated that this application served as a useful tool for learning drug-related information. This instructional method can be employed across various academic disciplines ( 39 ). The traditional roles of teachers and students in teaching and learning have changed nowadays, emphasizing the active participation of learners. When students actively engage in their learning process and construct meaning proactively, a better and deeper learning experience is achieved ( 40 ). Therefore, gamification is among the most active and student-centered educational approaches. It enhances the quality of learning by creating a dynamic environment with visual appeal.

The results of this study also indicate that most surgical technology students (85%) had a high motivation for learning through gamification. Numerous studies have demonstrated that incorporating game elements enhances student motivation. The findings of Mosalanejad and colleagues ( 37 ), who conducted a study to evaluate gamification in the field of psychiatry on a group of medical and paramedical students, showed that when educational content is combined with appropriate game elements, it significantly boosts learners' motivation (mean>2.5) ( 21 ). Furthermore, Permanasari and colleagues (2021) conducted a study in Indonesia to teach anatomy to medical science students through gamification. They concluded that educational media based on gamification, incorporating elements such as rankings and scores, significantly enhances students' motivation ( 41 ). The study conducted by Felszeghy and colleagues (2019) aimed to examine the impact of the gamified online platform (Kahoot) on medical and dental students in the histology course. The study demonstrated that gamification increased motivation for learning in 77.5% of the participants ( 42 ). Based on the findings of our study and in line with our self-determination theory, we found that learners, by answering questions and facing challenges presented in the educational software and progressing through stages to acquire the necessary knowledge, felt a sense of competence and capability in the scientific (77.5%) and practical (70%) aspects. They expressed that the software effectively increased their participation in the operating room environment (65%). Regarding learner interaction, due to the elements present in gamification, such as immediate feedback (77%) and a leaderboard (77.5%), participants made efforts to improve their performance and rectify errors. Furthermore, learners expressed that they put in their utmost effort to succeed in the learning process within the software (70%). Regarding autonomy, given the flexibility of time and place in the software and its student-centered nature, learners could guide their learning process without external pressure or constraints (72.5%). Despite the positive effects of gamification in health profession education, some studies have also pointed out unintended consequences ( 10 ). For example, some studies have mentioned that certain components, like competition and scoring tables, might decrease motivation for some students ( 43 , 44 ). The results obtained in these studies could be because students with weaker performance may feel discouraged and demotivated when they see their low rank and score compared to others. Another reason for decreased motivation could be the lack of attention to motivational components tailored to learners' preferences and personality traits. The findings of the present study indicated that elements such as points (77.5%), immediate feedback (77%), leaderboards (77.5%), stages (77.5%), and challenges (57.5%) were effective in increasing student motivation. Therefore, considering that most studies demonstrate the positive impact of gamification on learners' motivation levels, it can be concluded that when educational content is combined with appropriate game elements, and learners have control over their learning process, they will exhibit high motivation.

 According to the results of the present study, the students' predominant personality traits were Philanthropists, free-spiritedness, and achievement. We tried to use game components suitable for the type of player in the gamification design. In various studies, students' game personalities have been investigated. For example, in a study by Kocadere and Çağlar (2018), player types were determined as killer, achiever, explorer, and socializer ( 45 ). In the study by Krath and von Korflesch (2021), athletes and philanthropists were the most dominant ( 46 ). Certainly, according to demographic characteristics (such as age, gender, field of study, etc.) and educational content, students have individual player types. It is important to pay attention to the personality characteristics of students in gamification design to create motivation and better learning.

Strengths and Limitations

In this study, we endeavored to design game-based educational software in an effective and student-centered manner, considering the personality traits of widespread gamers and the nine gamification principles. The web-based educational software we developed was compatible with various operating systems. We also extracted several motivational components and their impact percentages on students. It was a prerequisite for the participants to have completed a comprehensive theoretical unit on brain and nerve surgery before engaging with the software. The research sample was limited to 6th and 8th-semester surgical technology students at Iran University of Medical Sciences. Also, one of the limitations of our study was that it was carried out in a single group.  

Recommendations for Future Studies

Future studies can be conducted with a larger sample size and the inclusion of a control group. Additionally, it is possible to utilize game-based software in blended learning and face-to-face instruction.

The results of this study demonstrated that game-based software significantly influenced the enhancement of learning and increased motivation among surgical technology students. In today's world, technology has impacted all fields, and education is no exception. Technology creates new opportunities for educating digital-native students. Gamification is an innovative and active educational approach that optimizes and makes learning engaging, offering substantial potential for fostering self-directed learning in learners. Integrating technology and gamification elements in e-learning environments enhances the enjoyment of learning and improves learners' motivation, potentially positively affecting personal and professional development. Educational specialists and designers can apply the findings of this research in all medical-related fields, especially surgical technology. Further studies in this area are warranted to explore its full potential.

Ethical Considerations and Acknowledgments

This research was conducted under the ethical code IR.IUMS.RES.1402.102, approved by the Operating Room Department of the Iran University of Medical Sciences, as part of a Master's thesis. The financial support provided by the Research Deputy of this university is gratefully acknowledged. The researchers now express their sincere gratitude to the students who participated in this study.

Authors’ Contribution

Conceptualization and supervision: S.H. and M.S. Data collection: M.S.; statistical analysis: N.A.A.; investigation: M.S.; methodology: F.A. and M.S.; resources: M.S.; software: M.S. and S.H. The final manuscript has been read and approved by all authors, who agree to be accountable for all aspects of the work.

Conflict of Interest

The authors reported no potential conflicts of interest.

• Open access
• Published: 22 August 2024

Factors influencing fidelity to guideline implementation strategies for improving pain care at cancer centres: a qualitative sub-study of the Stop Cancer PAIN Trial

• Tim Luckett 1 ,
• Jane Phillips 2 ,
• Meera Agar 1 , 3 ,
• Linda Richards 4 ,
• Najwa Reynolds 5 ,
• Maja Garcia 1 ,
• Patricia Davidson 6 ,
• Tim Shaw 7 ,
• David Currow 6 ,
• Frances Boyle 8 , 9 ,
• Lawrence Lam 10 ,
• Nikki McCaffrey 11 &
• Melanie Lovell 5 , 9  

BMC Health Services Research volume  24 , Article number:  969 ( 2024 ) Cite this article

27 Accesses

Metrics details

The Stop Cancer PAIN Trial was a phase III pragmatic stepped wedge cluster randomised controlled trial which compared effectiveness of screening and guidelines with or without implementation strategies for improving pain in adults with cancer attending six Australian outpatient comprehensive cancer centres ( n  = 688). A system for pain screening was introduced before observation of a ‘control’ phase. Implementation strategies introduced in the ‘intervention’ phase included: (1) audit of adherence to guideline recommendations, with feedback to clinical teams; (2) health professional education via an email-administered ‘spaced education’ module; and (3) a patient education booklet and self-management resource. Selection of strategies was informed by the Capability, Opportunity and Motivation Behaviour (COM-B) Model (Michie et al., 2011) and evidence for each strategy’s stand-alone effectiveness. A consultant physician at each centre supported the intervention as a ‘clinical champion’. However, fidelity to the intervention was limited, and the Trial did not demonstrate effectiveness. This paper reports a sub-study of the Trial which aimed to identify factors inhibiting or enabling fidelity to inform future guideline implementation initiatives.

The qualitative sub-study enabled in-depth exploration of factors from the perspectives of personnel at each centre. Clinical champions, clinicians and clinic receptionists were invited to participate in semi-structured interviews. Analysis used a framework method and a largely deductive approach based on the COM-B Model.

Twenty-four people participated, including 15 physicians, 8 nurses and 1 clinic receptionist. Coding against the COM-B Model identified ‘capability’ to be the most influential component, with ‘opportunity’ and ‘motivation’ playing largely subsidiary roles. Findings suggest that fidelity could have been improved by: considering the readiness for change of each clinical setting; better articulating the intervention’s value proposition; defining clinician roles and responsibilities, addressing perceptions that pain care falls beyond oncology clinicians’ scopes of practice; integrating the intervention within existing systems and processes; promoting patient-clinician partnerships; investing in clinical champions among senior nursing and junior medical personnel, supported by medical leaders; and planning for slow incremental change rather than rapid uptake.

Conclusions

Future guideline implementation interventions may require a ‘meta-implementation’ approach based on complex systems theory to successfully integrate multiple strategies.

Trial registration

Registry: Australian New Zealand Clinical Trials Registry; number: ACTRN 12615000064505; data: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspxid=367236&isReview=true .

Peer Review reports

Pain is a common and burdensome symptom in people with cancer [ 1 ]. Barriers to pain care occur at all ‘levels’, including the patient and family (e.g., misconceptions regarding opioids), clinician (e.g. lack of expertise), service (e.g. inadequate referral processes) and healthcare system (e.g. lack of coordination) [ 2 , 3 , 4 , 5 , 6 , 7 , 8 ]. A recent systematic review suggests that around 40% of cancer patients with pain may not receive adequate management [ 9 ]. Research has demonstrated that routine screening and implementation of evidence-based guidelines has potential to improve quality of cancer pain care and outcomes [ 10 , 11 , 12 , 13 , 14 ]. However, experience suggests that clinicians are unlikely to utilise screening results or follow guidelines unless these are supported by targeted strategies [ 15 , 16 ].

The Stop Cancer PAIN Trial (ACTRN 12615000064505) was a phase III pragmatic stepped wedge cluster randomised controlled trial conducted between 2014 and 2019 which compared the effectiveness of screening and guidelines with or without implementation strategies for improving pain in adults with cancer attending six outpatient comprehensive cancer centres in Australia ( n  = 688) [ 17 , 18 ]. A pen/paper system to screen for pain using 0–10 numerical rating scales (NRS) for worst and average intensity over the past 24 h was introduced to each centre prior to observation of a ‘control’ phase, in which clinicians were also made aware of the Australian Cancer Pain Management in Adults guidelines [ 19 ]. At the beginning of the training phase, trial investigators presented at staff meetings on the importance of better managing pain and the rationale and evidence base for the intervention components. Implementation strategies (collectively termed the ‘intervention’) were then introduced in a ‘training’ phase and maintained during an ‘intervention’ phase as follows: (1) audit of adherence to key guideline recommendations [ 19 ] and feedback delivered to clinical teams in one or two cycles; (2) health professional education via a ‘Qstream’ email-administered ‘spaced education’ module [ 20 ]; and (3) a patient education booklet and self-management resource for completion together with a clinician that included goal setting, a pain diary and pain management plan [ 21 , 22 ]. Selection of these strategies was informed by the Capability, Opportunity and Motivation Behaviour (COM-B) Model of behaviour change [ 23 ], and evidence that each strategy had been separately effective for supporting guideline implementation for other health conditions. The intervention was supported at each centre by a consultant physician who agreed to be a ‘clinical champion’ [ 24 ].

As reported previously [ 18 ], the Stop Cancer PAIN Trial found no significant differences between the intervention and the control phases on the trial’s primary outcome - the proportion of patients with moderate-severe worst pain intensity who reported a 30% decrease at 1-week follow-up. Fidelity to the intervention was lower than anticipated and variable between centres: only 2/6 centres had two audit cycles rather than one; completion rates for the health professional spaced education varied from 12% to 74% between centres; and the proportion of patients reporting receipt of written information of any kind rose to an average of only 30% (20-44%) versus 22% (2-30%) in the control phase. Unexpectedly, secondary measures of mean, worst and average pain over a 4-week follow-up period improved by 0.5 standard deviation during control as well as intervention phases. However, the lack of a comparison group with no screening system made it difficult to conclude whether improvement in the control phase was due to effects from screening, a Hawthorne effect, or some other explanation.

The current paper reports a sub-study of the Stop Cancer PAIN Trial which aimed to identify factors influencing fidelity to the intervention that might warrant consideration by similar initiatives in the future.

The intervention, methods and results of the Stop Cancer PAIN trial have been described in previous open-access articles [ 17 , 18 ]. The sub-study used a qualitative approach with pragmatic orientation to enable in-depth exploration of factors influencing success from the perspectives of clinicians at each participating centre [ 25 ]. Clinician views canvassed at interview were considered the most efficient means of identifying barriers and enablers among complex contextual factors at each centre, including personnel’s knowledge, attitudes and beliefs towards pain care and the intervention.

The sub-study was approved by the Southwestern Sydney Local Health District Human Research Ethics Committee (HREC/14/LPOOL/479) as part of the overall trial. All participants gave written informed consent to participate.

Reporting adheres to the consolidated criteria for reporting qualitative research (COREQ) [ 26 ].

Participants

Participants were eligible if they were employed on a permanent basis either full- or part-time at a participating centre in a role that provided clinical care to cancer patients or patient-focused administrative support. The clinical champion at each centre was invited to participate by the research team. Other personnel were invited by means of email circulars and verbal invitations during meetings. Given the diverse range of roles at each centre, no limit was set on sample size to canvass as many perspectives as possible.

Data collection

Data were collected by means of semi-structured interviews conducted by one of two researchers, a female pharmacist with experience of medical education for pain management (LR), and a male social scientist with a doctorate (TL). Both interviewers had prior experience in qualitative research and knew some participants through their project roles.

Participants were fully aware of the study purpose before consenting. Interviews were conducted face-to-face or by telephone, with the participant and interviewer being the only people present. Interviews began with open questions about ‘what worked’ and ‘didn’t work’ across the intervention before focusing on each implementation strategy in more detail and important contextual factors at their centre (see Table  1 for a topic guide, which was developed specifically for this study). Interviewers explicitly invited criticism, expressing a tone of open enquiry and neutrality throughout. Prompts were used as necessary to explore factors identified by participants in more detail. Factors identified at previous interviews were raised at subsequent ones for verification, inviting participants to disagree or agree as they felt appropriate. No requests were received to return transcripts to participants for comment. Interviews were audio-recorded and transcribed verbatim.

Analysis used the framework method [ 27 ] and a largely deductive approach based on the same theoretical framework used during intervention design - the COM-B Model [ 23 ]. Based on a systematic review, the COM-B Model posits that behaviour change requires three conditions, namely ‘capability’ (including both psychological and physical capacity), ‘opportunity’ (all the factors that lie outside the individual that make the behaviour possible or prompt it) and ‘motivation’ (including habitual processes, emotional responding, as well as analytical decision-making). Initial line-by-line coding categorized data against these conditions according to which best described relationships between factors and behaviours within and across implementation strategies and the levels of patient, clinician and centre. While the COM-B model originally focused directly on human behaviour, it became clear during coding that behaviour was substantially influenced by centre, specialty and disciplinary factors, so these were also considered appropriate foci for coding against COM conditions. To enhance credibility, the same data were coded in different ways where multiple interpretations seemed plausible until coding of further interviews identified consistencies to help with disambiguation. Charting of codes for data within and between centres enabled mapping between the relative contributions made by each condition, summarised as lessons learned for guiding similar initiatives in the future. Dependability was increased by ensuring coding was conducted by two members of the research team (NR, MG) who had no previous involvement in the project but were experienced in qualitative research. Review and discussion with two team members who were involved in the project throughout (TL and ML) was intended to balance ‘outsider’ and ‘insider’ perspectives to guard against bias from preconceived interpretations whilst also referencing contextual understanding. Both Excel 2019 (Microsoft) and NVivo V12 (QSR) software were used to help manage different stages of the analytic process.

Twenty-four people participated across the six centres, ranging from one to six participants. Fifteen were physicians (of whom six were clinical champions), eight were nurses, and one was a clinic receptionist. This response rate ranged from 2 to 27% of eligible personnel at each centre. See Table  2 for a more detailed summary of participant roles at each centre. Interviews were a median of 20 min long, with an inter-quartile range of 13 to 28 min.

Capability, opportunity and motivation

Coding against the COM-B Model identified ‘capability’ to be the component having most influence over intervention success, with ‘opportunity’ and ‘motivation’ playing largely subsidiary roles.

Capabilities: Pertinent capabilities were reported to include: a pre-existing, centre-level culture of continuous improvement, communication pathways between senior management and other personnel, established roles and responsibilities for pain care among disciplines and specialties, systems and processes that could readily accommodate the intervention, and a culture of involving patients as partners in care. These capabilities influenced the degree to which personnel and patients had the opportunity and motivation to fully engage with the intervention.

Opportunity and motivation: These elements were most frequently discussed by participants in terms of ‘time’ that personnel could commit to pain care relative to other responsibilities. Clinical champions were perceived to play a critical role in supporting intervention success but were under-resourced at every centre and challenged by turnover in the role at two. In addition to more systemic drivers, individual personnel’s motivation was influenced by the degree to which they accepted the intervention’s value proposition at the outset and perceived this to be demonstrated over time.

Interactions between capability, opportunity and motivation are explored below in terms of their implications for similar future initiatives. Findings suggest that fidelity could have been improved by: considering the readiness for change of each clinical setting; better articulating the intervention’s value proposition; defining clinician roles and responsibilities, addressing perceptions that pain care falls beyond oncology clinicians’ scopes of practice; integrating the intervention within existing systems and processes; promoting patient-clinician partnerships; investing in clinical champions among senior nursing and junior medical personnel, supported by medical leaders; and planning for slow incremental change rather than rapid uptake.

Consider centres’ readiness for change

The degree to which centres had a pre-existing culture of continuous improvement was considered important in providing a fertile context for the intervention. At Centre 5, there was a consensus that change of any kind was difficult to instigate, even according to the head of department: “… because it’s new - because we’re so entrenched in our ways ” (C5P04 [Centre 5, participant 04] medical oncologist, head of department and clinical champion). At another, the complex centre-level nature of the intervention was perceived to pose particular challenges compared to oncology drug trials with which they were more familiar: “ we haven’t been a principal site [in a trial of this kind] previously and I think that’s sort of opened up some gaps in knowledge for us and some opportunities for learning in the future … what kind of support we’d need to come with that trial to help it be a success in this culture ” (C3P02 palliative care physician and clinical champion).

Articulate and deliver on the intervention’s value proposition

Interviews highlighted the importance of articulating the intervention’s value proposition to every member of the workforce and maintaining engagement by demonstrating benefits over time. At Centre 5, some participants perceived that the intervention had been imposed by management rather than generated from clinical priorities: “…senior staff say [to researchers] ‘come to our clinics, but we expect everyone else to do the work’ ” (C5P05 radiation oncologist). This was compounded by a perceived lack of communication about the project, which limited personnels’ opportunity to take a more active role even when they were motivated to do so: “ I would have facilitated [the intervention] … but I didn’t know about it ” (C5P01 nurse practitioner). Eliciting and maintaining engagement was said to be additionally challenged at this centre by high staff turnover, especially among junior medical officers on rotation: “ it was very accepted by the junior medical staff [but] I think, unfortunately, when there’s a relatively high turnover of staff … ” (C5P07 radiation oncology trainee). At two other centres, turnover among personnel required a transition in the role of clinical champion, interrupting support for the intervention while the new incumbents familiarised themselves with the role.

Across centres, participants reported reservations among some of their colleagues regarding the project’s fundamental premises, including the assumption that pain care needed improving at their centre (“ they actually felt this trial was a little bit insulting for their clinical skills. There was a bit of eye rolling and ‘of course we do that already!’ ” (C3P02 palliative care physician and clinical champion)) or that pain warranted a specific focus rather than symptoms more generally: “ I find it more useful when more than one symptom is targeted ” (C5P06 palliative care physician).

More specific criticism was also levelled at each of the intervention strategies as follows.

Pain screening

In the case of screening, two participants questioned the validity of a 0–10 numerical rating scale (NRS) for different reasons: “ sometimes getting the numbers breaks the flow of the narrative” (C6P04 medical oncologist); “they [patients] would say, ‘no, I’m not in pain but I have a lot of discomfort when I swallow’ - it was in the wording ” C5P02 registered nurse). Even one of the clinical champions felt that screening was redundant where pain was very severe: “ if someone is clearly in a pain crisis, you don’t need to be asking … you kind of know what number - they might tell you it’s 15 [out of 10] ” (C6P02 palliative care physician and clinical champion). Perceptions of the value of screening were also influenced by the degree to which it led to demonstrable improvements in pain care, which was undermined by problems with establishing an efficient process at some centres: “ I think I’ve still probably got stray [pain screening] forms on my desk ” (C3P06 palliative care physician). A lack of understanding among personnel and patients about how screening might lead to better pain outcomes was said to result in “ fatigue ” (C5P03 clinical nurse consultant [clinical nurse consultant]; C1P01 palliative care physician and clinical champion), manifest as a downward spiral of effort in, and value from, screening.

Audit and feedback

The audit and feedback strategy attracted limited attention from personnel at most centres: “ I don’t think that the audit and feedback were terribly noticeable ” (C4P01 medical oncologist and clinical champion). At the centre where only the palliative care department participated, one participant perceived baseline audit results to be acceptable and therefore demotivating for change: “[ the audit results showed] we were doing a good job even ahead of time … it did sort of make you think – ‘well where do we go from here?’ ” (C6P04 pain medicine physician). At another centre, motivation among personnel to improve on less favourable audit findings was perceived to depend on whether they prioritised pain care to start with: “ people have come up to me and said, ‘Gee, we really did very badly didn’t we?’ … but they’re not necessarily the people who don’t treat pain well - that’s the problem ” (C1P01 palliative care physician and clinical champion).

Spaced education for health professionals

Participants’ opinion on the value of the online spaced education depended on discipline and seniority, with nurses and junior medical officers reporting benefits “( it gave me a bit more confidence that I was on the right track” (C5P01 nurse practitioner)) but consultant physicians perceiving the knowledge level too “basic” (C6P04 pain medicine physician) or questioning advice from online spaced education that their responses were ‘wrong’: “…some of the multiple answers could have been equally valid” (C504 medical oncologist and clinical champion). Where consultants remained engaged, motivation was said to rely on cultivating “ competition” between colleagues (C602 palliative care physician and clinical champion). Inevitably, the voluntary nature of online spaced education also meant that only motivated personnel engaged to begin with.

Patient self-management resource

All participants who had used the patient self-management resource perceived at least some value. However, its use was limited by barriers relating to role and process considered below.

Define roles and responsibilities

Among the most commonly voiced barriers was a lack of clarity about which specialties and disciplines should be responsible for pain screening, patient education and management. This was usually described in terms of a ‘lack of time’ for pain care relative to other duties afforded greater priority within their scope of practice. Perspectives on roles and responsibilities are considered separately for each aspect of pain care as follows.

While most centres allocated the clinical task of pain screening to clinic receptionists, there was widespread reflection that this had been suboptimal. The only participating clinic receptionist felt that pain screening fell outside her area of responsibility: “but I’m an administrative person - I don’t have anything to do with pain management ” (C2P03 clinic receptionist). Clinician participants across disciplines similarly perceived that pain screening required clinical expertise to assist patients with reporting their pain and triage for urgent follow-up: “ you need somebody talking to the patients, rather than just handing the form, say ‘fill this in’ ” (C2P04 clinical nurse consultant). One centre that recognised this early on reallocated screening from an administrative to a nursing role, leading to substantial improvements in the completeness and quality of data: “ it made a big difference and certainly improved our ability to recognise people who had pain and allowed access for those people who were in severe pain to medications or at least an assessment … implementation through the clerical staff was not a long-term strategy ” (C1P01 palliative care physician and clinical champion).

Patient education

There was little consensus on which disciplines should be responsible for supporting patients to use the self-management resource, with medical personnel deferring to nurses and vice-versa. Role allocation was challenged by the diverse components within the resource, with each perceived to fall within a different scope of practice: “ pain is something I always do as an assessment … [but] … I’m not managing the pain … I’ll review and make recommendations and talk about the pain diaries and discussing their diary with their palliative care doctor or their general practitioner. And I would encourage that process. [But] I wouldn’t be the one that’s setting the goals on their daily activities and stuff ” (C5P01 nurse practitioner). Some oncology nursing roles were perceived to focus on chemo- or radiotherapy protocols to the exclusion of supportive care unless symptoms arose from, or impeded, treatment. Meanwhile, oncologists tended to interpret their role as solely focused on prescribing rather than also encompassing patient education: “ junior doctors only [have] 15 minutes to take a history and everything. [They] could enter in meds [into the patient resource] if everything else is done by someone else … part of me knows it’s [patient resource] important, but the other part of me - I just - when will I have time in my clinical practice to do it? ” (C5P05 radiation oncologist).

Pain management

Some oncologists viewed even pharmacological pain management as peripheral to their scope of practice when consultation time was short, prioritising cancer treatment instead. These participants viewed their role as limited to referring to palliative medicine or pain specialists, especially where pain was believed to have causes other than cancer: “ if the pain is a complex pain where the patient doesn’t have evidence of cancer, and it may be treatment-related, then in those scenarios we tend to divert to the chronic pain team ” (C5P07 radiation oncology advanced trainee). While participants from palliative care and pain medicine welcomed referrals for complex cases, they felt that oncologists sometimes referred for pain they could have easily managed themselves: “ what about some regular paracetamol? … These are things that you’d expect any junior doctors, never mind consultants [to have provided advice on] ” (C5P06 palliative care physician).

Integrate within existing systems and processes

Participants from several centres expressed a view that the intervention’s complex nature had proven overwhelming for systems and processes at their centres. At two centres, integration was especially challenged by broader infrastructure shifts and process failures that limited receptiveness to further changes. Participants at several centres emphasised the process-driven nature of oncology services and the challenge of changing established processes: “ they have got a pro forma that they use for chemo-immunotherapy review, and pain is not part of it, and that perhaps needs more of an organisational nuance … why doesn’t pain feature as a clinical outcome as part of the chemotherapy, immunotherapy review?” (C6P01 clinical nurse consultant). Participants emphasised the need to integrate pain care into existing processes to help personnel understand what was expected of them: “…nursing staff were getting them [screening forms] in the patient’s files and going, ‘what am I supposed to do with this?’ ” (C2P04 clinical nurse consultant). Moreover, centres’ focus on cancer treatment meant that pain care struggled to gain traction even when a process could be instituted: “ unless pain is the presenting complaint and is at the forefront it goes into those, sorts of, you know, the ‘other details’ ” (C5P06 palliative care physician). For the palliative care centre, where pain care was already prioritised, there were doubts about how the proposed process improved on those already in place: “ I generally ask pretty detailed questions about pain anyway [so don’t need patients to be screened in the waiting room] ” (C6P04 pain medicine physician).

Suggestions for better integrating the intervention included “in-building” (C3P04 medical oncologist) responsibility for the strategies within new staff roles or introducing the strategies gradually by means of a “ multistep process” (C5P04 medical oncologist, head of department and clinical champion). Features of two strategies were singled out as having positive potential for supporting existing processes of care. The patient resource was said to “ facilitate communication between the oncology teams and the palliative care team ” (C5P05 radiation oncologist) and serve as a “ visual cue ” (C3P02 medical oncologist) to cover educational topics that “ they might have otherwise forgotten ” (C2P01 palliative care physician and clinical champion). Participants also found the spaced education email administration, spacing and repetition “ easy to manage ” (C2P01 palliative care physician and clinical champion) within their daily routines.

Promote patient-clinician partnership on pain care

Several participants expressed surprise at the prevalence of moderate-severe pain in screening results, and acknowledged that this revealed under-reporting of pain in usual care. Under-reporting was perceived to stem partly from patient expectations that pain from cancer was “ normal ” (C4P03 nurse practitioner) and to be especially common in the context of certain generational or cultural attitudes towards pain and opioids (“ I certainly think there’s a cultural element but there’s also your elderly patients who you know have been through the war and they’re just used to coping with things and you just suck it up … it’s like a badge of honour to be able to say ‘I’m not one of these pill-takers ’” (C3P03 registered nurse [RN])) or when patients were concerned that reporting pain might reduce their fitness for anti-cancer treatment: “[ patients might think that] if I tell them honestly how crappy I am with other symptoms and pain and everything, then they might stop my chemo” (C3P02 palliative care physician). Several participants perceived that under-reporting was also due to patients taking an overly passive role in consultations: “[clinicians assume that] if the patient doesn’t bring it up, it’s not a problem for them and … then the patient [is] thinking ‘the doctor will only talk about important things that are important for me and I won’t mention it because obviously it’s not important’ ” (C3P02 palliative care physician and clinical champion).

The screening component of the intervention was considered to address under-reporting by “ normal[ising] ” pain care, thus encouraging disclosure. The patient resource was also considered helpful for building patient capability to partner with clinicians on pain management by “ encouraging self-efficacy ” (C2P01 palliative care physician and clinical champion) through the tools it provided and its positive message that “ you can get control of your pain ” (C3P02 palliative care physician and clinical champion). It was also perceived to help patients “ keep a record ” (C5P03 clinical nurse consultant) of breakthrough pain and analgesia to discuss in their consultation. However, some participants delineated patient groups who might be less able to use the resource, including those with lower educational levels who struggled to set goals and identify an ‘acceptable’ level of pain balanced against side-effects from pharmacological management. For these patients, it was suggested that too many resources could be overwhelming rather than supportive: “ it’s almost like, the more resources they have, the less resourced there are ” (C5P06 RN). At one centre with an especially diverse demographic, patients were said to require substantial support even to understand the purpose and process of pain screening: “ most [patients] look at you going ‘oh, do I have to do anything?’ … They don’t want to read the [instruction] page which is relatively simple ” (C2P03 clinic receptionist).

Invest in clinical champions

All participants perceived the role of clinical champion to be pivotal to the intervention’s success. Champions were perceived to have two major responsibilities: advocating for the intervention among colleagues to boost motivation and providing practical support to build capability.

To be effective advocates, champions were perceived to need support from senior management ( “[leadership of change] it’s got to happen from the top ” (C5P02 RN)) as well as established, cordial relationships with colleagues they could leverage to motivate engagement: “ it also relies on the champion’s personal relationship with the staff which you’re asking to perform these roles and trying to change their management ” (C1P01 palliative care physician and clinical champion). Where champions felt under-supported by management, they relied on moral support from the project team to sustain their advocacy work: “ being the champion, and sometimes being the nagging champion, it actually felt quite nice to have the back-up of other people ” (C1P01 palliative care physician and clinical champion). Both physicians and nurses perceived the champion role might better suit the scope of practice of a junior doctor or senior nurse rather than consultants, based on their willingness to engage and approachability: “ realistically, you’re probably always going to get more engagement with registrars compared to consultants, unless it’s their own trial ” (C5P07 radiation oncologist); “ just give it [the role] to the CNCs [clinical nurse consultants] because as a general rule they’re the best at everything and have the best relationships with the patient ” (C3P04 medical oncologist).

From a practical perspective, clinical champions were expected to provide human resources for establishing and supporting pain screening and patient education: “ you need a body ” (C2P04 clinical nurse consultant). Unfortunately, however, champions across centres reported having limited time protected for the role within their usual duties: “ there just wasn’t the manpower to do that here ” (C3P02 palliative care physician and clinical champion). One suggestion for boosting capacity was to narrow the focus to one clinic and delegate practical tasks to less senior delegates than required for advocacy to render the time commitment more cost-effective: “[ it] might have been better to focus on one clinic and have full-time … junior nurse ” (C5P05 radiation oncologist). This presented an opportunity to train more than one clinical champion to provide better coverage across shifts and safeguard against the risk of losing champions to staff turnover.

Increasing pain awareness is the first step: Plan for slow incremental change rather than rapid uptake

While the barriers above meant only modest practice changes could be achieved, champions at half the centres perceived incremental progress had been made through increasing awareness among personnel regarding pain care as a focus for improvement: “ I think just trying to make pain something that people think about was probably one of the better strategies ” (C1P01 palliative care physician and clinical champion); it’s more at the top of our minds to remember, to screen the pain at every visit ” (C2P01 palliative care physician and clinical champion); “ I think it has highlighted those issues for us and we now need to take this on ” (C5P04 medical oncologist, head of department and clinical champion). Both nursing and medical participants at Centre 5 emphasized the need to be persistent in striving for continuous improvement: “ I think to get practice change, even for well-motivated people, I think it just needs to be pushed … they’ve done similar things with hand washing for doctors and it’s finally getting through ” (C504 medical oncologist and clinical champion); “ it would take more than just one of these kind of programs to get people to change ” (C5P03 clinical nurse consultant). Encouragingly, participants at this and one other centre expected some clinicians to continue using the patient education booklet and resource after the project ended: “ I’d just love to continue using these booklets ” (C5P02 RN); “[the] patient-held resource has been useful and has been taken up by people and I think they will continue to use those ” (C6P02 palliative care physician and clinical champion).

This qualitative sub-study of a cluster randomized controlled trial identified centre-level capabilities to be the most influential factors impeding or facilitating guideline implementation strategies for improving pain care for outpatients with cancer. Findings suggest that future initiatives of this kind should: consider centre readiness for change; articulate and deliver on the intervention’s value proposition; define clinician roles and responsibilities; integrate the intervention within existing systems and processes; promote patient partnership; invest in the clinical champion role, drawing from senior nurses and junior doctors, with support from medical leaders and management; and design the initiative around slow incremental change rather than rapid uptake.

Our findings are largely consistent with those from an ethnographic study exploring factors influencing implementation of cancer pain guidelines in Korean hospital cancer units, which identified a ‘lack of receptivity for change’ to be a key barrier [ 28 ]. However, observations from the Korean study suggested that a lack of centre leadership and cultural norms regarding nursing hierarchy were the most important underlying factors, whereas our Australian sample focused more on constraints imposed by centre systems and processes and a lack of clarity regarding disciplinary roles. These factors were consistently emphasized regardless of participants’ discipline and seniority, including by one centre’s head of department. Consistent with these findings, a recent Australian qualitative sub-study of anxiety/depression guideline implementation in oncology centres found greater role flexibility to be a key factor underpinning organisational readiness for change [ 29 ]. This team also provided quantitative evidence consistent with our finding that centres’ readiness for change is associated with personnel’s perception of benefit from guideline implementation [ 30 ]. Future initiatives should work harder to persuade clinicians of the intervention’s rationale and evidence base prior to commencement, given that perceptions of coherence and effectiveness are key dimensions of acceptability required for clinicians to invest time and effort [ 31 ]. Since our Trial was conducted, evidence has emerged for an impact from cancer symptom screening on survival that could be used persuasively [ 32 ]. Furthermore, the spaced education module might be more acceptable if made adjustable to the knowledge levels of a broader range of clinicians.

Other studies on implementation of cancer pain guidelines [ 11 , 13 ] suggest that structured approaches to process change tend to be more successful than less prescriptive approaches of the kind taken in the Stop Cancer PAIN Trial. We provided centres with guideline implementation strategies but no clear guidance on how to integrate these within existing contexts - i.e. implementation of the implementation, or ‘meta-implementation’. It was wrongly assumed that clinical champions could support integration with centre processes based on their knowledge of local context, but this turned out to be unreasonable given champions’ limited time for the role and lack of training in change management. Like most research to date [ 33 , 34 ], our trial focused largely on the advocacy role played by clinical champions, neglecting more practical and time consuming aspects that our interviews identified to be just as important. We join others in calling for more research on the mechanisms by which clinical champions can optimally facilitate change and ways to maximize their efficacy through training and support [ 24 ]. This should include exploration of optimal models by which different aspects of the champion role might be shared between more than one person where no-one is available with all the necessary attributes, as well as ways to ensure sustainability after support from the project team is withdrawn.

Theory-based research suggests that adding complex interventions to complex healthcare systems creates dynamic interplay and feedback loops, making consequences hard to predict [ 35 ]. In the current trial, this was likely exacerbated by our attempt to combine multiple strategies targeting patient, clinician and centre levels. We chose each strategy based on evidence for its stand-alone efficacy, and combined strategies rather than used them singly with the intent of leveraging complementary mechanisms, as recommended by the COM-B Model and US Institute of Medicine [ 36 ]. However, findings from our interviews suggest that interactions between the strategies and local processes separated their spheres of influence, precluding intended synergies. The Stop Cancer PAIN Trial is not alone in having over-estimated the value of combining guideline implementation strategies; a recent systematic review found that 8 other multi-component interventions similarly demonstrated limited effects on guideline adherence and patient outcomes [ 37 ]. Collectively, these findings suggest that future attempts at combining strategies should consider complex systems theory as well as behaviour change frameworks at each of a number of stages [ 38 ]. Alternatively, a more manageable approach for most cancer centres might be to focus on just one component at a time, periodically reviewing progress against SMART goals and, depending on results, supplementing with additional components using plan-do-study cycles [ 39 ].

Given the challenges with integrating screening into centre processes, it seems unlikely that improvements in pain scores during the control phase reported in our primary results article were due to the spontaneous use of screening data in consultations [ 18 ]. Indeed, while routine use of patient-reported outcome measures (PROMs) in oncology has been researched for more than a quarter-century [ 40 ], benefits to patient outcomes have only recently been demonstrated in the context of electronically-administered PROMs (ePROMs) that enable remote self-reporting, real-time feedback to clinicians, and clinician-patient telecommunication [ 12 ]. Further research is needed on how best to support clinician engagement with ePROMs, including training on how to use results in partnership with patients to assist shared decision-making and self-management [ 41 ].

A worrying finding from the current study was that some or all aspects of pain care were perceived to fall between the scopes of practice for oncology clinicians from each discipline. Clinical practice guidelines emphasize the need for pain care to be inter-disciplinary in recognition of the need for comprehensive assessment, non-pharmacological as well as pharmacological management, and patient education and support for self-management [ 42 ]. While the patient self-management resource included in the intervention was perceived to support communication between clinicians and patients, its potential for assisting coordination of care between disciplines was limited where roles and responsibilities were not previously established. Our findings and other research suggest that future initiatives may benefit from ‘process mapping’ with clinicians to identify where clinical workflow and roles might be reconfigured to incorporate the various aspects of pain care in the most efficient ways that do not substantially add to workload [ 41 ].

Patient education has been proven to improve pain outcomes by clinical trials [ 43 , 44 ], and we have argued previously that supporting pain self-management should be core business for all clinicians working in cancer care [ 45 ]. The ‘coaching’ approach needed to empower patients to recognize themselves as ‘experts’ on their pain and equal partners with clinicians in its management is iterative rather than a single event, and is ideally built on established and ongoing therapeutic relationships of trust with a particular team member. However, findings from patient education research more generally suggest that patient education and behaviour change is also optimally supported when key messages are reinforced by differing disciplinary perspectives [ 46 ]. Results from the current study suggest that these principles of pain care need more formal recognition within the scope of practice of oncology clinicians to ensure they are afforded sufficient time alongside anti-cancer treatment and related supportive care. Findings also indicate that clinicians may require training in the person-centred, partnership-oriented aspects of pain care beyond the educational approach used in the Stop Cancer PAIN Trial and other research [ 47 ]. Such training should be repeated regularly to ensure it reaches the majority of personnel at cancer centres, allowing for turnover.

Limitations

The current study had several limitations. Transferability even within Australia is limited by a focus on metropolitan services in only three out of eight jurisdictions. Data relied on clinician perspectives, and the response rate was less than one quarter of personnel at each centre, with the disciplines and specialties of participants being unrepresentative of centre workforces. Over-sampling of medical compared to nursing personnel likely reflects the fact that all clinical champions were medical consultants, while the predominance of palliative care physicians among medical participants presumably arises from the central focus this specialty has on pain care. Notably, our sample included no perspectives from allied health disciplines, despite the important roles these can play in non-pharmacological pain management. Confirmability was threatened by the potential for cognitive bias among researchers towards a favourable view of the intervention given their long-standing investment as members of the project team. We attempted to offset this by explicitly inviting criticism of the intervention from participants, and having the initial analysis conducted by researchers with no prior involvement in the project. A final limitation concerns reliance on the COM-B Model for analysis rather than an alternative framework or more inductive approach. While the COM-B has been widely used to explore barriers and facilitators across a wide range of healthcare interventions, we applied the model in a somewhat novel way to systems and processes as well as individuals’ behaviour after finding that participants perceived their agency to be majorly constrained by these. An implementation framework such as the integrated-Promoting Action on Research Implementation in Health Service (i-PARIHS) framework (iPARIHS) [ 48 ] or Consolidated Framework for Implementation Research (CFIR) [ 49 ] would have conceived of factors and their relationships in alternative ways that might have proven equally informative [ 50 ].

This qualitative sub-study elucidated important factors influencing the success of guideline implementation strategies at six cancer centres in the Stop Cancer PAIN Trial. Findings underscore the value that a qualitative approach offers for understanding the role of context when evaluating complex interventions [ 51 ]. Ultimately, the Stop Cancer PAIN Trial may have been overly ambitious in the scale of its intervention, especially given limited resources available at each centre. Further research is needed to understand how multi-component guideline implementation strategies can be optimally introduced within the context of local roles, systems and processes.

Availability of data and materials

The qualitative interview datasets generated and analysed during the current study are not publicly available due to the conditions of ethical approval which acknowledge the risk of participant re-identification.

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Acknowledgements

The authors would like to dedicate this article to the memory of Sally Fielding, who worked as a valued member of the project team throughout the Stop Cancer PAIN Trial. We would also like to acknowledge the contributions of project manager A/Prof Annmarie Hosie, data manager Dr Seong Cheah, and research assistant Layla Edwards.

This research was supported by a grant from the National Breast Cancer Foundation.

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TL, JP, MA, PMD, TS, DCC, FB, LL, NM and ML contributed to the concept and design of this research. TL, LR, MR, MG and ML contributed to the acquisition, analysis or interpretation of the data. TL and ML contributed to drafting of the manuscript. All authors contributed to revisions of the manuscript and approved the final version.

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Luckett, T., Phillips, J., Agar, M. et al. Factors influencing fidelity to guideline implementation strategies for improving pain care at cancer centres: a qualitative sub-study of the Stop Cancer PAIN Trial. BMC Health Serv Res 24 , 969 (2024). https://doi.org/10.1186/s12913-024-11243-1

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DOI : https://doi.org/10.1186/s12913-024-11243-1

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