Motivation Strategies for Learning and Their Influences in Students’ Feedback Literacy During Undergraduate Medical School: An Explanatory Sequential Mixed Methods Study

Abstract

Feedback from educators to students is considered an important and essential element of effective learning in medical education. Feedback literacy is the process in which a student receives, comprehends, accepts, and makes use of feedback. Factors affecting medical students’ feedback literacy include students’ characteristics, motivation, abilities in self-assessment, emotional reactions to feedback, and maturity. To generate a deeper understanding of this phenomenon, a sequential explanatory mixed methods study was conducted to measure students’ motivational orientations and explore their strategies towards learning, how these orientations and strategies are related to students’ feedback literacy, and how this relationship changes as students progress through a Canadian medical school. In the first quantitative phase, the Motivated Strategies for Learning Questionnaire (MSLQ) was administered to first- and last-year medical students at a Canadian university to measure their motivational orientations for learning and learning strategies. Using the quantitative results (N = 58) to develop a sampling strategy for the second phase, individuals with different motivational orientations and learning strategies were identified based on their questionnaires’ scores. This purposeful sample (N = 15) was then invited to participate in the second explanatory phase of this study, where a qualitative description approach was applied. We conducted semi-structured interviews with students, divided into two groups: those who through the measurement of 4.62 or below by the MSLQ were identified as having a low motivational orientation for learning (n = 4), and those who through the measurement of 5.34 or above by the MSLQ were identified as having a high motivational orientation for learning (n = 3). Participants’ views were explored and synthesized, with the intent for these findings to further explain how medical students’ learning motivations and strategies might influence feedback literacy. The integration of findings showed that five factors could be taken into consideration when improving students’ feedback literacy skills: learning goal orientation, self-regulation, help seeking, personality traits, and learning experience. Based on those factors, we identified some approaches that could allow the students to enhance their own feedback literacy. Feedback literacy could empower students to have more control over the feedback process and help them to overcome the barriers they still face during the feedback process.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-025-02310-1.

Introduction

Feedback from educators to students is considered an important and essential element of effective learning [1–3]. Feedback can be typically described as a complex phenomenon that involves communication of information between a deliverer and a receiver [3–6]. Different factors can influence this process impacting students’ learning. Some of these factors are related to the deliverer, such as how the educator encodes one’s ideas, feelings, and interactions into a message [4, 7, 8]. Other factors are related to the environment where feedback occurs, such as the feedback culture in the institution or professional environment [9–11]. Further factors are associated with the attributes of the receiver [7, 12, 13]. Research examining the student’s role in the feedback process have focused on how students perceive the feedback received, how they react to it, and how they decode and appraise the information [13–16]. To acknowledge the complexity of the feedback process, the term “feedback literacy” has been introduced into the medical education literature [17, 18]. Feedback literacy is the process in which a student receives, comprehends, accepts, and makes use of the feedback. The overall intention of the feedback literacy concept is to help students to make the most of feedback opportunities, without diminishing the importance of educators and institutions to provide them with support and encouraging students to be more active in the feedback process [18].

Critical factors influencing students’ feedback literacy skills include their emotional reactions, learning motivation, ability to self-regulation and self-assessment, educators’ credibility, and previous feedback experiences [19–21]. For instance, students’ emotions could explain why some students attribute failures of performance to situational factors and their successes to their own ability, affecting their perception and acceptance of the feedback received [21]. Moreover, it seems that students with strong self-regulated learning traits, a mastery-approach goal orientation, and a growth mindset have more adaptive learning behaviors, and are better able to understand what needs to be done, create a learning plan, and implement it, therefore making better use of the feedback received [22]. Additionally, it has been suggested that students perceive and use feedback differently depending upon their seniority in the programme [19]. Junior students perceive feedback as being a passive and summative activity and value positive and written feedback. Contrarily, senior students perceive feedback as being generally formative, and they value specific and constructively critical feedback [19].

Despite the importance of feedback in medical education, the mechanism underpinning this process are not well understood [4]. Medical educators and students often indicate that the process of feedback needs improvements [4, 23]. One of the reasons for that is the existence of a complex number of factors that influence how students receive, interpret, and make use of feedback [17]. While the delivery of feedback has long been studied, the literature on feedback literacy is new, especially within the medical undergraduate education field [4, 17]. Past research in medical education has only partially explored this topic [17]. The purpose of this study was to provide a deeper understanding of the phenomenon of feedback literacy and some of the factors associated to it in the undergraduate medical school context. A mixed methods study was conducted, which included the measurement of the different students’ motivational orientations and strategies towards learning, how these orientations and strategies are related to students’ feedback literacy, and how this relationship changes as these students progress through the years of undergraduate medical school. Strategies to improve students’ feedback literacy skills could enhance the positive impact of feedback in learning, enabling students to feel more in charge of their own learning to overcome challenges such as the variation in the feedback givers’ training [7, 24] and in the institutions’ feedback culture [25, 26].

Research Questions

In the first phase of this mixed methods study, the following quantitative research question was answered: What are the motivational orientations and learning strategies among students enrolled in their first and last years of undergraduate medical education at a Canadian university? Following analysis of this quantitative data, and the identification of a purposeful sample of students, the following overarching qualitative research question was answer in the second study component: What can we learn about feedback literacy from medical students with different motivational orientations and learning strategies at a Canadian university? Finally, to purposefully link the findings from the two study components, the following mixed methods research question was answered: In what ways do the interview data reporting the views of medical students about feedback literacy explain how medical students’ learning motivations and strategies reported in the survey might influence feedback literacy at a Canadian university?

Theoretical Foundations

This study was based on the general cognitive view of motivation and learning strategies framework, which outlines that students’ characteristics, cognition, and motivation are conjoined in student learning, and they should be taken into consideration when teaching students more effective skills for learning and thinking [27, 28]. Two other theories served as a theoretical foundation for this study: the Achievement Goal Theory that strives to explain motivation and why individuals expend effort to learn [29], and the Mindset theory that suggests that individuals hold certain beliefs about intelligence (a fixed or a growth mindset) [30, 31]. Additionally, our study took into consideration previous research suggesting that students become more metacognitively, motivationally, and behaviorally effective in learning as they advance in school years [19, 32, 33].

Methods

This overall research study was an explanatory mixed methods study conducted to measure students’ motivational orientations for learning and learning strategies in medical school and then explain how students’ motivational orientations for learning and learning strategies influence students’ feedback literacy as they progress through the years of undergraduate medical school [34, 35]. Priority was placed on the second qualitative phase to focus on a qualitative examination of the phenomenon, but the initial quantitative results were needed to identify and purposefully select the best participants. Constructs from the survey were then used to develop the questions for the first part of the interview guide. The purpose of the interviews was to elicit students’ reflections on their own learning motivations and strategies, and students’ perspectives on how these factors might influence feedback literacy.

A comprehensive description of the methods and results for the quantitative phase were previously published in this journal [36]. Briefly, we conducted a cross-sectional survey study using the Motivated Strategies for Learning Questionnaire (MSLQ) to construct a portrait of medical students’ motivational orientations and learning strategies, and to analyze whether students’ learning maturity changes as they advance year by year through their medical education. The findings showed that there were no statistically significant differences between students in their first and last year of medical school. However, the MSLQ showed to be a reliable instrument to measure motivational orientations and learning strategies in the study’s sample, and we were able to identify two distinct groups with higher and lower scores in the MSLQ. Part of the survey results was used to identify and purposefully select the best participants for the qualitative phase of this mixed methods study, and to build part of the interview guide.

In this paper, the focus will be to describe how the quantitative component informed purposeful sampling, to describe the qualitative component, and to present the qualitative and integrated findings.

Ethical Considerations

Each phase of this mixed methods study was separately submitted to and approved by the Hamilton Integrated Research Ethics Board (HiREB approval number 16097) and by the Undergraduate Medical Education Program Protocol Review Committee (PRC). Additional procedures were taken to minimize participants’ risks and discomfort during the interviews. During data collection, course activities in the university were not interrupted, and interviews were scheduled according to participants’ preferences. The interviews were conducted on the video conferencing Zoom platform, but only audio, and not video, recordings were made, unless participants had wanted to leave their camera on. To ensure confidentiality, participants’ names were not collected, and all data obtained were de-identified after the interview was transcribed and stored in a private password-protected desktop. During the final report, quotes were completely de-contextualized to preserve anonymity.

Context

This study took place at a Canadian university undergraduate medical education (UGME) program [37]. Medical school is a unique context representing one of the medical trainee’s first experiences in the medical field. The underlying mechanisms that shape how feedback is positioned within the undergraduate medical learning might be unique and different from other health professionals and the postgraduate years of medical education. In Canada, UGME programs are either 3 or 4 years long, and students are eligible to apply after completion of a bachelor’s degree. The program, where this study was conducted, is a 3-year UGME curriculum program that uses the Problem-Based Learning (PBL) approach to learning. During the 15-month pre-clinical curriculum, students learn in small groups (six to eight students) of tutorials that are facilitated by a faculty member acting as the tutor for the group. Between tutorials, large group teaching sessions with expert faculty employ active learning pedagogy to consolidate and review concepts introduced in tutorials. A 63-week clinical curriculum follows the pre-clinical phase. It consists of clinical rotations in different medical specialties.

Participants

Participants in this study were undergraduate medical students. We included medical students in their first and last years of medical school to compare novice and senior students. Exclusion criterion included medical students in their second year of medical school. In the academic year when this study was conducted (2022–2023), there was a total of 207 first-year and 203 last-year students enrolled in the program.

Qualitative Phase

In the qualitative phase of this study, we explored medical students’ perceptions of feedback literacy and their attitudes towards learning in medical school. The principles of qualitative description informed all the methodological decisions in this phase [38].

Qualitative Phase: Selection of Participants

During the quantitative phase, we found that the survey overall score (mean) and individual scale scores did not differ by students’ academic year (p 0.764), age group (p 0.910), or previous undergraduate education (p 0.639). Therefore, we decided that we would not separate participants per academic year when selecting them to the qualitative phase of this study. We would base our decision only on their survey overall scores. Nevertheless, we decided to pay attention to students’ academic years when conducting the interviews in case similarities or differences were detected during the qualitative phase.

To select participants for the qualitative phase, students were divided into two groups based on their overall survey score: group 1—students that scored 0.5 below the standard deviation for the study mean (survey score < 4.62); group 2—students that scored 0.5 above the standard deviation for the study mean (survey score > 5.34). We used 0.5 as a cutoff because, after looking at the distribution of our data, we decided that 0.5 would allow us to invite enough participants with distinct motivational orientations and learning strategies that would represent different groups. Figure 1 is a histogram showing the survey score frequency distribution among all participants; the frequency distribution in groups 1 and 2 is highlighted by the circles.

Fig. 1.

Groups of participants according to survey total score

In March 2023, we invited, by email, all 15 students who met the qualitative study inclusion criteria. We sent two reminders 2 weeks apart. Participation was voluntary, and we used written digital consent. We offered an online store gift card for those who accepted being interviewed. We recruited seven students in total (four students that scored 0.5 below the standard deviation for the study mean, and three students that scored 0.5 above the standard deviation for the study mean).

Qualitative Phase: Data Collection

Data were collected using semi-structured individual interviews with the students. The semi-structured interview guide (Supplementary File I) was piloted for feasibility and acceptability with two medical students who were not part of the study sample. Interviews were done through the Zoom platform. At the beginning of the interview, we showed the students their MSLQ scores, and provided them with a brief explanation of the meaning of each scale and their results.

Qualitative Phase: Data Analysis

The study data were analyzed following the six-step process of reflexive thematic analysis approach [39, 40]. We attended to its core assumptions, namely (1) researcher subjectivity is considered a resource to generate knowledge, (2) data analysis processes involve immersion for engagement and distancing for reflection, (3) a single coder and group collaboration are recommended, (4) data analysis is always underpinned by theoretical assumptions, (5) reflexivity is essential, and (6) data analysis is a creative process; therefore, multiple analyses are possible and the researcher needs to decide which one works best for their project. Supplementary File II shows the data analysis process step-by-step, including some examples to illustrate and specify what was done. During the analysis process, a constant comparative approach was used, which required paying attention to differences and similarities between the two groups of students with different motivational orientation and learning strategies.

Qualitative Phase: Rigor

We followed the 15-point checklist of criteria for good thematic analysis [39]. Table 1 summarizes the study rigor checklist we used.

Table 1.

Study rigor checklist. Based on Braun and Clarke [40]

Criteria
1. Data detailed transcribed and checked against the recording with accuracy
2. Each data item has been given equal attention in the coding process
3. Coding process was thorough, inclusive, and comprehensive
4. All relevant extracts have been collated
5. Themes have been checked against each other and data set
6. Themes are coherent, consistent, and distinctive
7. Data have been interpreted rather than just paraphrased
8. Analysis and data match each other
9. Analysis tells a well-organized story about the data and topic
10. Good balance between narrative and illustration
11. Enough time has been allocated to complete data analysis adequately
12. The thematic analysis approach is clearly explicated
13. What you claim you do is consistent with what you show you do
14. The language and concepts are consistent with the epistemological position of the analysis
15. The researcher is positioned as active in the research process

Results

Qualitative Phase: Results

A purposeful sample of seven undergraduate medical students completed an in-depth interview as part of the qualitative study component. The average length of the interviews was 33 min (between 27 and 40 min each). Four participants were first-year students, and three participants were last-year students.

In the analysis of medical students’ different motivational orientations and learning strategies and their experiences of feedback literacy, five themes were developed to summarize the key findings: (1) Students’ reasons for learning, (2) Students’ perceptions of how they learn in medical school, (3) The influence of the problem-based learning (PBL) approach on students’ learning motivations and strategies, (4) Students’ perceptions of feedback in medical school, and (5) Students’ own power during the feedback process. Figure 2 illustrates the thematic map showing the five themes, their subthemes, and the relationship among them.

Fig. 2.

Qualitative results thematic map

Table 2 summarizes the themes and exemplifies similarities and differences in students’ thoughts according to students’ group within each theme, as we noted when conducting the interviews and analysis.

Table 2.

Themes and students’ thoughts according to students’ group

Themes	Group 1	Group 2
1. Students’ reasons for learning	Intrinsic and extrinsic goal orientations were reasons to learn Examples of intrinsic: to be a good doctor, to learn, to gain clinical knowledge Examples of extrinsic: to get good evaluations, to pass the exams, to match the residency program, to get some autonomy Feelings could influence reasons to learn	More intrinsic than extrinsic goal were reasons to learn Examples of extrinsic: curiosity, passion, being a good physician, to learn, to enjoy Grades were important to get in Medical School Feelings were not mentioned as influencing reasons to learn
2. Students’ perceptions of how they learn	Elaboration and critical thinking are time-consuming Rehearsal is a faster way to learn. It seems to be the most used strategy in this group A lot to do with being overwhelming, too many things to learn Planning seems to be important for them Learning support • Only when they really need it • Usually rely on the internet sources • Usually they don’t study in groups	Elaboration and critical thinking are very important tools used in this group Rehearsal was considered much easier, but not used as much Time/amount of material influences learning style in this group Strategies related to self-regulation seem to be most important Having control of their own learning and self-effort is also very important Learning support • Rely on peer learning as much as studying by themselves • Ask for help
3. The PBL approach influences	Less pressure Less stressful	Learning for the sake of learning Peer learning in tutorials
4. Students’ perceptions of feedback	Positive and negative Good frequency Not constructive, too subjective Feedback literacy was not effectively taught Maybe it is related to maturity/experience and/or personality It should be taught through workshops with examples and practice. Specifically before clerkship	Positive and negative Good frequency Not always specific to content Feedback literacy was not effectively taught Feedback literacy should be taught. Specifically before clerkship. Through practice sessions and examples
5. Students’ own power	Factors affecting receptiveness to feedback are mostly internal Personal factors seem to have a bigger impact in this group Other factors: having an extrinsic or intrinsic goal orientation, working hard, and having control of your own learning There is much that students could do to help themselves in the feedback process: reflections and actions	Factors affecting receptiveness to feedback are all internal, such as personality, maturity, having an intrinsic goal orientation, and control of your own learning There is much that students could do to help themselves in the feedback process: reflections and actions

Group 1—participants that scored < 4.62 in the survey

Group 2—participants that scored > 5.34 in the survey

Students’ Reasons for Learning

Participants’ descriptions of their motivations to learn, and the factors influencing this process, contributed to the theme students’ reasons for learning. These factors included motivations that were clustered as being intrinsically (e.g., learning for the sake of learning) or extrinsically (e.g., learning to be able to receive good evaluations) goal oriented. Additionally, because students recurrently described how some feelings could influence their reasons to learn (e.g., how fear and stress could make them less motivated to learn), factors related to it were also part of this theme. Therefore, within the theme students’ reasons for learning, three subthemes (i.e., reasons influenced by intrinsic motivation to learn, extrinsic motivation to learn, and feelings) were generated.

Although both groups described intrinsic and extrinsic goal-oriented motivations to learn, the balance between these two motivation types was different for each group. Students in group 2 were more intrinsic goal-oriented, mentioning learning for the sake of learning, for curiosity, for passion, for enjoyment, and to be a “good” physician. When talking about learning, these students did not articulate negative feelings; on the contrary, they expressed appreciation for their learning journey, as one medical student in group 2 explained:

Maybe you should be doing well at something because you are passionate about it and you want to do it (…) you want to make the best out of that opportunity (ID7)

In comparison, there were no consistent patterns among students in group 1. Students in group 1 related to be intrinsic and extrinsic goal-oriented. Whether they were more intrinsic or extrinsic goal-oriented depended on the learning subunit or rotation, on their preceptors or mentors, and whether they were preparing for an upcoming exam, as one students in group 1 exemplified:

I do have curiosity for things (…) but in order to stick with something for a long time, I need some extrinsic motivation (…) otherwise, I just get bored (ID3)

Additionally, students in group 1 described many negative feelings involved when they talked about their reasons to learn in medical school. They often mentioned how overwhelming medical school is, and the fear and stress of realizing that there is so much to learn. The number of things to study and the positive or negative relationship with their preceptors seem to be related to their motivation orientation. One student in group 1 stressed the negative emotional impact that teachers (i.e., preceptors) can have in students’ motivations to learn:

I had such great preceptors (…) these were the most fun and enjoyable rotations even though they were really hard (…) and then, the opposite (...) they made me feel small and bullied me with my skills (…) it turned me off from the specialty (…) I wasn’t learning, I was just trying to survive. (ID2)

Moreover, there was a consensus among students that their mindset changes depending on the learning context. For group 2, grades were a learning motivation to enable them to get into medical school, as one student in group 2 explained:

In undergraduate [before medical school], I was extremely focused on my grades, and I would sacrifice other things in order to do better on a test. Since I got here [medical school], I realized that grades are not so important to me anymore (…) I just try to learn what I am curious about (ID6)

In comparison, for participants in group 1, grades and evaluations were still an important learning motivation, especially when the students do not like the topic or when a high stakes evaluation is upcoming. They were not able to abandon their study behaviors from before medical school, the habits that made them getting good grades in high school or to get into medical school, something that group 2 was able to do.

Students’ Perceptions on How They Learn

This theme was built on the previous theme (students’ reasons for learning) by further explaining one of the constructs measured in the quantitative survey, students’ learning strategies in medical school. The main concept of this theme was defined by the different strategies that students use to learn in medical school. It was built with patterns that clustered around three subthemes: cognitive strategies (i.e., elaboration, critical thinking, and rehearsal), metacognition processes (i.e., planning, monitoring, and regulating their studies), and learning support (i.e., peer support, help seeking, learning tools support).

Within our sample, while students in group 2 put more emphasis on factors related to elaboration and critical thinking than rehearsal, the opposite was observed in the comments of students in group 1. Overall, students agreed that elaboration and critical thinking are more effective tools for learning; however, rehearsal (i.e., memorizing) was seen as a faster way to learn. For students in group 1, the amount of material and lack of time was identified as an important learning strategy determinant, and that is why they would use rehearsal more often. Therefore, rehearsal could be another study behavior (like the extrinsic motivation to learn discussed above) that students bring with them from their study habits before medical school, but it is not necessarily the best approach to learn in medical school. One student in group 1 illustrated that thought by sharing:

(Rehearsal)… I did this a lot [before medical school] (…) you know, I had 2 weeks to study before an exam (…) Okay, here are the big topics, the headers, the summary sheet (…) I feel like I was still doing that [in the beginning of medical school], even though it might not have been the best strategy. (ID2)

Students within group 2 recurrently described the use of metacognition processes. They put emphasis on self-regulation, self-effort, and having control of their own learning, as factors that would shape their learning experience. One student in group 2 commented:

I do have control [of my learning] because I've noticed when I try, like new sort of study or tutorial preparation techniques, I really see like first hand, all my efforts to study have made a difference in my learning. (ID6)

Although students in both groups commented about the relevance of students’ support for learning, the opinions between the two groups of students were very distinctive. Students in group 2 said that they rely on studying with their peers as much as studying by themselves because, sometimes, peer learning can be distracting. Thus, whenever they feel that studying with their peers would not be effective, they would change their strategy, showing (again) how this group of students is able to shift their study habits to regulate their learning. They also would ask for help more often than the students in the other group because they perceived this improves their learning, as one of the students in group 2 emphasized:

I think this is so important; you got to ask for help. Everyone is very actually helpful and they actually want to see you do the best actually… because if you don’t ask for help, no one knows that you need help. (ID7)

In contrast, students in group 1 prefer to study alone because studying with their peers is more distracting, they not always study things that are important, they can be less productive, and some peers seem too confident when giving wrong answers. These students rarely ask for help, relying on their own resources, including their notes and the Internet.

The joint display Table 3 illustrates how the qualitative findings from the first two themes supported and added some explanations to the quantitative scale scores, as it was discussed above. This integration of data represents the first step to answer this study mixed methods question because it provided a richer portrait of the different students’ learning motivations and strategies within this sample.

Table 3.

Joint display—integration of survey scales scores and qualitative results

Scale	Group	Score mean	Qualitative results	Students’ quotes
Rehearsal	1	3.65	Rehearsal is a faster way to learn. It seems to be used more in group 1	I think it’s just the volume and the lack of specialization and focus (…) kind of prohibit that critical thinking for me. I’ll memorize it. It’s just faster. (ID2—group 1)
	2	3.55
Anxiety	1	4.36	Group 1 demonstrated many negative feelings when talking about their learning (overwhelming, a lot of things they don’t know, stress)	A lot of times I just realize how little I know and how much there is to know (…) I know I should go back and re-read (…) I make a plan (…) but I just don’t actually see it through. (ID3—group 1)
	2	3.62
Extrinsic goal orientation	1	4.00	Students in group 1 seem to bounce between being intrinsically and extrinsically goal oriented	It definitely depends on the subunit with regards if I am more intrinsic, more curious (…) and then, if I’m kind of bored, I would definitely be more extrinsic. (ID4—group 1)
	2	3.90
Intrinsic goal orientation	1	4.81	Students in the group 2 seemed to be much more intrinsically goal oriented	Maybe you should be doing well at something because you’re passionate about it. (ID7—group 2)
	2	5.77
Elaboration	1	4.99	Students in group 2 indicated that they use elaboration and critical thinking more than rehearsal	I know elaboration is the most effective way to learn (…) to make sure I understood. (ID6—group 2) I think that’s what you should do all the time (critical thinking). (ID7—group 2)
	2	6.41
Critical Thinking	1	3.37
	2	5.48
Self-regulation	1	3.97	Students in group 2 highlighted the importance of self-regulation, self-effort, and having control of their own learning	I do believe if you put in the effort you will be good enough … the times when I don’t succeed in something, it was never unexpected. (ID5—group 2)
	2	5.48
Effort-regulation	1	4.53
	2	6.00
Peer learning	1	1.70	Students in group 2 rely on studying with their peers more often than group 1	I think peer learning played a key role in my success in medical school. (ID7—group 2)
	2	5.36
Help seeking	1	4.15	Students in group 2 would ask for help more often than the students in the other group	Every time I ask someone for help (…) (they have) been patient and answered my question. So I just keep doing it. (ID6—group 2)
	2	5.25
Survey	1	4.01	Students agreed with their overall MSLQ scores	I feel like this is a pretty much fair score. (ID3—group 1)
	2	5.75

Group 1—participants that scored < 4.62 in the survey

Group 2—participants that scored > 5.34 in the survey

The PBL Influences on Students’ Learning Motivations and Strategies

Most participants consistently discussed how the context in which they were learning, specifically their engagement with a PBL approach to pedagogy, was perceived to strongly influence their learning motivation, including reasons for learning and their process of learning. For both groups of students, PBL guided their learning because of the lack of high-stake exams and grades during their units of study, and the importance given to tutors’ evaluations (formative assessments), as opposed to summative assessments. The students in group 2 explained that the PBL approach stimulates their intrinsic motivation to learn because they do not have to worry about high-stake exams and grades, so they can study for the sake of learning or interest, as one student in group 2 exemplified:

The PBL, how medical school is structured, at least here, it’s like all pass or fail. I think the incentive is to know the stuff that would be applicable to whatever specialty that you are going to be pursuing in in the future, and knowing, just knowing the medicine, just to know the medicine, because you’re interested in medicine. (ID7)

Moreover, students in group 2 repeatedly commented on how the PBL approach might encourage peer learning because, in PBL, learning happens in small groups of students trying to discuss problems and producing explanations for the problems. One student in group 2 excitedly illustrated this:

I think peer learning played a key role in my success in medical school (…) it is the best thing (…) [in PBL tutorials] explaining concepts to others, and then other people explaining concepts to you, and then, answering questions together (…) it is awesome. (ID7)

This quote explains more in detail how PBL might influence the peer learning strategy measured in the MSLQ. In describing this experience in tutorials, the student ID7 appeared to illustrate how tutorials could influence peer learning, and how peer learning could influence one’s motivation to learn.

Students’ Perceptions of Feedback

In the second part of the interview, participants were asked to talk about their feedback experiences in medical school, and their thoughts about feedback literacy. The students consistently linked their previous experiences in receiving feedback in medical school with comments on areas of improvement in the feedback process. Therefore, within the theme students’ perceptions of feedback, we created two subthemes: room for improvement and feedback literacy. The last subtheme was greatly influenced by the way the interview questionnaire was organized. One of the interview guide questions asked about their perceptions of feedback literacy in medical school. However, the students did not know the meaning of the term. Because talking about feedback literacy was essential to help answering this study’s research questions, we provided them with a brief explanation of the term (i.e., the process in which a student receives, comprehends, accepts, and makes use of feedback). After that, students started elaborating on this idea.

There was consensus across participants that while their experiences of receiving feedback from medical school educators were generally good that there was “room for improvement.” While they expressed high levels of satisfaction with the frequency in which they received feedback, there was criticism of the content or substance of the feedback provided. Feedback was most useful when the content was constructive, specific, and appropriate. However, within this sample, many participants expressed that the feedback they typically received was not constructive nor did it assist them in identifying specific knowledge gaps or skills to focus on. The feedback tended to be broad and expressed without specificity. One participant summed up this experience by explaining:

[It’s not] the positivity or the negativity of the feedback that [the medical school educators] are giving to you…it is how they present it to you. I think the people who say, “good job” or “keep it up!” The don’t really elaborate on that too much. (ID1)

Feedback that focused on intrinsic personality traits of the learner, which participants perceived might be difficult to address, was also perceived to not be useful in promoting their learning and advancing their skills. One participant explained:

I’ve definitely gotten feedback that, “Oh, you’re really quiet” and “You don’t share enough.” But that’s part of my personality. For all the years I’ve lived, that’s how I have been! (ID3)

Within the subtheme feedback literacy, there was a consensus across participants that feedback literacy has not been taught in medical school, or it was vaguely mentioned. The codes were clustered around ways to teach feedback literacy skills to students and the factors that could influence feedback literacy. Within this sample, students believed that they could better accept and use the feedback received when they are highly motivated to learn, when they realize that the feedback can help them, and when they believe that they have control of their own learning. Some students went beyond describing factors that could influence feedback literacy, and they elaborated on suggestions on how to best teach feedback literacy, as one student in group 2 explained:

It [feedback literacy teaching] would be interesting, specifically, before clerkship starts. I think that’s probably the best time, because that’s when you, during clerkship, that’s when you really grow as an individual through those clinical shifts. (ID7)

While the student above elaborated on the best timing to teach feedback literacy, other students within this sample shared that the best ways to teach feedback literacy would be through workshops, practice sessions (simulations), and examples, instead of lectures or articles discussions. However, there was a consensus across students in group 1 that there might be factors related to feedback literacy that could not be taught, such as students’ maturity, clinical experience, and personality, as one student in group 1 illustrated:

I think learning how to take feedback, I think, is an ongoing skill, that you learn as you have more experience. I also think that there’s a lot of personality factors (…) or just based on their either personal disposition or background. (ID3)

Students’ Own Power During the Feedback Process

This theme was defined by the idea that students can have some control over the feedback process, instead of relying only on the feedback giver’s skills or the learning environment in the institution. It moved beyond the theme students’ perceptions of feedback because the codes around this concept shared factors that students believed they actually could do to help themselves during the feedback process. These factors were later organized in self-reflections and actions, as described in the following text.

Both groups of students believed that there is so much they could do for themselves. They commented on their power on reflecting about what was said to them, and the choice that they have of accepting or not accepting the feedback. They also elaborated on the big impact that feedback can have, not only on students’ medical skills and performance, but also on their professional decisions and self-perceptions, as one student in group 2 explained:

Sometimes it can be hard to receive it (…) for example, the feedback is you would be great in psychiatry because you're like a good listener, or you have a nice and kind voice… it seems like positive feedback. [And I think] that's the feedback I got after learning about the gastrointestinal system? (…) Is this something I want to accept and implement? (ID6)

Within our sample, students suggested some actions that they could take to improve their feedback literacy, such as being more proactive, asking for clarifications, and bringing concerns up.

Integration of Findings

To find ways of how the quantitative and qualitative results could help to explain the influences of students’ learning motivations and strategies in feedback literacy, overall results were integrated into a second joint display (Table 4). This table includes the three factors, among the MSLQ scales, that could be related to feedback literacy according to this study’s qualitative findings: goal orientation, self-regulation, and help seeking. The qualitative results most relevant to these scales are summarized in the joint display, and some students’ quotes are showed to support the findings.

Table 4.

Joint display—MSLQ scales and qualitative results related to feedback literacy

MSLQ scales that might affect feedback literacy	Qualitative results	Students’ quotes
Goal orientation	Group 1 expressed that either being intrinsically or extrinsically orientated facilitates feedback literacy Group 2 expressed that being intrinsically orientated facilitates feedback literacy	Learning for the sake of learning or to be a good doctor would motivate me to seek feedback (…) or to get good evaluations sort of depends on the fact that you are able to get feedback. (ID1—group 1) I think being intrinsically goal oriented is so important (…) because if you present yourself out there as like I want to be the best doctor (…) I think that makes it better for feedback. (ID7—group 2)
Self-regulation	Both groups expressed the importance of having the sense of controlling your own learning in order to improve the way you accept, use, and seek feedback	I think when you are willing to work hard (…) it makes you more willing to get the feedback and not slack it off (…) if you have less effort you might not be willing to use the feedback. (ID4—group 1) I want to be in control of your own learning (…) and I think that helps me be more open to feedback, because I really see it as decisions that may affect my learning. (ID7—group 2)
Help seeking	Both groups commented on how students that seek out help might be more willing to seek out feedback; although this was a stronger remark in group 2	I think that the willingness to seek out feedback would be higher if you are more willing to seek out for help. (ID4—group 1) I always seek out for help and I always seek out for feedback (…) I think that’s so important. (ID7—group 2)

Group 1—participants that scored < 4.62 in the survey

Group 2—participants that scored > 5.34 in the survey

Discussion

The purpose of this study was to measure students’ motivational orientations for learning and learning strategies in medical school, and then explain their influences in students’ feedback literacy at a Canadian university. To do that, we have first provided a general picture of students’ different learning motivations and strategies, and then, we refined this portrait by exploring students’ views. The findings and joint displays illustrated how the integration of the two phases of this study helped us with that first purpose. We identified different motivational orientations and strategies for learning based on the MSLQ, and then, students provide us some explanations for the quantitative findings during the interviews. We could not identify differences in motivational orientations and strategies for learning between first- and last-year medical students in this sample, maybe due to its small sample size. However, we were able to identify two distinct groups with higher and lower scores in the MSLQ, and the qualitative analysis supported and added to the quantitative findings. Later, we integrated the results one more time to provide further explanations on how medical students’ learning motivations and strategies might influence feedback literacy. We identified three factors, among the MSLQ scales, that could be related to feedback literacy (i.e., goal orientation, self-regulation, and help seeking) and two others that are not related to the MSLQ scales (personality traits and learning experience). We also identified some strategies to improve feedback literacy suggested by the students.

All those five factors that might be related to feedback literacy (i.e., goal orientation, self-regulation, help seeking, personality traits, and learning experience) were previously mentioned by other authors and by the general cognitive view of motivation and learning strategies’ framework [19, 21, 22, 27, 32]. It is believed that those factors are intimately conjoined in students learning and they should be taken into consideration when teaching students. Some authors suggested that senior medical students perceive and use feedback differently from junior medical students [19]. Although we were not able to detect this difference between first- and last-year medical students in this sample, the participants did express that learning experience could affect feedback literacy during the interview phase. Based on the Achievement Goal Theory [22], we were expecting that goal orientation would be one of the factors that could affect feedback literacy. This theory holds that mastery-oriented students (intrinsically goal-oriented) are more likely to seek and accept feedback, when compared to performance-oriented students (extrinsically goal-oriented). Students in group 2 were more intrinsically goal-oriented, and they emphasized that being more intrinsically goal-oriented is relating to having better feedback literacy skills, reinforcing the Achievement Goal Theory. However, students in group 1 seemed to bounce between being intrinsically and extrinsically goal-oriented, and they could not link one or another to feedback literacy. In fact, they expressed that having motivation to learn in general (independently on being intrinsically or extrinsically goal-oriented) could enhance feedback literacy skills. The Achievement Goal Theory also endorsed the association between students’ self-regulation and feedback literacy. It seems that students with strong self-regulated learning traits have more adaptive learning behaviors; therefore, they are better able to receive and use feedback. Interestingly, we noticed that students in group 2, with higher scores in the self-regulation scale, seemed to be the ones that would shift their learning mindsets easier, adapting their learning strategies to a new context, thus reinforcing the idea that strong self-regulated students might have better feedback literacy skills by adapting their learning behaviors. Lastly, one of the foundational principles that underpin motivation theories is social-cognitive interactions, meaning that learning results from interactions among personal and environmental factors [41]. Students that more often seek for help might be better able to manage aspects of their learning environment by getting support from others, including getting feedback to facilitate their learning achievement. Therefore, students that score higher in the help-seeking scale might have stronger feedback literacy skills, especially in seeking out feedback from others.

Limitations

There are some limitations inherent to the type of methodological approaches we have chosen. The students might have had the MSLQ scales in mind when talking about their perceptions on how they learn in medical school because patterns were seen around those strategies. In the qualitative phase of this study, we used the constructivist philosophical assumptions. Thus, realities were presented through the comments of medical students of this sample. Moreover, as in all qualitative approaches, the results of this study are not completely free of interpretation. There are other limitations that are related to our sample. We based our sample size on the concept of information power [42, 43] suggesting that a small (less than 10 participants) data set could be used [42]. However, the small sample size might reflect a narrow range of responses and experiences described in the qualitative results. It is also likely that students with negative experiences may not have wished to participate in this type of study because interviews are not anonymous. Moreover, the data collection took place in one institution, and the unique context of this medical school (i.e., PBL approach, 3-year medical degree program) must be taken into consideration when expanding the conclusions of this study to other populations. Lastly, we might have overlooked the negative impacts that the concept of feedback literacy could have on students. By asking students to have more control over the feedback process, we might be, in fact, increasing students’ learning burden, instead of facilitating the learning experience for them. To address this limitation, future studies should explore feedback literacy learning activities and their impact on students’ learning perceptions and outcomes. Additionally, we suggest that future research should include a larger sample size (maybe offering more incentives to increase participants recruitment), data collection in different institutions, and the use of different research methodologies, such as longitudinal designs, to analyse same participants in different academic years.

Implications and Recommendations

We propose that students could work on some of the factors that might be related to feedback literacy discussed in this study (i.e., goal orientation, self-regulation, help seeking), in order to improve their feedback literacy skills. Previous authors suggested that goal orientation to learn could be adjusted by self-reflecting on ones’ motivational beliefs, specifying intrinsic and extrinsic interests, and then, creating and implementing strategies to manage motivations, such as using learning strategies that better fit the purposes of the course or the current reality of the student [33, 44]. Institutions could use learning motivations questionnaires (such as the MSLQ) to help students to identify their own motivational beliefs. When looking at self-regulation in learning, students could regulate their learning in three different areas: planning (e.g., setting learning goals, setting tasks to be completed), monitoring (e.g., tracking own attention, self-testing, setting criterion to comparison), and regulating (e.g., making adjustments to adapt based on self-reflection, summative, and formative feedback, paying attention to effort their own effort to learn) [22, 33]. Institutions could help students by promoting programs that would allow them to critically discuss and reflect about these areas of self-regulation, such as the Pause 2 learn sessions suggested by Sandars and Timothy [44, 45]. Lastly, the results of this study showed that help seeking seems to facilitate feedback literacy because students would seek out feedback from others. Students should learn to manage their study environment to receive support from others by identifying study areas and people (peers or instructors) that could provide them some assistance, and reflect on ways to be more proactive in the feedback process. Participants in this study suggested that students could be more proactive by bringing their concerns up, asking questions, and asking for clarifications to the feedback giver. Institutions could help students by promoting a safe feedback environment. For example, faculty development activities could emphasize the need to move away from the concept of feedback as a top-down process, and show the importance of sharing the feedback process responsibility with students [18, 46]. Table 5 summarizes the recommendations discussed above.

Table 5.

Summary of recommendations

MSLQ scales that might affect feedback literacy	Students’ strategies to improve learning motivations and strategies related to feedback literacy	Instructors’ strategies	Institutional strategies
Goal orientation	• Identifying motivational beliefs through questionnaires • Self-reflection on motivational beliefs • Finding intrinsic and extrinsic interests • Selecting strategies to manage motivation • Creating a plan to implement strategies	Allowing time for students to self-reflect on their goal orientation and interests • Encourage students to select strategies to manage motivation and create a plan to implement strategies	Promote learning motivations questionnaires to help students to identify their own motivational beliefs
Self-regulation	• Planning • Self-reflection on learning strategies • Setting learning goals • Setting tasks to be completed • Monitoring • Tracking attention to tasks • Self-testing • Setting criterion for comparison • Regulating • Making adjustments to adapt to new situations • Effort control • Time and environmental management • Study strategies	Helping students to discuss about specific areas of self-regulation by allowing time for them to do that and bringing information and resources to their attention	Promote programs that would allow students to critically discuss and reflect about specific areas of self-regulation
Help seeking	• Identify people that could provide assistance • Identify areas that would need assistance	Showing availability and support to students that want/need assistance	Promote a safe feedback environment

Conclusion

Feedback literacy is the processes in which a student receives, comprehends, accepts, and makes use of feedback. This study explored how learning motivation orientations and strategies could be related to feedback literacy. The results showed that five factors could be taken into consideration when improving students’ feedback literacy skills: learning goal orientation, self-regulation, help seeking, personality traits, and learning experience. Based on those factors, we have identified some approaches that could allow the students to enhance their own feedback literacy. Feedback literacy could empower students to have some control over the feedback process and help them to overcome the barriers they still face during the feedback process.

Supplementary Information

Below is the link to the electronic supplementary material.

Data Availability

The data that support the findings of this study are available from the corresponding author (LC) upon request.

Declarations

Ethics Approval and Consent to Participate

The Hamilton Integrated Research Ethics Board (HiREB) has reviewed and approved this study (project ID 16097).

Conflict of Interest

The authors declare no competing interests.