Deciphering Learning Motivation in Open Distance Learning towards Sustainable Medical Education

: Open distance learning has become a new norm in medical education since the COVID-19 pandemic. The abrupt shift from conventional medical education to fully virtual learning deserves a reﬂection on how it affected the learning motivation among medical students. Hence, this study aimed to investigate the effect of open distance learning on their learning motivation during this pandemic period, with suggestions to improve through reﬂections and recommendations. This qualitative study involved 152 medical students undertaking the Doctor of Medicine program in Universiti Kebangsaan Malaysia, Malaysia, during the COVID-19 pandemic. All data were collected through a validated questionnaire. We found that medical students portrayed intrinsic motivation— mainly self-motivation, self-discipline, and self-adaptation—in open distance learning during the pandemic period. Feedback from medical students also showed that they advocated a better internet connection, innovative teaching, and learning, as well as new appropriate assessment methods and strengthening of the learning management system for a sustainable open distance learning outcome. Hence, medical educators should be creative in making use of open distance learning as an attractive complementary platform in medical education to ensure life-long learning.


Introduction
Open distance learning has emerged to be the new norm since the novel coronavirus disease 2019 (COVID- 19) pandemic. Medical education is not spared from this new norm, as the implementation of the nationwide Movement Control Order (MCO) has forced all medical teaching and learning to be conducted fully online. The abrupt transformation from conventional medical education to exclusive open distance learning is challenging [1][2][3][4][5][6] and the effect on learning motivation among medical students remains unelucidated.
Generally, open distance learning, also known as digital learning, is a way to complement students' learning process by integrating the advancement of technology in assessing, tutoring, and instructing students for educational purposes [7]. It comprises a few components, mainly digital teaching materials, digital tools, digital delivery, and autonomous learning [8]. Other terminologies that are commonly used to represent open distance learning include 'e-learning', 'technology-enhanced learning', 'internet-based training', 'web-based training', 'online learning', 'network learning', and 'distance learning' [7,9]. Students can learn online synchronously and asynchronously without time and location restrictions, with indirect cultivations of autonomous learning ability through open distance learning [10,11].
In fact, open distance learning has been incorporated into Malaysia's medical education through the Learning Management System (LMS) in conjunction with the ministry's initiative, MyHE4.0 (Education 4.0) in the Higher Education Blueprint 2015-2025. A 'blended learning' environment is created that enables virtual communications between students and lecturers, assignment submission, and group discussion [12]. Even though most Sustainability 2022, 14, 4497 2 of 13 medical students are tech-savvy and support the use of open distance learning in medical education due to its interactivity, cost-effectiveness, and convenience [13][14][15], open distance learning has been a complementary role in medical education. Our conventional medical education setting is mainly involved a physical lecture in the hall and conventional bedside teaching and learning methods with real patients. However, the shift towards fully open distance learning will involve several challenges, including the increasing time constraints and demands faced by educators and students, network issues, availability of infrastructures, and the perception of being distracted while using high-end technologies that will further impede the development of open distance learning in medical education [16][17][18][19].
The effectiveness of open distance learning depends on students' ability to learn independently, initiate discussions with peers and educators, and develop understandings through active engagement with digital resources [27]. This requires sustainability of learning motivation [28]. Previous studies have reported that blended learning in medical education improves learning motivation. However, the impact of the COVID-19 pandemic on open distance learning and learning motivation remains unexplored. The unforeseen stressors of the pandemic may affect learning motivation and the outcome of open distance learning [29].
The recommendations and reflections from medical students are crucial to enhancing the sustainability of medical education. Hence, this study aimed to qualitatively analyse medical students' learning motivation during this COVID-19 period, as well as their points of view on improving open distance learning.

Study Design
This study embraced a qualitative approach in collecting both reflection and feedback from undergraduate medical students of Universiti Kebangsaan Malaysia (UKM), Malaysia. A set of validated questionnaires including an information sheet and a consent form were distributed via Google Forms (Supplementary file), from March 2020 to May 2020, two weeks after the initiation of lockdown in Malaysia. A pilot study to validate the questionnaire was carried out among 35 UKM medical students, with Cronbach's alpha, α = 0.91. This study was approved by UKM Ethics Committee (UKM PPI/111/8/JEP-2019-702).

Selection of Respondents and Data
All current UKM students undertaking the course of Doctor of Medicine were eligible to participate in this study. Stratified convenience sampling was used in which the sample was stratified by year of study and each year contributed an equivalent ratio to population. A study by Universiti Putra Malaysia, Malaysia (UPM) [30] with a power of 1.000 was referenced for sample size calculation. Eventually, there were a total of 152 year 1-year 5 UKM undergraduate medical students that participated in this study.
Demographic data and educational background of respondents were collected, including age, year of study, and phase of the study. The phase of the study consisted of year 1 and year 2 representing the preclinical phase, and year 3 to year 5 for the clinical phase. Reflections regarding their learning motivation during the pandemic period, as well as their opinions on future open distance learning improvements, were collated and further divided into different emerging themes.

Statistical Analysis
Results were recorded using Statistical Package for Social Science (SPSS) Version 27 by the IBM Corporation, New York, United States, and analysed qualitatively based on the aforementioned objectives. The reflections on learning motivation during the pandemic and recommendations to improve open distance learning were coded into respective emerging and main themes. The coding was performed by two independent authors and crosschecked to determine any discrepancies. Should there be any discrepancies in opinions, a third author would address the difference in opinions and reach a consensus together with the two authors.

Demographic Characteristics
Among 152 UKM undergraduate medical students, the mean age was 21.94 ± 1.63. Preclinical and clinical medical students comprised 38.8% and 61.2% of the total students, respectively (Table 1). Table 1. Demographic characteristics of respondents (n = 152).

Demographic Data Number of Students, n(%)
Year of Study

Themes of Learning Motivation (LM) during the COVID-19 Period
The reflections on learning motivation during the pandemic period were collated into 11 emerging themes (Table 2), which were further summarised into 2 main themesintrinsic and extrinsic motivations ( Figure 1). Respondents were labelled as 'R'. 'Ask motivation from friends and family.' (R11) Family 'By continuously keeping in touch with my friends, making a checklist of the subjects that I need to cover, having a conducive study area, and online group study with friends.' (R31) Friend 'Not having a conducive studying environment at home ...' (R43) Learning motivation

Theme LM1: Intrinsic Motivation
Out of 152 responses, 55.9% of students reflected intrinsic motivation in their answers. Of those, 28 responses pointed towards self-motivation during the COVID-19 pandemic. Most of the responses mentioned reminding oneself subconsciously regarding the reason for choosing the medical profession and the necessity of continuous learning.

'Regardless of whether we're in difficult times, learning is a continuous journey, the one that can only stop you from learning new knowledge is your own self.' (R12)
Some medical students also boosted their self-motivation via other sources available while learning at home.
'Watch vlogs of medical students like Ali Abdal, etc. to make me feel like studying.' (R59)

'By watching motivational videos.' (R64)
Another emerging theme that was categorised under intrinsic learning motivation would be self-discipline. In total, 50 responses portrayed medical students applying the principle of self-discipline as learning motivation.

'I set up a to-do list every day and focus on things I want to study in small sessions.' (R2)
'A lot of self-studies, researching materials, and discussions with lecturers.' (R45)

'Study a lot and never forget to rest in between online sessions.' (R110)
Additionally, there were three responses that mentioned the feeling of indifference despite the transformation.

'To pass the year and move on.' (R39)
Shifting from face-to-face learning to open distance learning is an enormous challenge for medical students, especially those clinical students who used to practice clinical skills in hospital settings. This transformation requires one to have the skill of self-adaptation. However, despite various themes of learning motivation, there were four 'Regardless of whether we're in difficult times, learning is a continuous journey, the one that can only stop you from learning new knowledge is your own self.' (R12) Some medical students also boosted their self-motivation via other sources available while learning at home.
'Watch vlogs of medical students like Ali Abdal, etc. to make me feel like studying.' (R59) 'By watching motivational videos.' (R64) Another emerging theme that was categorised under intrinsic learning motivation would be self-discipline. In total, 50 responses portrayed medical students applying the principle of self-discipline as learning motivation.
'I set up a to-do list every day and focus on things I want to study in small sessions.' (R2) 'A lot of self-studies, researching materials, and discussions with lecturers.' (R45) 'Study a lot and never forget to rest in between online sessions.' (R110) Additionally, there were three responses that mentioned the feeling of indifference despite the transformation.

'To pass the year and move on.' (R39)
Shifting from face-to-face learning to open distance learning is an enormous challenge for medical students, especially those clinical students who used to practice clinical skills in hospital settings. This transformation requires one to have the skill of self-adaptation. However, despite various themes of learning motivation, there were four responses pointing towards incapability to adapt due to the lack of both intrinsic and extrinsic motivation. Three out of four responses were from clinical students.

Theme LM2: Extrinsic Motivation
The learning environment was the extrinsic factor that cause the inability to adapt, as indicated by one student with the following statement: '...Not having a conducive studying environment at home and also a lot of reading materials have been left at the college . . . ' (R43) As online classes had become the bread-and-butter routine of everyday life, there were students (n = 10) who said that online learning motivated them to understand the lessons better.
'Weekly teaching and lecture motivate me to understand things better.' (R1) Among the students whose learning motivation was extrinsic, six of them thought that lecturers can be a source of learning motivation.
'My supervisor is the main reason why I am able to cope with this kind of learning method.' (R4) Different sources of open distance learning which were found online such as research articles, e-books, educational videos, etc. were considered students' extrinsic motivation because these sources were very informative and easily accessible.

'I watch videos to understand better.' (R54)
Cancellations or delays of examinations over the COVID-19 pandemic did not demotivate the students; in contrast, upcoming delayed examinations had become a learning motivation for 18 students, especially those who were in the final year.

'Counting days for professional exams.' (R7)
A total of 32 students reflected that family (n = 6) and friends (n = 26) acted as strong support for them to study at home during COVID-19.
'Ask for motivation from friends and family.' (R11) 'My friends and I have discussions frequently regarding questions we encounter during our teachings . . . ' (R26)

Reflections on Methods (RM) to Improve Open Distance Learning
Recommendations on open distance learning improvement were collated (Table 3), consisting of a total of 18 emerging themes, which were further summarised into 5 main themes ( Figure 2).

Theme RM1: Better Internet Connection
Online learning is dependent on internet access, and without a stable internet connection, the learning process would be interrupted since most of the materials and resources were available online. In this theme, there were two groups of responses which included improvement of Wi-Fi connection (16 responses) and free internet access (2 responses).

Theme RM2: Different Teaching and Learning Methods
Twelve different approaches used in medical learning were collated from the responses under the main theme of different learning methods. Due to occasionally unstable internet connections, some students were unable to access synchronised online classes; therefore, there were nine students who suggested that lectures and educational videos be prerecorded before the class or recorded during the class as a reference for those students.
'Record teaching video for practical besides concept lecture because it is better than online discussion. Sometimes the line does not cooperate, I can't get the full content of the discussion...' (R32) There were students (n = 27) who deemed e-learning as a more interactive way of learning and involved intercommunication between both lecturers and students instead of plain lecturing.
'More group discussions and problem-based learning than mass lecture.' (R46) While all medical students were staying at home under the Movement Control Order, three students mentioned that online teaching should be delivered more frequently, and one of them gave the following example: 'Having an online lecture every day at least for one hour to sustain the knowledge.' (R90) To enhance the understanding of certain topics, especially lessons involving anatomy and physiology, there were two comments about the preparation of more graphical explanations; for instance, lecturers may incorporate more mind maps or diagrams when delivering lectures. Students also suggested that history taking can be carried out through video conferencing with patients whose condition was stable to be interviewed.

'Can involve real patients in learning history taking.' (R64)
There was one response that suggested virtual ward rounds to replace the routine ward round performed in a hospital setting.

'Can improve session like 'DxR Clinician' so students can improve (on) their clinical reasoning skills.' (R14)
Three responses suggested virtual reality replacing clinical exposure learning for medical students.
'We need virtual reality; it will make it a lot more fun but then again not realistic at all.' (R51) Two students hoped that the faculty can subscribe to more learning applications during this COVID-19 period.
'.... subscribe to UpToDate.' (R21) For students who used to borrow medical books from the library or left their study materials at their accommodation in the faculty, there was one suggestion about free e-books which can be accessed online.
'... provide free eBooks or any study materials that are reliable/easy to understand . . . ' (R79) To consolidate one's knowledge and explore their own understanding of certain topics, there were 16 responses that mentioned quizzes, question banks, or Kahoot. 'Improve the assessment system. Instead of sticking to the same weightage for final semester exams, maybe the management team can adjust the weightage and methods of evaluation if either exams or teaching and learning sessions are held online.' (R39)

Theme RM5: Traditional Method of Learning
A total of four students insisted on having traditional methods of learning, as they believed that clinical components especially cannot be replaced with open distance learning. Three out of these four students were clinical students. Two of them even proposed that they were willing to postpone the current semester and graduation until they were allowed to enter the hospital and resume the usual way of learning from patients.
'I prefer traditional ways of learning rather than online as history taking and physical examination cannot be trained via digital learning.' (R7) 'Nothing, no online classes ever can beat the actual learning method by seeing patients. Postpone the semester.' (R130)

Discussion
Generally, it is believed that open distance learning cannot replace the conventional teaching and learning methods in medicine [31][32][33][34], as the nature of the medical degree involves substantial hands-on skills that open distance learning lacks. Open distance learning has been playing a complementary role in medical education thus far [31]. Indeed, the unanticipated full implementation of open distance learning upon the introduction of the Movement Restriction Order (MCO) in Malaysia has left all faculty members unprepared, and the actual outcome is yet to be observed. Open distance learning has been implemented in medical schools worldwide during the COVID-19 pandemic [2,[35][36][37][38]. Various innovative teaching and learning methods have been introduced such as virtual clerkships, simulation software, and digital clinical placements [39][40][41][42][43][44]. However, one of the main concerns is internet connection issues such as poor coverage, low speed, and network congestion [16]. This has been the main challenge faced by undergraduate students throughout their studies [45][46][47][48]. In fact, our preliminary data found that 40% of medical students had a poor internet connection (<5 Mbps). Feedback from the medical students also showed that internet connection must be improved, and free internet should be provided to achieve effective open distance learning.
We believe that this medical education transformation has caused certain changes and impacts on learning styles among medical students. Multimodal has been the preferred style of learning among medical students, especially among universities that use integrated curricula [49][50][51][52][53]. Hence, with the implementation of open distance learning, there are adaptations from lecturers and medical students, as they are required to make use of the available resources in digital platforms to gain the utmost knowledge and skills for practical clinical components that were initially obtained through clinical clerkships at the hospital. As such, clinical students would be more impacted, as they have missed the most crucial part of learning directly from patients. Indeed, there were several responses from clinical students stating that they had a tough time adapting to open distance learning. They hoped that they could be provided with more interactive forms of digital learning, simulation software, videos regarding the topics to be learned, and recordings of lectures. These strategies make up the multimodal style of learning, including aural and visual, and can partially replace the kinaesthetic style since students do not have any direct experience with patients via clerkships in hospitals during the pandemic period. In fact, medical students have positive views towards the use of simulation-based learning [54][55][56][57] and virtual reality [40,[58][59][60], as they provide hands-on practice and improve learning competency with clinical reasoning skills especially when there is limited availability of patients in hospitals. Hence, the development of simulation labs should be encouraged in medical institutions to allow medical students to gain medical-procedural experience with more intensive training workshops provided for lecturers so that it could be used as an additional tool for medical teaching and learning.
Our results found that medical students portrayed intrinsic motivation, mainly selfmotivation, and self-discipline, in coping with this tough time. For instance, some of them motivate themselves to learn continuously by recalling the actual intention of medical pursuit, while some create an organised study plan with daily learning objectives to ensure that they learn something every day. This is reasonable, as medical students are known to have high intrinsic motivation, compared with undergraduate students of other courses [61,62]. High motivation has been one of the vital components during selections or interviews for the course of medicine [63,64]. Thus, medical students with pre-existing high intrinsic motivation will make use of all available digital resources for their study despite the challenges they faced during the pandemic.
Hence, it can be concluded that most of the medical students' learning motivations are not impacted by the pandemic. As open distance learning has been part of the blended learning in UKM medical curricula, medical students generally adapted well during the pandemic. However, the challenges that they face from full digitalisation of open distance learning mainly emerged from extrinsic factors, especially the learning environment. As suggested by medical students, stable internet connection, more variety of online learning platforms such as UpToDate and full-text journals that are accessible without any time and place restrictions, and ideal LMS platforms to access all learning materials while encouraging discussions between lecturers and students via online assessments such as quizzes and viva sessions are required if the university were to embark on the sustainable open distance learning experience. Based on these recommendations, students with high intrinsic motivation can improve their lifelong learning skills through open distance learning.
This study was conducted with a few potential limitations. Further quantitative synthesis to determine the impact of potential confounders such as age, gender, the phase of the study, and household income on learning motivation among medical students was not carried out due to the lack of relevant data. Since only UKM medical students were involved in this study, the representativeness and generalisability of the findings to other medical faculties are limited. Additionally, there was a likelihood of respondents giving socially desirable responses, as they may answer the questionnaire positively based on what they perceived to be expected of them since our study used self-reported data. Further longitudinal studies with mixed methods are recommended to explore the impact of open distance learning on learning motivation among medical students. Constant feedback, reflections, and evaluations from medical students on the implementation of open distance learning are required to improve medical education.

Conclusions
The majority of medical students portrayed intrinsic motivation in their studies during the current pandemic period. Better internet connection, innovative ways of teaching and learning, new assessment methods, and strengthening of LMS is recommended for optimal outcome of open distance learning. Open distance learning should be improvised based on students' needs and recommendations to be an additional driving factor to further increase learning motivation, especially during this pandemic period, when face-to-face teaching and learning methods are limited. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data of this article are available upon reasonable request from the corresponding author.