Associations between teacher self-efficacy and the use of Objective Structured Clinical Examination in medical education

Introduction: The inclusion of new methodologies and assessments in the medical education area has indicated the need to understand teachers’ perception of their own ability to use them adequately. Objective: Thus, the present study aimed to investigate possible associations between teacher self-efficacy and the use of OSCE. Method: The Teacher Self-efficacy Scale and Self-Efficacy Sources Scale and a characterization questionnaire were used. Forty-seven medical teachers from a private university, of both genders, aged between 31 and 78 years, participated in the study. Results: The results indicated that the factors Social Persuasion and Vicarious Learning were the most endorsed, suggesting that these sources are the ones that interfere the most in the formation of the participants’ beliefs. There was only one positive and statistically significant correlation, with a weak magnitude, established between the Intentionality of Action Efficacy and Vicarious Learning. The other identified correlations were statistically negative and of moderate magnitude. Conclusions: The teachers who agreed with some important characteristics about the OSCE method also showed higher levels of self-efficacy. Therefore, professionals with greater perseverance, resilience and confidence, have also been more committed to teaching, research and student assistance.


INTRODUCTION
Since the end of the 20 th century, medical education has been constantly evolving, which has led to changes and updates in the area over the years. Around 1910, the Flexner Report tried to establish norms and guidelines for medical education in the United States and Canada and the Flexnerian paradigm has been recognized and used as the basis for worldwide medical education. However, over the years, the model ended up being seen as synonymous with a mechanistic, biologistic, individualist, specialistic and technical medical education¹.
At the end of the twentieth century, these criticisms and discussions led Medicine to get closer to collective health². Then, in 1970, a new model emerged, known as the Integral Medicine paradigm, which was reinforced at the International Conference of the World Health Organization, in Alma-Ata, in 1978. After that, the concept of community medicine and its importance in the health-disease process triggered changes in the way of teaching and exercising the profession. The trained physicians would start to meet social expectations, have more specific skills such as communication techniques and leadership positions, in addition to being generalists and knowing Primary Health Care³ , ⁴.
In addition to the paradigm changes, medical education undergoes modifications in the teaching and learning process, which corroborates with new concepts seen in the area of overall education. "In the educational context, at present one hardly talks about stimulus anymore […]. Currently, the catchphrases are significant learning, conceptual change and studentcentered teaching" 5 . The students become autonomous in their learning and new methodologies try to help them build their own ways to reach their cognitive potential 6 .
Considering these factors and the need for practical training in the medical field, since the 1960s new methodologies at different universities around the world have put the student at the center of the learning process 7 . Aiming to meet this demand, the inclusion of a set of educational innovations has been initiated, such as simulation, which has been highlighted mainly in the medical field, as technological and didactic devices that help the teaching-learning process 8 .
In this regard, it is worth clarifying that there are several types of simulators and simulations, from the simpler mannequins to robots that simulate specific and high-fidelity realistic situations 9,10 . In the simulation, a problem-situation can be created with standardized actors or patients, which allows evaluating specific tasks in several areas. With this flexibility, the simulation can come close to real-life and guarantee the student's observation in a safe environment, where the error can be practiced and contribute to significant learning without harming the patient¹¹.
The assessment of clinical skills is, as well as practical and meaningful teaching, a necessity in current medical education, as it seeks to verify the efficacy of learning in the professional act and the most active pedagogical technologies and instruments can assist in the training of future professionals 12 .
Accordingly, Miller's Pyramid is the most often used instrument in medical education to help the teacher to not be restricted to theoretical knowledge alone, and to develop the "know-how" in the assessment of competences and skills 13 .
Thinking about the development of these qualifications, the OSCE (Objective Structured Clinical Examination) methodology can better guide this "know how to demonstrate" that the medical student needs to perform during the course.
Simulation and feedback help teachers to build together with students the necessary professional knowledge and skills in a joint and more simultaneous manner 14 . The OSCE is one of the best and most reliable methods of assessing competences in medical education. The first experience of this method was described in 1975 and, since then, the OSCE has been one of the most widespread evaluation methods worldwide. It is standardized and structured, allowing students to learn from their mistakes and successes throughout the learning process and, therefore, it is considered a formative assessment 15,16 .
The teachers-examiners in the OSCE method constitute a fundamental element of learning, as they are responsible, according to their specialty, to check the ability, competence and correct imperfections in the students' work process 17 .
Several elements can contribute to the effectiveness of this type of evaluation, not only the technical knowledge of the method, but also the belief of the teacher who performs it. Therefore, as advocated by Bandura 18 , thoughts, feelings and beliefs interfere with the way a person will behave when facing a certain action.
In the educational context, specifically, one can consider the teacher self-efficacy beliefs, which is the teachers' judgment about their own ability to organize and achieve their students' involvement and learning, in a significant way, even in the face of the diversity found in the classroom 19  When correlating student behavior to their performance, the teacher cannot disregard the emotional dimension in the teaching-learning process 23 . And, consequently, the teachers must also evaluate themselves, as human relations are not one-sided. It is necessary to stimulate a reflective culture of the teaching action, assessing the personal structure of this professional, their feelings and desires and, mainly, their beliefs 24,25 , aiming to strengthen pedagogical processes such as the OSCE. The greater the teachers' perception and understanding of their educational practices, their feelings and beliefs, the more easily they will avoid reactions that can potentiate anguish and impair their role as educators 26 .
According to Iaochite 27 "[...] as important as for future teachers to acquire the skills, competences and knowledge necessary for teaching, is that they believe they will be able to exercise their roles as teachers with some success". An important aspect to be clarified, when discussing teacher self-efficacy, concerns the role of self-efficacy beliefs in the performance of this professional. "These beliefs influence whether people think pessimistically or optimistically and in ways that help or hinder the individual" 28 .
With all that has been exposed, one can consider that self-efficacy beliefs can interfere in the teaching-learning process not only when associated with student learning but also related to teacher action. Therefore, only teachers who constantly reflect on their pedagogical actions, evaluate, monitor and regulate their self-efficacy beliefs are able to trigger a significant learning process in their students 19 .
Additionally, a teacher with a higher perception of self-efficacy may demonstrate greater acceptance and better use of training techniques and instruments, such as the use of the OSCE as an evaluation process in medical education.
As for the studies that sought to identify and associate the self-efficacy of the medical teacher, these are scarce in the literature. What is indicated is that being exposed to good teachers can improve the understanding of knowledge and the clinical performance of medical students. Still, few studies have been dedicated to the understanding of the psychological mechanisms related to teaching practice 29 . Therefore, according to Dybowski, Sehner and Harendza 29 , the quality of teaching can benefit from teachers who are self-effective and capable of detecting and promoting the students' competences.
Thus, the overall objective of this study is to analyze the association between teacher self-efficacy and the effectiveness in the application of OSCE as an instrument of formative assessment. Therefore, the associations of selfefficacy concerning classroom management and the teacher's intentionality of action were verified, and the associations between the application of OSCE and the teachers' self-efficacy beliefs were identified. Finally, regarding the area of expertise/specialty, most of them were from the area of Internal Medicine (31.9%; n = 15), followed by Emergency Care (19.1%; n = 9), Surgical Clinic (14 , 9%, n = 7), Public Health and Pediatrics (12.8%, n = 6 in each) and the lowest frequency of participants was found in the Gynecology and Obstetrics area (8.5%, n = 4).

Instruments
The following instruments were used for data collection: A. Teacher Self-Efficacy Scale (TSES) 30 : it is an adaptation of the Ohio State Teacher Efficacy Scale 31 and evaluates the teacher self-efficacy in relation to classroom management and the teacher's intentionality of action. The scale has two factors (subscales), namely Factor 1 (Teacher's intentionality of action), which represents the teacher's capacity to mobilize the students to carry out their tasks and teaching mediation (α = 0.87); and Factor 2 (classroom management efficacy), which is related to the teacher's belief to manage and deal with the multiple aspects of the class routine (α = 0.76). The reliability of the total scale was 0.91 (alpha). B. Self-Efficacy Sources Scale (SESS) 27 : it assesses the interference of the four sources of self-efficacy belief formation.
This instrument consists of items that refer to the four sources of elf-efficacy (SE) proposed by Bandura 32

Data analysis
The data were analyzed using the Statistical Package  Subsequently, we tried to verify the association between Perception (TPCONTEXT and TPOSCE) and the Sources of Self-efficacy factors. Table 3 shows that no statistically significant correlations were found in relation to the sources of Direct Experience and Physiological and Affective States. As for the sources of Vicarious Learning and Social Persuasion, the correlations were statistically significant, in a positive sense and with a magnitude varying from weak to moderate.
The correlations between the isolated factors of TPCONTEXT and TPOSCE with the factors of the Self-efficacy Sources Scale were mostly null or showed no statistical significance. In relation to those that were statistically significant, these ranged from weak to moderate in magnitude and had a positive sense, except for item Q13 (Feels prepared to teach) and the factor Physiological and Affective States, in which the correlation was negative. This can mean that the more they feel prepared to teach, the less the source of physiological and affective states interferes in the formation of the teachers' beliefs in this studied group.
between the items of TPCONTEXT and TPOSCE with the Teacher Self-Efficacy Scale (TSES), as shown in the tables below. Finally, the association between the types of self-efficacy and the sources was assessed, as shown in Table 4. Most of the correlations were null or without statistical significance. Regarding the statistically significant correlations, these were negative and showed moderate magnitudes between the factors of Self-efficacy and the Physiological and Affective States sources, indicating that the greater the belief in the ability to teach or control the academic environment, the lower the influences of physiological and emotional pressures on the performance and formation of these beliefs. There was only one positive and statistically significant correlation, of weak magnitude, which was established between Intentionality of Action Efficacy and Vicarious Learning, suggesting that teachers who believe in their capacity to mobilize students for the teaching-learning process may have these beliefs formed from their own experiences in the classroom or from the experiences of their training process as a whole.

DISCUSSION
Initially, the data indicate the importance of the Intentionality of Action Efficacy on the teachers' sense of self-efficacy, information that corroborates other studies that have been previously carried out 27,35 . As observed by Polydoro, Winterstein, Azzi, Carmo and Venditti 30 in the national adaptation of the Ohio State Teacher Efficacy Scale 31 instrument, the Intentionality of Action represents the teacher's belief in their capacity to mediate teaching and mobilize the student to perform the activities. Therefore, it is related to how teachers can help their students to value the teaching/learning process and encompass the actions of monitoring, encouraging, valuing, and providing feedback during the learning process.
Another source that was highlighted about the teachers' appraisal of their own capacities was Social Persuasion, which was analyzed as the source of greatest interference. According to Bandura 32 , social persuasion is one of the most prevalent sources in new teachers and, in this group, there is also a high percentage of teachers without any experience in the professional activity, considering that 20 (42.6%) had less than 10 years of teaching activity and, of the latter, 10 (21.3%) had less than 5 years of experience.
Still from this perspective, social persuasion is one of the most distant sources for strengthening SE, as it can be limited regarding the scope of personal belief in a longlasting manner. But it can reinforce self-assessment, if there is a positive appreciation that the incentive is within the limits of reality 21 . Supposedly, the teachers participating in this research are being encouraged by the HEI but have not yet acquired the experience or pedagogical and scientific knowledge of the formative evaluation method to adequately strengthen their beliefs. Thus, as stated by Bandura 32 , the simple verbal note about someone's capacity is not enough, as it is also necessary for the environment to provide experiences that corroborate the efficacy over a period of time.
Regarding the associations between the professional performance factors and the perception of self-efficacy, it was observed that, if you feel prepared to exercise your activity, you will increase your belief in the capacity to manage the classroom and will maintain your intentionality of action. In other words, feeling prepared to exercise the teaching practice strengthens the teacher's beliefs in managing daily life in the classroom and mobilizing the students to perform their tasks. presumably, teachers who have strong beliefs in their ability to mobilize students to perform tasks and in their teaching activities also believe that the OSCE prepares students for professional practice. Moreover, it also points out that teachers who mobilize students to perform tasks and for teaching activities believe that the OSCE provides greater security for the teachers' work and greater efficacy in student learning.
Regarding the feeling of being prepared to teach and to use the OSCE, correlations were identified, albeit negative, with the teachers' physiological and emotional states. Emotional physical states such as stress, fatigue, anxiety, tension, pain and the mood states are manifestations that can interfere with the perception of self-efficacy. This occurs because these feelings directly affect the person's judgment of their own ability to perform a task 21 . The control of these feelings and dealing with them is an important condition to be successful, contributing to strengthen self-efficacy beliefs 36 . Therefore, there is a decrease in these states when the teacher's perception of being prepared is strengthened. The OSCE should be designed to assess certain competences or skills that cannot be assessed using pen and paper or tests based on computed methods 37 .
At the national level, other studies that used the same instruments as this study, showed a tendency towards medium and, often, high levels of teacher self-efficacy among higher education teachers 27,35,38 . The hypotheses that justify the fact that the teaching group of the present study obtained a more median level of self-efficacy must be confirmed with new studies and qualitative analyses, which will address the specificities of medical teaching and with the use of techniques such as the OSCE.
Regarding the means in the TSES subscales, a higher mean can be seen in the Teacher Intentionality of Action Factor, when compared to the Classroom Management Factor. This difference was also found in the studies carried out by Iaochite 27 and Rocha 35 . Dybowski, Sehner and Harendza 29 also used their own self-efficacy scale developed in their studies and the results imply that the quality of teaching can benefit from teacher training, the capacity to detect their students' competences and the improvement of self-efficacy in medical education.
As postulated by Bandura and confirmed by several studies, the main sources of self-efficacy are direct experiences, vicarious experiences, social persuasion and subjective interpretation of physiological and affective states during an action 32,21,22 .
According to Dybowski, Sehner and Harendza 29 , teacher training should be based on these principles to effectively improve the self-efficacy of medical education. Progress assessments such as the OSCE can be more reliable to assess teaching quality and clarify the association between teaching motivation, teaching self-efficacy and quality of clinical teaching.

CONCLUSIONS
The present study aimed to analyze the association between teacher self-efficacy and the effectiveness in the application of OSCE as an instrument of formative assessment. The study found a higher number of teachers with medium and low self-efficacy and the most prevalent source of efficacy was verbal persuasion, which needs to be confirmed with new qualitative approaches such as a focal group, interview or even an ethnographic study. Trends that also need to be studied and confirmed in further studies with a greater number of teachers and in different institutions were evidenced.
Nevertheless, the data indicate important points to be considered, such as the main observation made, that teachers who agree with some important characteristics about the OSCE method also showed higher levels of selfefficacy. Therefore, they are the professionals with greater perseverance, strategies to overcome difficulties, confidence and resilience, essential qualities for a teacher committed to teaching, research and assistance. As for the study limitations, the small sample size stands out, and therefore, future investigations that expand the sample to different contexts and medical schools are recommended. Moreover, studies with a larger sample would allow the use of other approaches to describe the association between the constructs, such as the theory of response to the multidimensional item included in the structural equation modeling.
This investigation aims to contribute to the dissemination of the self-efficacy construct in medical teaching and to strengthen the OSCE technique as meaningful learning. Therefore, the evaluation can stop being a "payback" to becoming an effective learning opportunity, different from pure mechanical learning. To persistently review the teaching work process and instrumentalize the teacher with the seriousness of methods such as the OSCE and constructs such as self-efficacy will make the training of a medical professional more in line with current social needs and more humanistic.

CONFLICTS OF INTEREST
We declare no potential conflicts of interest that could influence the publication process.

SOURCES OF FUNDING
None to be declared.