Jan WIllem Grijpma

Jan Willem Grijpma FROM SMALL SPARK TO GREAT FIRE Optimizing medical students’ engagement in small-group active learning

FROM SMALL SPARK TO GREAT FIRE Optimizing medical students’ engagement in small-group active learning Jan Willem Grijpma

Author: Jan Willem Grijpma Cover lay-out: Jan Willem Grijpma Provided by thesis specialist Ridderprint, ridderprint.nl Printing: Ridderprint Layout and design: Michèle Duquesnoy, persoonlijkproefschrift.nl DOI: http://doi.org/10.5463/thesis.657 Copyright 2024 © Jan Willem Grijpma The Netherlands. All rights reserved. No parts of this thesis may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission of the author. De uitgave van dit proefschrift is mede ondersteund door de Nederlandse Vereniging voor Medisch Onderwijs.

TABLE OF CONTENTS CHAPTER 1 General introduction 7 CHAPTER 2 Appreciating small-group active learning: what do medical students want, and why? A q-methodology study 25 CHAPTER 3 Changes in student appreciation of small-group active learning: a follow-up q-methodological study 49 CHAPTER 4 Medical student engagement in small-group active learning: a stimulated recall study 75 CHAPTER 5 Learning from the experts: stimulating student engagement in small-group active learning 99 CHAPTER 6 Preparing medical teachers for small-group active learning: a design-based research study focusing on transfer 117 CHAPTER 7 General discussion 135 APPENDICES Summary and conclusions 158 Samenvatting en conclusies 163 PhD Portfolio 168 Dankwoord 171 About the author 173

CHAPTER 1 General introduction

8 Chapter 1 Medical education is increasingly making use of active learning, recognizing its potential to enhance student learning (1–3). However, its implementation can be optimized. Faculty and students continue to struggle with integrating active learning into their teaching and learning practices, resulting in reduced effectiveness (4–6). Student engagement has been identified as a major contributor to active learning effectiveness, yet it has also been described as a complex process that can be difficult to influence (1,7,8). The aim of this thesis is to contribute to the implementation of active learning by advancing understanding of the student engagement process and the role that teachers can play in optimizing it. To illustrate the potential and process of student engagement in active learning, I have titled this thesis ‘from small spark to great fire’. It refers to the saying (from unknown origins and phrased in various ways): ‘Education is not the filling of a bucket, but the lighting of a fire’. This saying captures how I approach my work. I strive to inspire and motivate the teachers and students I work with to develop their competencies: to light their fire. The title also holds promise. That great fires follow from small sparks, or in other words, optimal student engagement in the active learning process. Through the research conducted in this thesis, we will see whether that promise holds. Lastly, the saying is consistent with a constructivist view of learning, which I will elaborate on later in this introductory chapter. To outline the following parts of this general introduction, I will first describe how this PhD started. Then, I will introduce the research topic and describe its implementation in medical education, followed by a description of this thesis’s overarching aim and central research question. Next, I will contextualize the research and describe the methodological approach applied in the investigation of the topic. After that, I will provide some reflective thoughts about our approach. To conclude the chapter, I will provide an overview of the subsequent chapters. Starting this PhD After completing my studies in 2010, I began my career as a small-group teacher at a medical school. My role was to support medical students in developing their non-technical skills, such as communication, collaboration, and professionalism. All classes I taught incorporated at least some elements of active learning. I was both fascinated and frustrated by the differences I experienced between student groups. While some groups engaged easily with the content and with each other, others remained disengaged despite my best efforts. This discrepancy was particularly puzzling to me, as many factors were constant across those groups: they had the same teacher (me), employing the same teaching methods, in the same course, in groups with comparable student demographics and of equal sizes. This made me curious: what was causing these differences? Moving ahead to the year 2018. I had taken the next step in my career by joining the Vrije Universiteit Amsterdam as a faculty developer. Here, I fully embraced the concept of active learning as an essential teaching and learning strategy in any study program. During

9 General introduction faculty development initiatives, I would often introduce this strategy to participating teachers. After discussing the concept, suggesting learning activities, and allowing teachers to experience active learning within the meetings, they typically decided to incorporate active learning into their own teaching. In subsequent meetings, teachers would share experiences and many reported clear improvements in student participation, as well as increased enjoyment of their teaching. However, this was not always the case. Despite adhering to recommended practices and repeated attempts, some teachers found that their students remained passive and detached from the learning process. As a result, the teachers felt that they had little choice but to fall back on familiar teaching and learning strategies that did not require interaction, such as lecturing. These contrasting experiences of teachers triggered memories of my personal experiences and reignited my curiosity: what factors contribute to some teachers successfully adopting active learning and engaging students, while others encounter such difficulties? As a faculty developer, I was familiar with various facilitators and barriers that impact active learning, such as the influence of assessment methods, time constraints, group size, student resistance to active participation, class planning, and classroom infrastructure. Still, this knowledge did not provide sufficient answers to my questions or aid the teachers in my faculty development initiatives. This gap prompted me to delve deeper into this matter. Consequently, this thesis represents a means to offer more effective support to the teachers I work with. Introducing active learning and student engagement Active learning is an educational concept describing the process of students actively engaging with study materials through learning activities, and teachers serving as facilitators in the learning process by guiding students as they learn, practice, apply, and evaluate the subject matter (9–12). It is often positioned as the opposite of traditional or passive learning, where students mainly listen to an expert telling them what they should know. Underlying active learning is a constructivist theory of learning, which proposes that learning is an active process that requires learners to construct their own understanding (13,14). Students are not empty buckets to be filled with knowledge but are actively making sense of new information by relating it to prior knowledge and experiences (15). Reviews and meta-analyses on active learning in various fields demonstrate its superior effectiveness on student learning, compared to passive learning (11,16–18). Furthermore, the use of active learning has also been linked to outcomes such as enhanced student motivation, lower student dropout, shorter study duration, and more equitable outcomes for students from disadvantaged backgrounds (7,19–23). A critical factor that directly influences the effectiveness of active learning is student engagement (1–3,24). Student engagement refers to the participation or involvement of students in a learning process. It is often conceptualized as a multidimensional construct, encompassing cognitive, emotional, and behavioral components (1,25). The cognitive 1

10 Chapter 1 component refers to a student’s investment in learning, willingness to put in effort, persevere through challenges, and the use of metacognitive strategies to stimulate their learning. The emotional component refers to a student’s feelings about learning and the learning environment. Finally, the behavioral component refers to a student’s conduct and their observable actions during learning (25). In other words, student engagement concerns what students think, feel, and do regarding the learning process (7). While engagement is characterized by positive cognitions, emotions, and behaviors, a student can also be disengaged, which is characterized by negative cognitions, emotions, and behaviors. Student disengagement refers to a student’s detachment from the learning process (26). When disengaged, a student is not invested in their learning, does not experience positive affect towards their learning, and their actions do not contribute to learning. It is important to note that, although the three components are related, they can function independently. A student can remain disengaged on one component (such as behaviorally disengaged by not participating in class discussions), but become engaged on another component (such as cognitively engaged by thinking deeply about the course content) (27). Despite a large body of research on student engagement, concerns have been raised about the conceptual haziness of the construct (28,29). To improve conceptual clarity, the Dual Component Framework of Student Engagement has been proposed, which defines learning engagement and school engagement as separate constructs under the broader concept of student engagement (29). In short, learning engagement is related to in- or out-of-class learning activities, while school engagement is related to the broader context of the school setting (and includes participating in clubs and identifying with a school). In this thesis, the term student engagement is used to describe the former. Another attempt to improve the conceptual clarity of student engagement comes from the ICAP framework (30). According to this framework, it is useful to differentiate student engagement in distinct activities that allow teachers and researchers to observe and elicit specific modes of student involvement. The ICAP differentiates Interactive, Constructive, Active, and Passive learning modes. Students in an Interactive learning mode are collaboratively generating knowledge beyond the course material. It involves students working together to construct their knowledge, often through discussions or group problem-solving. The dialogue or interaction between students is key in this learning mode. Students in a Constructive learning mode also go beyond what was taught to them. However, in this learning mode, self-construction activities are key, such as by creating concept maps or asking questions. Students in an Active learning mode are physically active or manipulate something in the physical environment, such as gesturing, taking notes, or underlining text. There is no knowledge generation in this learning mode. Finally, students in a Passive learning mode pay attention and receive information, but do nothing with it. Examples include reading a text, watching a video, and listening to a lecture (8,30,31). In addition to differentiating student engagement, ICAP also predicts that, as students become more engaged with learning materials, their learning increases. In other words,

11 General introduction students learn more from Passive to Active to Constructive to Interactive. Empirical studies indeed provide support for this hypothesis (24,31,32). Reflecting on the paragraphs above, and the picture that may appear from it, one might assume that the benefits of active learning are clear and undeniable. It might even seem that educators should feel morally obligated to implement active learning and possibly even eliminate methods that could be considered passive. However, before we proceed with this line of thought, it is important to make room for critical perspectives on active learning research. The following paragraphs will describe four critical perspectives. First, the opposition of active and passive learning is not as black and white as it may appear (33). Usually, passive learning methods involve some active learning. In lectures, for example, teachers often ask questions or use digital tools to engage students at some point. Likewise, active learning methods usually include some form of passive learning or knowledge transmission. In a small-group learning setting such as case-based learning, for example, a teacher may explain material through a presentation. In fact, authors suggest that it may not be a question of whether to choose passive or active learning, but rather a question of how to combine them for optimal results (11,18,34). Second, the specific implementation of active learning can vary greatly between studies, making it difficult to aggregate findings. While critically examining sources of variation, researchers have found that studies have compared different active learning methods, amount of in-class and out-of-class time spent on these methods, characteristics of students and teachers, educational settings, disciplines, dependent variables, designs, and methodologies (33,35). These variations may explain why studies have found mixed results in active learning effectiveness, even though meta-analyses report positive outcomes (11,16–18). Meta-analyses adeptly consolidate findings from individual research studies, offering a broad overview, but they are limited in taking into account the variables that can potentially affect the results and meaning of individual studies (35). One author therefore suggests moving from the question ‘does active learning work’ to ‘which active learning methods taught by which instructors, in what kind of contexts and circumstances, lead to significant better learning results for which learners, and are these methods genuinely better than traditional [i.e., passive] methods?’ (35). Other authors suggest that studies should not compare active with passive learning methods, but compare different types of active learning to identify appropriateness and effectiveness (11). Thus, how active learning is implemented and researched influences findings. Third, student engagement is critical in an active learning process, but teachers may find it difficult to recognize in their classrooms. Behavioral engagement can be observed directly. However, this is not possible for cognitive and emotional engagement. They are internal processes. Therefore, they have to be inferred from behavioral cues. This is, at least partly, why teachers use these behavioral cues to assess if their students are engaged and why 1

12 Chapter 1 the ICAP framework uses overt student behaviors to distinguish the four learning modes (31,36–38). In fact, one assumption of the ICAP framework is that student behavior is a good indicator of student engagement (8). However, critical questions have been raised about this. Verbal participation, for example, is an aspect of behavioral engagement and is typically seen as an indicator of student engagement (39,40). However, to show why this is not a reliable indicator, in one qualitative study, a student described speaking up in class just to get points without much effort (39). This motivation to get points without effort actually aligns with student disengagement. Therefore, being behaviorally active does not necessarily mean being cognitively active (36,41). And it seems that cognitive engagement has the strongest evidence linking it with academic achievement (1,25,30). Fourth, and related to the previous point, student disengagement is common and limits the effectiveness of active learning (26,42). As active learning is typically collaborative in design, it requires students to work together to develop their understanding. When a student does not engage, or even displays disruptive behaviors, they not only reduce their own learning, they can negatively impact the learning of others (25). Factors influencing disengagement are related to both intrinsic and extrinsic factors, such as motivation, unmet expectations, stress, teaching factors, and factors related to the curriculum and institution (26,42,43). Some of these factors may be directly or indirectly under the control of a teacher or of a study program, others are not. This means that although student (dis)engagement can be targeted through interventions, their success is not guaranteed (7). Furthermore, teachers may need to develop their competencies in addressing student disengagement (4,44). One common reaction of teachers experiencing student disengagement is to fall back on more passive learning methods, like lecturing, to avoid such negative situations in the future (45). To summarize, educational literature describes how active learning can be a more effective method to achieve desired student outcomes than passive learning. To be effective, it requires students to engage individually or collaboratively with the course material, preferably in a knowledge-generating way. However, educators should take four important criticisms into account: 1) active and passive learning combined might both be most effective in a learning process, 2) active learning implementation can vary, which affects its potential effectiveness, 3) designing engaging activities and identifying if students are engaged with the material can be difficult, and 4) student disengagement may be difficult to influence and limit the effectiveness of active learning. Thus, active learning can work, but how it is implemented matters. Implementation of active learning in medical education Active learning has been adopted and is increasingly becoming a cornerstone in medical education. The impact of curricular reforms to accommodate active learning is evident in the changing roles of both medical students and teachers within the learning process. Students are less perceived as consumers or clients and are increasingly recognized as partners. Simultaneously, teachers have transitioned from a focus on ‘teaching’ to a focus

13 General introduction on ‘facilitating the learning of their students’ (46–48). Active learning plays a central role in various educational strategies used in medical education, such as Problem-Based Learning (49–51), Case-Based Learning (52,53), and Team-Based Learning (54–56). Various commonly used methods, such as flipped classrooms (57), simulations (58), and peer teaching (59) also stimulate medical teachers to create learning environments in which students can engage with information and construct their understanding. The overall picture that emerges from medical education research into these strategies and methods aligns with the findings of educational research in other disciplines, supporting the effectiveness of active learning (1,2). However, despite the increased use and support of its effectiveness, medical students and teachers do not always appreciate active learning, nor have they learned to implement it consistently and successfully (5,60–63). First, let us focus on the students’ perspectives on active learning. Research on medical students shows that they understand the potential of active learning for their development and support its use in their training (44,60). One scoping review identified that students were generally willing to engage and that their engagement was enhanced in situations with positive student-peer and student-faculty relationships, a stronger sense of competency, and perceived relevance of learning activities (1). Therefore, it may come as a surprise that students can also be reluctant to engage in active learning methods. This reluctance seems to stem from perceptions that such methods may not be the most effective or efficient use of their study time (64,65). Students also seem to prefer some methods over others (66). Finally, when students perceive active learning to be poorly implemented and does not contribute to their goals, they are likely to resist engaging in it (42,44,60,61,67). Thus, it seems that although students generally appreciate active learning, there are factors that influence their engagement. Now, let us focus on the teachers’ perspectives on active learning. Teachers are pivotal in shaping active learning environments in which students want to engage. Their attitudes and competencies directly affect students’ level of engagement in and out of class (8,44,62,68,69). Furthermore, they can serve as mediators for other factors that influence student engagement, such as student characteristics, cultural aspects, curriculum design, and other contextual elements (25,44,68,70,71). In practice, however, teachers have reported to lack the competencies and support needed to fulfill their roles as facilitators of learning successfully (6). Even experienced teachers with advanced knowledge and skills related to active learning have been reported to experience difficulties in engaging their students (5). Research using the ICAP framework has also shown that teachers experience difficulty designing the most engaging (i.e., Constructive and Interactive) activities (8). There is, therefore, an urgent need for teachers to improve their mastery in engaging students in active learning. Finally, let us include a faculty development perspective on active learning. To assist teachers in developing the teaching competencies essential for active learning, faculty development 1

14 Chapter 1 initiatives in medical education regularly address this topic (5,72). Research shows that faculty development can indeed develop relevant knowledge, skills, and attitudes of teachers (72–74). However, additional literature shows that it can be difficult for teachers to implement the lessons learned from these initiatives in their teaching practice (75). Various factors have been identified that contribute to this difficulty, such as that teachers may not receive the necessary time or support to apply their newly acquired competencies or that classrooms are not designed to accommodate active learning (5,76). Thus, even when teachers have mastered competencies related to active learning, other factors can hinder its implementation. In conclusion, active learning has been adopted by medical education, leading to enhanced student learning. However, its implementation could be improved. To fully harness the benefits of active learning in medical education, it is imperative to delve deeper into the challenges of student engagement from the three perspectives described in this section. First, by investigating the students’ perspectives on active learning: given that students generally appreciate active learning, but their engagement may vary, how can their engagement be optimized? Second, by investigating the teachers’ perspectives: given their pivotal role in student engagement, which knowledge, skills, and attitudes are essential for engaging students in active learning methods? Third, by investigating a faculty development perspective: given that faculty development can be effective in developing teachers’ competencies, how can the transfer of these competencies from training to practice be stimulated? By addressing the challenges highlighted here, we can fill knowledge gaps and medical teachers can better stimulate the learning of their students and prepare them for a future as healthcare professionals. Overarching aim and central research question The overarching aim of this thesis is to further enhance student learning in medical education through the implementation of active learning, focusing on student engagement in small-group learning settings. To this end, the central research question of this thesis is: “How can medical teachers be supported in implementing small-group active learning into their teaching practices in such a way that student engagement is optimized?” Context of the research Medical education in the Netherlands starts with a three-year Bachelor’s program, followed by a three-year Master’s program (77). The programs are designed to meet the end qualifications outlined in a national framework (78). These end qualifications integrate knowledge, skills, and attitudes, and are aligned with the CanMEDS framework (79). The studies in this thesis were conducted in the Bachelor’s phase of medical training at the Medical Faculty of the Vrije Universiteit Amsterdam.

15 General introduction At the start of their first year in this medical school, students join study groups consisting of a maximum of twelve students. These study groups, guided by a tutor, meet once or twice per week for two-hour sessions throughout a semester. The course follows a collaborative casebased learning approach in the first two years and shifts to a team-based learning approach in the third year. During these meetings, students discuss written patient cases and work on accompanying assignments designed to help them relate clinical signs and symptoms to underlying mechanisms. The meetings aim to integrate and apply the knowledge, skills, and attitudes gained in lectures, labs, and other meetings. Students are responsible for a range of roles, including chairing meetings, presenting findings, taking notes, and providing peer feedback. They also collaborate between meetings to prepare presentations and work on cases. In the third year, the focus shifts to clinical reasoning skills to prepare students for their roles as interns in the subsequent year. Tutors serve as facilitators during study group meetings, guiding the learning process rather than acting as content experts. Their main tasks are to observe individual contributions, give feedback on professional behavior and personal competencies, and support students’ professional development. In the final year of the bachelor program, tutors are required to have a medical background given its focus on preparing students for the clinical phase of their training. Tutors in earlier years have various backgrounds; some have a medical background, while others come from research or para- or nonmedical fields. The work of this PhD began in 2018, with two studies conducted in a face-to-face manner. The tutoring course at this time was also designed to be conducted face-to-face. Then, the course switched to an online or mixed format from March 2020 to January 2022 due to the COVID-19 pandemic. The third study was conducted online at this time. However, because of the nature of our research question and aim, the last studies were postponed until faceto-face education was possible again. Methodological approach Just as active learning is based on a constructivist theory of learning, we believed that the central research question required a constructivist approach to study it (although our last study also adopted pragmatism to combine qualitative with quantitative data) (80). Constructivist research is characterized by methods that aim to understand events and processes and the processes by which individuals construct meaning from them (81,82). Knowledge and reality are subjective and result from multiple, diverse, and personal interpretations. Constructivist research mainly relies on qualitative methods, although mixed methods can be used when quantitative data is used to gain a more comprehensive understanding of the researched events and processes. In this thesis, a combination of qualitative and mixed-method research designs was used to explore the topic of active learning from three perspectives. Specifically, stimulated recall and constructivist grounded theory were the qualitative methods used, while q-methodology and design-based research constituted the mixed-method approaches. Through this varied 1

16 Chapter 1 methodological framework, combined with the three perspectives we studied, a rich answer to the central research question could be obtained. Reflexivity Given that knowledge is subjective in constructivism and understanding is actively constructed between researchers and participants, reflexivity is an important aspect of qualitative research (83). From the start of this PhD, I had extensive knowledge of active learning and believed that improved implementation of it in medical education would benefit both teachers and students. Therefore, I always collaboratively conducted the research and analyses, kept audit trails, considered multiple interpretations, and regularly discussed findings at various stages with the author team. I had many years of experience working as a teacher in medical education and as a faculty developer working with medical teachers. At the time of this research, I had no (hierarchical) relationships with participants in the studies, nor with the context in which the research was conducted. This ensured that I could use my professional experience and personal curiosity to inform the studies without potential organizational pressure. The other members of the research team were a mix of educational and healthcare professionals: an assistant-professor with a background in linguistics, teaching, and faculty development, a professor of Health Professions Education with a medical background and involved in teaching medical students, and a professor of Educational Sciences with a psychological background. For each study, we deliberately sought collaborations to strengthen the author team. The diversity in the team contributed to rich discussions and new insights. Overview of chapters To answer the central research question and achieve our aim of contributing to active learning implementation in medical education, we will study the knowledge gaps from the three perspectives outlined above: students, teachers, and faculty development. We will focus first on the students’ perspectives. Although students generally appreciate active learning, there are factors that influence their engagement. Furthermore, their engagement might be difficult to recognize and influence. Understanding exactly when students appreciate active learning and what they need to stimulate their engagement is the first step we will take (Chapters 2, 3, and 4). Then, we will shift our focus to the teachers’ perspectives. Teachers play an important role in creating learning environments in which students can engage to construct their understanding, but teachers may need to master specific competencies before they can claim that role more effectively. Understanding which competencies are essential for engaging students in an active learning setting is the second step we will take (Chapter 5).

17 General introduction Finally, we will delve deeper into a faculty development perspective. Faculty development initiatives can support teachers in their development, and we can use the information from previous studies to better prepare teachers to teach in engaging ways. However, the transfer from training to practice may pose a problem. Understanding how teachers can be stimulated to apply the active learning competencies they mastered to their teaching practice is our final step (Chapter 6). Table 1.1 presents an overview of each study’s research questions, along with their respective methods, data sources, and analytical approaches. Table 1.1. Overview of the empirical studies in this thesis Chapter Research Question Method Data Source Analysis 2 When and why do medical students appreciate small-group active learning? Q-methodology Physical Q-sorting procedure and semi-structured interviews with students Centroid method of factor analysis with Varimax rotation (quantitative), analyzed concurrently with interview data (qualitative) 3 How and why does student appreciation of small-group active learning change during the Bachelor program? Q-methodology Online Q-sorting procedure and open-ended questions Centroid method of factor analysis with Varimax rotation (quantitative), analyzed concurrently with interview data (qualitative) Online semistructured interviews with students Conventional content analysis 1

18 Chapter 1 Table 1.1. Overview of the empirical studies in this thesis (continued) Chapter Research Question Method Data Source Analysis 4 1) How do the three dimensions of student engagement interrelate in a classroom setting? 2) How do antecedents of student engagement influence student engagement in class? 3) How can the multidimensional view of student engagement help us to understand why it can be difficult for teachers to engage their students? Stimulated recall Semi-structured interviews with students Template analysis 5 How do expert medical teachers stimulate high levels of student engagement in smallgroup active learning sessions? Constructivist grounded theory Semi-structured interviews with teachers Iterative data analysis using constant comparison 6 How can a Faculty Development Initiative, aimed at enhancing medical teachers’ competencies in facilitating smallgroup active learning, be designed so that transfer is stimulated? Design-based research Observations of meetings Surveys and semi-structured interviews with teachers Descriptive statistics (quantitative) and Directed content analysis (qualitative)

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23 General introduction 1

CHAPTER 2 Appreciating small-group active learning: what do medical students want, and why? A q-methodology study Jan Willem Grijpma Anne de la Croix Anke J.H. Kleinveld Martijn Meeter Rashmi A. Kusurkar Adapted version of the published article in Medical Teacher, 2021;43(4):411-420. https://doi.org/10.1080/0142159X.2020.1854705

26 Chapter 2 ABSTRACT Introduction For Small-Group Active Learning (SMAL) to be effective, students need to engage meaningfully in learning activities to construct their knowledge. Teachers have difficulty in engaging their students in this process. To improve engagement, we aimed to identify the diversity in medical students’ appreciation of SMAL, using the concepts of epistemic beliefs and approaches to learning. Method Q-methodology is a mixed-method research design used for the systematic study of subjectivity. We developed a set of 54 statements on active learning methods. In individual interviews, first-year medical students rank ordered their agreement with these statements and explained their reasons. Data were analyzed using a by-person factor analysis to group participants with shared viewpoints. Results A four-factor solution (i.e., profiles) fit the data collected from 52 students best and explained 52% of the variance. Each profile describes a shared viewpoint on SMAL. We characterized the profiles as ‘understanding-oriented’, ‘assessment-oriented’, ‘grouporiented’, and ‘practice-oriented’. Discussion The four profiles describe how and why students differ in their appreciation of SMAL. Teachers can use the profiles to make better-informed decisions when designing and teaching their SMAL classes, by relating to students’ epistemic beliefs, and approaches to learning. This may improve student motivation and engagement for SMAL.

27 Appreciating small-group active learning INTRODUCTION Small-group active learning methods are effective in developing students’ knowledge, skills, and personal and professional attributes (1–3). They are therefore an important component of many medical programs, and medical students increasingly spend their contact time in small-group settings (4,5). To be effective, active learning methods require students to engage meaningfully in learning activities to construct their own knowledge (6). Students, however, can be reluctant to engage as they feel that these methods are not an effective or efficient use of their study time (7). Consequently, active learning becomes a source of negative emotions, like frustration and anxiety (8), as well as a reason for students to complain (9). In addition, teachers who perceive their students to resist active learning methods might be unable or unwilling to use these methods, and revert to less effective (i.e., more passive) learning methods, like lecturing, that require little student engagement (6, 9–11). Although (medical) education research has identified many factors that influence students’ appreciation of active learning methods, these mainly focus on aspects of curricula, courses, teacher behaviors, and student sociodemographic characteristics (1,7,8,12,13). Only recently have researchers begun to investigate the student’s perspective more deeply in an attempt to explain their continued reluctance towards active learning (7,14). These studies suggest that student appreciation of active learning is not a ‘one-size-fits-all’ issue. Because students have different beliefs about knowledge and learning, strive for different goals, and employ different learning strategies, they appreciate active learning differently. We need a better understanding of students’ diversity in appreciation of active learning to help teachers to improve all students’ motivation for these types of learning activities. Two conceptual frameworks help us to investigate students’ diversity in perception of active learning. Epistemic beliefs are beliefs about the nature of knowledge and the process of learning. Students have different beliefs about how to obtain, perceive, organize, and use knowledge (15,16). Perry’s model of intellectual and moral development describes different stages students can be at, ranging from dualist beliefs (black-and-white thinking: there is one correct answer to everything, students need to memorize these answers), to multiplistic beliefs (problems can have multiple answers and even when contradicting each other, all answers can be correct, knowledge is subjective), to relativistic beliefs (some answers are better than others, depending on your stance or context), to committed beliefs (using personal values to evaluate answers)(16,17). Relating epistemic beliefs to active learning; students in the dualistic stage appreciate teaching and learning activities that will help them to obtain the clear-cut correct answer to questions, while later stages are more open for activities that allow multiple answers to question to coexist, or even activities that allow students to conclude different answers. 2