143 General discussion The two Q-methodology studies have illuminated these perceptions of active learning. Our primary finding was that medical students vary in their appreciation of small-group active learning, and can have conflicting motives and preferences for learning in such settings, resulting from differences in epistemic beliefs and approaches to learning (1,12,13,17–21). This finding contributes to understanding why teachers can experience mixed success in engaging their students. Their teaching approach or the design of the course may be more aligned with students in one profile than in another. A secondary finding was the dynamic nature of student appreciation of small-group active learning (2). It changes over time, along with students’ development of epistemic beliefs and approaches to learning. This finding is consistent with previous research, suggesting that students’ expectations of themselves and their learning environment change as they advance in their studies (12,22–28). As students advance, there is a corresponding growth in their knowledge and skills, personal and professional attributes. This growth results in more sophisticated beliefs about knowledge and learning, refined study strategies, and altered expectations from the learning environment (12,28). This finding contributes to the notion that students at different stages of a study program may have distinct needs and preferences for active learning methods. In our integrated perspective, the interaction between students and teachers is identified as a critical factor for achieving optimal student engagement. Consequently, the challenges that became apparent due to the varied, conflicting, and changing needs of students, call for advanced teaching competencies to cultivate an active learning environment in which all students can engage. During their interviews, expert teachers revealed their strategies for navigating these challenges (29). We zoom in on one component highlighted in the constructed theory of expert teaching practice. For expert teachers, getting to know their students was always the first step. They would ask, for example, what their students needed from them as teachers and about their experiences in previous similar classes. This step provided them with valuable information about their students’ diverse and potentially conflicting needs, while also considering the course requirements and their own didactical and pedagogical beliefs. This information informed the next step: establishing agreements with the students on how to make the class a success for everyone. Following this, they would commit to doing what was agreed upon and regularly seek feedback on the active learning process. Thus, by listening to students and addressing their needs, the teachers worked to overcome any reluctance that may have been present at the start. By regularly seeking feedback and adjusting their approach as needed, they maintained high levels of engagement. In conclusion, by acknowledging that students may have varied, conflicting, and changing needs, and incorporating these needs into their teaching approach, expert teachers were able to optimally engage their students during their interactions. Our third study, the stimulated recall study, confirmed the critical importance of constructive interactions between teachers and students in fostering student engagement 7
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