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
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