29 Appreciating small-group active learning at the end of a semester. Some tutors have a medical background, but this is not a necessity as the tutors do not have to function as content experts. Study design Q-methodology We used Q-methodology for this study. Q-methodology is a mixed-method research technique used for the systematic study of subjective viewpoints (22–24). It allows researchers to obtain a rich and differentiated understanding of participants’ perspectives of the topic under study (25,26). This aligns perfectly with the aim of this study. Q-methodology has been used in (medical) education research before, for example to understand graduate medical trainee’s attitudes towards teaching (27), to inform curricular change (28), and to elicit student attitudes towards their studies (29). Other aspects of education that have been studied using Q-methodology are e-learning (30), assessment (31), and self-regulated learning (32). Following the guidelines provided by Watts and Stenner (2012), we set up this study in five steps: 1) Q-set development, 2) participant selection, 3) data collection (Q-sorting), 4) data analysis, and 5) factor interpretation. These steps are described below in detail. Step 1: Q-set development The Q-set, or the set of statements about the research topic, was specifically developed and tailored to our research questions to cover all possible viewpoints (Figure 2.1). For our first draft, we reviewed relevant literature (on active learning, epistemic beliefs, approaches to learning), the medical school’s educational policy documents, and student evaluation forms of the study group meetings in previous years. We also observed study group meetings and interviewed various stakeholders. As a result of this work, we developed statements in four categories: preferred roles and responsibilities of the students themselves (in- and out of class), their study group, their tutor, and expectations from their medical school. Then, we revised the Q-set through three rounds of feedback. In round 1, we asked two educational professionals and two researchers to review the statements, using a thinkaloud procedure. This allowed us to delete or rephrase unclear statements. In round 2, the research team then assessed the relevance, phrasing, overlap, and completeness of the Q-set. In round 3, we discussed the Q-set with other researchers from the Research in Education team of FMVU. Finally, we pilot tested our Q-set with the study group coordinator, two tutors, and two students. We again used a think-aloud procedure to assess the clarity of the statements. The final Q-set consisted of 54 statements (Table 2.1), which aligns with general recommendations to stay between 40 and 60 statements (24). For publication purposes, we translated the original statements into English (and checked our translation using backtranslation by a native English speaker with Dutch fluency). 2
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