67 Changes in student appreciation of small-group active learning finding is that student appreciation remained fairly stable over time, although key aspects related to students’ epistemic beliefs and approaches to learning did develop. Concerning students’ epistemic beliefs, we identified students in the multiplicity stage (profile 1: success-oriented) and the relativism stage (profile 2: development-oriented). The success-oriented students appreciated how questions can have multiple answers, depending on the clinical reasoning process. The development-oriented students went further by stating how context, personal expertise, and vision contributed to evaluating answers and deciding which answers are better or worse. Being able to weigh answers and make contextdependent choices is what distinguishes the multiplicity from the relativism stage (18,20,21). We found no evidence of students in the dualism stage in this follow-up study, whereas we did find that in the original study (assessment-oriented profile) (12). In the original study, we also did not find evidence of students in the relativism stage. Therefore, in line with our expectations, we conclude that students indeed develop their epistemic beliefs through medical training (18). What this study adds to the literature is how students with different epistemic beliefs appreciate small-group active learning differently. Students in the multiplicity stage appreciate the opportunity to practice skills and gain knowledge collaboratively, whereas students in the relativism stage appreciate the opportunity to develop their own contextualized perspective on complex topics collaboratively. Concerning students’ approaches to learning, students become more strategic (profile 1: success-oriented) and deep (profile 2: development-oriented) learners. Success-oriented students indicated how their experience with small-group active learning settings and the way they were assessed made them more aware of how to study for success. The combination of achievement motivation with deep and surface learning strategies is what defines strategic learning approaches (26). Development-oriented students indicated how they wanted to develop a deep and meaningful understanding of the medical field and used their study groups to compare and contrast information from different sources to create their own perspectives. This motivation for a deep understanding with higher-cognitive strategies is what defines a deep learning approach (26). We did not see evidence for a surface learning approach in our sample. The development of students to become more deep and strategic learners has been found in other studies, and was thus confirmed in this study (17,28,29). What this study adds to the literature is how approaches to learning influence students’ appreciation of small-group active learning. Students with a strategic learning approach value the interactive and collaborative nature of small-group active learning when they feel it contributes to their study success. Students with a deep learning approach value small-group active learning as a way to develop themselves personally and professionally. Implications for practice This study supports the development of interventions to stimulate student motivation for active learning and their engagement in small-group learning activities. We will first 3
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