77 Medical student engagement in small-group active learning INTRODUCTION Student engagement is recognized as an essential yet difficult to achieve aspect of smallgroup active learning in medical training (1–4). Students who engage more, learn more (5–7). However, it can be difficult for teachers to recognize when and why their students engage or disengage in their classrooms, and to interact with students in ways that optimize engagement (4,8–10). If we could gain more insight into the dynamics of student engagement in small-group learning activities, teachers could be facilitated in effectively engaging their students in these settings. In health professions education, many schools have reformed their teaching and learning approaches to support active learning. Active learning requires students to become actively involved in the learning process (11). Although not definitively or unequivocally, reviews generally support the effectiveness of active learning in various health professions education curricula, like problem-based learning (5,12,13), case-based learning (5,14,15), and team-based learning (16–18). One of the reasons why active learning is effective is student engagement (2,19,20). Schools using active learning, need to create settings in which students can engage with teachers, peers, and study content to construct their own knowledge (21–23). Teachers play an important role in stimulating the engagement of their students (4,8,9). They can motivate their students for engagement (24,25), monitor and guide the learning process(26,27), and initiate reflection on the value of engagement (8,28). Students report, however, that teachers may lack the knowledge, skills and attitudes to do this effectively (8,9). Teachers, at the same time, may attribute a lack of students’ engagement to student characteristics, like low motivation, preparation, ability, confidence, or interest (9,29–31). For teachers to be effective in stimulating engagement, they need to understand what engagement really is and how it can be observed in practice. As active learning often requires students to voice their thoughts and collaboratively try to find answers, verbal participation is understood as a good indicator of engagement (29,32,33). The amount of verbal participation can sometimes count towards the grade of a course, or even be part of professional behavior assessments (31,33,34). The absence of verbal participation, or silence, is consequently perceived as a sign of disengagement. However, silence can be a sign of engagement, for example when students think quietly about a question, analyze a problem, or carefully listen to others (30,32). Likewise, student use of electronic devices (e.g., smartphones or laptops) in the classroom is easily understood as a sign of disengagement (35). However, electronic device use can be a sign of engagement, for example when students look up information or save information for later use (36). Therefore, we need to expand our understanding of student engagement, so that teachers can better recognize when and why students engage or disengage in their classrooms, and use that information to optimize the interaction with their students. 4
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