91 Medical student engagement in small-group active learning not the cognitive and emotional dimensions as these are internal to students. Furthermore, this study illustrated how student engagement is a dynamic process. Students can engage or disengage on any or all of the three dimensions, and this study showed they do so multiple times during a two-hour meeting. Moreover, student engagement levels vary from meeting to meeting. This complicates recognizing engagement. A recent review on disengagement acknowledges how difficult it is to accurately identify student disengagement (48). In the review, it is suggested to define standardized measurable indicators of disengagement and transform those in a ‘checklist of engagement’. We, however, would argue against such a course of action. As checklists for reflection can create ‘reflective zombies’, we would fear for ‘engagement zombies’(49). That is, students who are conditioned to behave in a certain way rather than truly engaging with the course content, teachers, and fellow students. Therefore, we recommend teachers to look at the contributions that students make to the learning objectives of a meeting and group dynamics. Engaged students contribute to achieving the learning objectives and positive group dynamics. Disengaged students do not. Stimulating engagement Based on our results, we reiterate the finding that teachers play an important role in stimulating student engagement (4,8,9,24–28). However, as described above, influencing inclass engagement can be difficult for teachers because it is difficult to recognize in practice. Additionally, as found in this study, an incorrect judgement of a student’s engagement can actually increase disengagement. This study adds three suggestions to the literature for teachers to have a positive influence on their students’ engagement: 1) initiate spirals of engagement; 2) address the (modifiable) antecedents; and 3) focus on the intentions behind student behavior. Adhering to these suggestions may help to optimize student engagement in active learning settings (8,9). 1) To initiate a spiral of engagement, tutors can make use of the multidimensional view of student engagement and the finding that students respond well to interventions from each dimension. Teachers can thus use students’ behavior, cognitions, and emotions. Examples from this study are asking students to read a patient case out loud, asking open-ended questions about the content, and having students reflect on their feelings. 2) To stimulate willingness, tutors can reinforce engagement-supportive antecedents, and discuss or challenge engagement-limiting antecedents. Examples from this study are to explore students’ thoughts and feelings about the content of a course, students’ prior knowledge, and the learning process. Teachers could increase willingness by discussing the relevance of the content, how to gain adequate prior knowledge to be able to participate, and how the learning process will help them achieve the course objectives. A limitation here is that teachers cannot address all antecedents, as some might be unknown to teachers 4
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