In the age of information explosion, active learning could help everyone to becomelifelong learners and hence be more capable of responding to the rapid changes in the future.In this study, we identified three CMO domains of medical students’ experiences of active learning. For the first: the context of hierarchical culture, the mechanisms of fear/boredom came about, prompting students to be silent, dare not to give opinions. For the second training domain, in the contexts of interaction between teachers and students, teacher-student familiarity and teachers’ guidance, learning motivation, self-regulation and enthusiasm were triggered, prompting positive learning outcomes and competencies. For the third individual domain, in the context of learning “how to learn actively” from early on, and medical learning environment, the mechanisms of internalization, professional identity and stress, resulted in recognized active learning and advanced preparation. These CMOs were synthesized into a process model of active learning.
Cultural membership, issues of authority and respect, and language proficiency were identified as having a direct influence on the clinical education process .Active learning, such as student-centred and problem-based methods rooted in Western culture, may not be of a truly international nature and its compatibility with non-Western cultures has been challenged [23, 24].Looking at the culture domain, we can see that our society will experience more difficultly with implementing active learning. East Asian education is often referred to as Confucian-heritage education, wherevirtue is achieved primarily bylearning from teachers,imitating their attitudes [25, 26].Confucian culture has undoubtedly been a significant influence on thinking on all aspects of society, unmatched by any other school of thought. It is one of the most frequently cited social factors in healthcare research in East Asian countriesand has also significantly influenced the learning styles in medical education in these countries, which need to be questioned and understood within the complex of local cultural influences[29, 30].Students therefore are more likely to limit their individual development by depending purely on the teacherteaching, and their ideas,which inhibits students from doing their own critical thinking. Moreover, students are also influenced by the oriental concept of "respecting teachers" while learning from them.
In this study, we use qualitative realist evaluation. The context of a hierarchical cultureis consistent with previous research that report similar findings, including hierarchy interfered with non-Western students’ applicationof PBL .Uncertainty, tradition, hierarchy and achievement have often been identified as more prominent in non-Western than in Western cultures[32, 33].In addition, fear and boredomare the mechanism derived from a hierarchical culture. This is a concern as it is a significant and specific context for Taiwan, sparking fear with negative learning outcomes.This suggests a certain incongruity between active learning methods and non-Western cultures. Thus, it complicates the straightforward transfer of active learning to such cultural contexts and the globalization of active learning does not postulate uniform processes and outcomes.Culturally sensitive alternatives might be considered .
The qualities of a good clinical teacher in the context of interaction between teachers and students are important. Sutkin found that excellent clinical teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students.Research has identified thatmedical students use dual processing to rate the effectiveness of classroom teachers; an interaction between the conscious appraisal of teaching attributes – specifically, the perceived charisma of the teacher – and the subconscious rating of variables that portray stereotypes, such as physical appearance .With regard to the interaction between teachers and students, as the context of the effectiveness of excellent teachers, in this study we identified the mechanism of motivation was triggered,resulting in students giving their opinions.
In many East Asian cultures schooling primary to secondary education is heavily influenced by a passive learning culture [36, 37], where reproducing teachers’ statements is strongly emphasizedand where teachersrecommended textbooks serve as the main sources of information, there is little opportunity for active learning. However, different learning contexts do not keep East Asian learners from being self-regulated. Awareness of their unique identity leads them to view learning tasks as high-stakes, and to initiate learning strategies that involve self-regulation.Thus, the teacher-student’s familiarity of active learning without traditional and teacher-centred education is an important context.andstudents’ self-regulation plays the important role for the mechanism, resulting in positive learning outcomes.
The development of active learning relies on teacher's guidance and encouragement. Facilitator’s guidance was a crucial aspect of this process, particularly in situations when students were new to the PBLprocess.In a Japanese context of medical education, medical students in Japan have difficulty extracting problems in PBL scenarios without instruction from teachers.In fact, exposing Year 1 students to the independent learning environment of PBL without providing them with adequate guidance may, rather than promoting the development of SDL skills, cause them to become severely dependent on tutors, predetermined learning objectives and on rote learning in order to ‘survive’[40, 41].
In the context of learning “how to learn actively” from early on, the mechanism of internalization results in recognizing active learning.The lack of readiness of active learning strategies that require self-regulation is problematic in East Asian medical students .They expect their teachers to instruct, and themselves to be instructed or “spoon-fed”.In a Japanese study, medical students consistently rely on teachers’ explanatory lectures and have low motivation to study after a pilot progress test .Student maturity has also been identified as an important factor for active participation .Thus, the learning context of "how to learn actively" from early on promotes internalization of active learning. This may cause them to view learning tasks as high-stakes, and lead to the recognition of active learning strategies.
In the context of the medical learning environment, the mechanisms of physician identity and stress result in studying ahead of time, particularly in the context of clinical setting where they may experience questions testing their knowledge from seniors. External pressure comes from peers, teachers and clinical responsibilities. They learn to think, act and feel like doctors by gradually taking up meaningful activities in the clinical context which help them to prepare for lifelong learning.During this process, they will become full members of a clinical community of practice and collaborate in daily activities [45, 46].Learners who are new to a clinical setting with external pressure from peers, teachers and clinicalresponsibilities are in an active struggle to manage themselves as they are in the process of constructing their professional identities in the clinical training context [47, 48].This helps process helps them to develop a new identity, first as a medical trainee and ultimately as a medical professional.Physician identity formation as a unique medical professional in the clinical setting led to the perception that the medical students as physicians had to allow patients to ask them about any wide-ranging medical problems. Immersion in a responsible individual role, which promotes physician identity formation in the clinical setting, causes medical students to view learning tasks as high-stakes, and to initiate learning strategies in an active learning manner.
Medical students need to feel like a valuable member of the clinical team, by thinking, acting and feeling like a future doctor.Therefore, helping them to engage in effective active learning in a clinical setting begins with helping them to understand what learning is and what effective learning strategies are in a clinical setting. Finally, it helps learners create a professional identity they want to develop, resulting in promoting life long learning.