Medical Education Online | behavior, emotional, cognitive, or agentic engagement, which is more effective?

In a recent publication, Dr. Xiaoming Xu and her coauthors delved into the critical realm of student engagement across various domains in medical education and learning outcome evaluations. Termed as the "interaction between students and institutions invested in optimizing student experiences, improving academic performance, fostering student development, and enhancing institutional effectiveness and reputation," this topic has garnered extensive attention. Despite widespread interest, previous research has shown inconsistencies in grasping and applying theoretical foundations, as well as a lack of clarity in the classification of student engagement.

This study addresses these gaps by applying Reeves' framework, which includes behavioral, emotional, cognitive, and agentic dimensions of student engagement, to the context of medical education. The aim is to elucidate the relationships between these dimensions of student engagement and learning outcomes. The study categorizes learning outcomes into knowledge and skills, with added classification criteria for cognitive educational goals, including memory, understanding, and application.

Research Questions:

1. How does student engagement (behavioral, emotional, cognitive, and agentic) relate to learning outcomes?

2. What relationships exist between the categories of learning outcomes (memory, understanding, and application) and the various dimensions of student engagement?

3. Does the relationship between student engagement and learning outcomes vary based on student demographics (gender and national college entrance examination results)?


The study utilized the China Medical Student Survey (CMSS) conducted nationwide to assess student engagement, coupled with standardized medical licensing exam results as a measure of learning outcomes. The research employed multiple regression analysis to explore the effectiveness of different types of student engagement. Additionally, the study assessed the moderating effects of gender and national college entrance exam scores on the relationship between student engagement and learning outcomes.

Key Findings:

Results indicate that emotional engagement is most effective in promoting learning outcomes related to basic medical knowledge and fundamental clinical skills. Emotional and cognitive engagement effectively promote memory, understanding, and application of basic medical knowledge. Conversely, behavioral and agentic engagement showed a negative impact on learning outcomes. Furthermore, the study revealed that high college entrance exam scores positively moderate the relationship between student engagement and learning outcomes.


This research provides robust evidence for the effectiveness of emotional and cognitive engagement in enhancing learning outcomes. On a broader scale, behavioral and agentic engagement may not accurately predict outcomes in comprehensive ability tests, highlighting a gap between daily teaching content and the content of such comprehensive tests. The study suggests that cultural influences may explain why active engagement might not positively impact outcomes, emphasizing the need for a conducive learning environment that encourages student participation in all dimensions. The findings propose collaborative efforts between students and educational institutions to bridge the gap between comprehensive ability tests and daily learning activities through effective communication.

About the journal--Medical Education Online:

Medical Education Online shines as a distinguished peer-reviewed journal committed to advancing the understanding, methodologies, and innovations in medical education. This esteemed journal serves as a vital conduit for disseminating cutting-edge research, insightful reviews, and transformative perspectives within the dynamic landscape of medical pedagogy. It is a Q1 journal among Health Professions Education research. The Impact Factor of last 5 years of this journal is 4.7.

Publication resource: Xiaoming Xu, Zehua Shi, Nicolaas A. Bos & Hongbin Wu (2023) Student engagement and learning outcomes: an empirical study applying a four-dimensional framework, Medical Education Online, 28:1, 2268347, DOI: 10.1080/10872981.2023.2268347