149 General discussion for the learning (53,55–57). Teachers can cultivate learning environments conducive to active learning, it is the students who have to engage in that environment. Therefore, we encourage students (both invited and uninvited) to express their opinions, concerns, beliefs, and provide feedback to teachers. This involves students in decision-making processes, educational improvements, and quality processes (52). It also directly influences their engagement during the active learning process, as teachers can adapt the learning processes to their input. The concepts of ‘student agency’ and ‘agentic engagement’ are closely related to this suggestion (58,59). They refer to the notion that students proactively express themselves to positively influence their learning environments. Methodological reflections The strengths of this thesis are the combination of various qualitative and mixedmethods research designs used to study three perspectives: students, teachers, and faculty development. Together, they have achieved a comprehensive understanding of student engagement in active learning. We were able to study this topic longitudinally through the two Q-studies and the DBR-study, which allowed us to track how student appreciation of active learning changed over time (Q-studies) and to improve upon the faculty development initiative we designed (DBR-study). We also constructed a theory of how expert teachers stimulated student engagement. Lastly, we were able to integrate the empirical findings of the first four studies into the fifth study (the faculty development initiative), so that we contributed to bridging the theory-practice gap that is present in educational research (60,61). When considering the limitations, our first focus is on the scope of this thesis. We have focused on student engagement in active learning, the interaction between students and teachers, and the supporting role of faculty development. However, through our studies and reading active learning literature, we realize that other factors within and beyond the classroom influence the adoption and implementation of active learning. Included in those factors are teacher identities, cultural aspects, curriculum design, policy, legislation, and organizational issues (4,10,34,62–65). As there are no hard borders between these factors, we have sometimes touched upon those factors, but each factor deserves full attention to further optimize the implementation of active learning in medical curricula. Another general limitation has to do with transferability. We employed strategies to enhance the transferability of findings to other contexts than the one in which the research was conducted. We provided detailed descriptions of the research setting, samples, and research approach, engaged in reflexivity, and were transparent in data collection instruments. However, these strategies do not guarantee the value of our findings and implications in other contexts. We urge careful consideration of our findings before applying them elsewhere. 7
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