Articles

Simulation-based learning (SBL) is widely recognized as an effective educational approach that bridges theory and practice in nursing education. Despite its global adoption, limited research has examined the experiences of Filipino nursing students with SBL, particularly in resource-constrained settings. This study explored the perspectives of Bachelor of Science in Nursing students from a university in Metro Manila, Philippines, on the impact of SBL on their skills, emotional responses, and challenges encountered. A descriptive qualitative design was employed using purposive sampling of ten students who had participated in at least one SBL activity. Data were collected through semi-structured interviews and short written reflections and analyzed thematically following Braun and Clarke’s framework to capture nuanced experiences. Three major themes emerged from the analysis. First, students reported initial anxiety, nervousness, and stress during their early SBL experiences, which gradually transformed into confidence, adaptability, and resilience as they gained familiarity and competence. Second, SBL enhanced technical and cognitive skills such as clinical judgment, decision-making, teamwork, and patient-centered care, supporting students’ readiness for real-world practice. Third, students identified resource limitations, insufficient equipment, and time constraints as significant barriers to optimal learning, though these challenges also fostered creativity and perseverance. The findings demonstrate that SBL fosters technical competence, critical thinking, and professional growth but requires institutional support to address resource constraints and faculty development needs. This study underscores the importance of expanding SBL in Philippine nursing curricula to align with international best practices and to contribute to Sustainable Development Goals 3 (good health and well-being), 4 (quality education), and 5 (gender equality).

Complexity Leadership Theory (CLT) is a new and revolutionary concept in addressing healthcare crises worldwide. Its relevance and applications were tested during the COVID-19 pandemic. However, no definite and encompassing research was done to apply it to nursing leadership. Thus, this study examines CLT integration into nursing leadership to address the challenges posed by the pandemic. Through a systematic review of literature from PubMed, Scopus, and Web of Science, relevant studies were analyzed to determine how complexity leadership theory was defined, conceptualized, and operationalized within nursing leadership context. The findings reveal that traditional hierarchical leadership models are insufficient in a dynamic crisis environment like the pandemic. Instead, CLT’s framework which encompasses adaptive, administrative, and enabling leadership facilitates innovation, resilience, and effective interprofessional collaboration. Nurse leaders employing these strategies are better positioned to manage resources limitation, foster shared decision-making, and implement technological advancements in rapidly changing healthcare settings. Overall, this study underscores the potential of complexity leadership theory to transform nursing leadership practices by promoting continuous learning and empowerment, thereby enhancing crisis response and preparedness for future pandemics.

The commentary paper reviewed the above research study conducted by Wang et al. (2025), and the investigators examined the association between nurse staffing, job satisfaction, and work engagement, and how these variables impact the quality of care provision provided among the Chinese hospitals. Despite knowing that low staffing within the healthcare facilities is a global issue, Wang and colleagues believed that low staffing is negatively and significantly associated with nurse’s welfare and patient care outcome. This issue causes an increase in burnout and decreased retention of healthcare providers within the clinical setting. It is important to consider and focus on improving and fostering job satisfaction and work engagement among nurses to provide better quality care even within a low staffing environment. According to Wang and colleagues, low staffing outcomes could be mitigated by encouraging workplaces to create healthy and supportive environments for the engaged and satisfied nurses. These would result in better out among patients and increase job fulfilment and welfare among nurses.

<b>Background:</b> Scapulohumeral periarthritis commonly afflicts individuals in their middle age. Its etiology is multifaceted, and treatment presents a challenge with a high risk of recurrence. The main symptoms include shoulder pain and limited joint mobility, seriously affect the quality of life of the patients. Recent research indicate that acupuncture combined with bloodletting cupping can significantly improve the function of activity of shoulder joint and the pain in individuals with scapulohumeral periarthritis. However, these studies have typically been limited in scope, therefore additional research to substantiate the efficacy and safety of these intervention. <b>Methods:</b> To evaluate the efficacy of acupuncture combined with bloodletting cupping for treating patients with scapulohumeral periarthritis. We conducted an online search of databases in both Chinese and English, including PubMed, the Cochrane Library, Embase, Web of Science, CNKI, Wangfang Data, China Science and Technology Journal Database (VIP) and Chinese BioMedical Literature Database (CBM), to collect randomized controlled trials (RCTs) concerning the use of acupuncture combined with bloodletting cupping in scapulohumeral periarthritis patients. We also examined the references within the identified literature. Search utilised subject headings and free-text terms in both languages, without racial restrictions, for records up to April 3, 2024. Two researchers independently screened the literature, extracted data, and evaluated their qualities. RevMan 5.3 software was used for meta-analysis of the included studies. The protocol of this review was recorded in the International Platform of Registered Systematic Review and Meta-analysis Protocols (PROSPERO). Its registration number is CRD42023454614. <b>Results:</b> This review incorporated 22 RCTs involving a total of 1,774 patients. The results of meta-analysis showed that the clinical effective rate (RR=1.25, 95%CI [1.20, 1.30], P＜0.00001) of treating scapulohumeral periarthritis with acupuncture combined with bloodletting cupping was higher in the experimental group than in the control group. The all of Visual Analogue Scale (VAS) score (MD=-1.70, 95% CI [-2.17, -1.22], P＜0.00001). Melle score (SMD=-2.45, 95% CI [-2.55, -2.34], P=0.007]) and recurrence rate (RR=0.23, 95% CI [0.07, 0.77], P=0.02) were lower in the experimental group than in the control group with statistical significance (P<0.05). <b>Conclusion:</b> The acupuncture combined with bloodletting cupping for the treatment of shoulder impingement syndrome demonstrates definite efficacy and safety, with superior clinical effectiveness, pain relief, improvement in shoulder joint mobility, and reduction in recurrence compared to acupuncture alone. Therefore, it is worthy of being promoted and applied clinically.

<b>Objective</b>: To investigate the status of the acoustic environment of a typical Chinese pediatric emergency care department in a time series and identify the relationship between noise levels and factors such as crowd density and movement. <b>Methods</b>: A descriptive study was designed based on a multi-loci time-series method. We measured three loci under three variable settings: the decibel value, observation volume, and emergency care volume. <b>Results</b>: The noise levels of the three loci were significantly higher than the internationally recommended levels, exceeding rate reached more than 86.3%. The 24-hour mean map of the three loci showed similar fluctuation patterns, all of which had two peaks at approximately 10:00 AM and 16:00 PM. <b>Conclusions</b>: The daytime and nighttime noise levels were well-fitted by cubic functions with different coefficients. It is suggested that crowd density and movement may play important roles in noise mean fluctuations, which can be optimized to ensure a satisfactory environment in a pediatric emergency care department.

<b>Background</b>: Disasters such as typhoons, floods, and earthquakes frequently impact the Philippines, placing nurses at the forefront of response and care. Given these recurring threats, ensuring that nurses possess adequate awareness, knowledge, and skills is crucial to mitigate risks, enhance preparedness, and promote effective disaster management. <b>Aim/Objectives</b>: This study sought to (1) assess the current levels of awareness, knowledge, skills, and involvement of private hospital nurses in Rizal Province across four phases of disaster management—mitigation and prevention, preparedness, response, and rehabilitation and recovery; and (2) propose a contingency and training plan based on identified gaps. <b>Methods</b>: A descriptive correlational design was employed. A total of 350 nurses from Level 1, 2, and 3 hospitals participated by completing a validated questionnaire. Data were analyzed using descriptive statistics, analysis of variance, and correlation tests to identify differences and relationships among variables. <b>Results</b>: Overall, the nurses reported very high levels of awareness and skills, coupled with a high level of knowledge and significant involvement in disaster-related activities. Nurses in larger (Level 3) hospitals exhibited higher practical readiness and engagement, while those in Level 1 and 2 facilities had comparatively lower scores. Positive correlations emerged between higher levels of awareness, knowledge, and skills and increased engagement in disaster initiatives. <b>Conclusion</b>: Building on these findings, a targeted contingency and training plan was designed using Pucel’s Performance-based Instructional Design, emphasizing hands-on simulations, structured policy briefings, and collaborative efforts with local disaster risk reduction offices. Addressing these specific gaps can bolster hospital preparedness, strengthen community resilience, and ensure more effective disaster response and patient care.

<b>Background:</b> Nursing students are exposed to significant stress due to academic and clinical demands, which can adversely affect their mental health, academic performance, and future clinical competence. Despite the global acknowledgment of this issue, limited research has been conducted to explore the prevalence and determinants of stress among nursing students in Bangladesh. <b>Methods:</b> This cross-sectional study was conducted from December 2023 to February 2024 among 372 nursing students enrolled in selected nursing colleges in Bangladesh. A purposive sampling technique was used, and data was collected using a semi-structured questionnaire. The questionnaire assessed socio-demographic characteristics, academic challenges, and psychological symptoms, with mental health stress measured using a Likert scale. Descriptive statistics and Chi-square tests were used to analyze the data, with a 95% confidence interval applied to all analyses. <b>Results:</b> The findings revealed that 31.7% of nursing students experienced severe stress, 23.9% reported moderate stress, and 16.7% had mild stress. Age, academic semester, and course load difficulties were significantly associated with stress levels (p < 0.05). Psychological symptoms such as anxiety, difficulty concentrating, and loss of interest in activities were also significantly linked to higher stress levels. Notably, students in their first semester and those reporting harder course loads were more likely to experience stress. However, gender was not significantly associated with stress levels. <b>Conclusions: </b>This study underscores the high prevalence of stress among nursing students in Bangladesh, driven by academic and clinical challenges and psychological symptoms. The findings highlight the need for targeted interventions, such as stress management training, enhanced mental health support, and policies to alleviate academic pressures. Future research should explore longitudinal trends in stress and evaluate the effectiveness of interventions to support a resilient nursing workforce.

<b>Background:</b> Diabetes is a chronic global health issue that requires effective management to improve patient outcomes and quality of life. Nursing education plays a critical role in empowering diabetic patients with self-management skills. Aim This systematic review evaluates the impact of diabetes-focused nursing education on patient outcomes and quality of life. <b>Methods:</b> This study uses PRISMA guidelines and a systematic approach to identify and evaluate relevant literature. <b>Results and Discussion:</b> Among the 14 studies reviewed, eight emphasized self-management education, while four incorporated multidisciplinary approaches. Findings consistently demonstrated that structured nursing education programs significantly improved self-management behaviors, glycemic control, and patient knowledge. For instance, nurse-led self-management programs resulted in substantial enhancements in self-care skills and diabetes-related knowledge. Moreover, interventions that combined health education with psychological support were particularly effective, leading to better blood glucose control and increased adherence to treatment. Studies that examined quality of life reported reductions in anxiety, improved lifestyle habits, and better overall self-management. These findings highlight the multifaceted benefits of nursing education, suggesting that structured, supportive programs positively impact both clinical and psychological aspects of diabetes care. <b>Conclusion:</b> The review emphasizes the value of comprehensive nursing education that integrates both clinical guidance and psychological support for holistic diabetes management. <b>Implications</b>: Ongoing professional development and culturally sensitive education programs are recommended to address the diverse needs of diabetic patients. Future research should investigate the long-term effects of nursing education and explore innovative strategies to enhance diabetes management outcomes.

<b>Background:</b> Nowadays, integrating online and remote instruction into education presents unique challenges, particularly in nursing education, where combining technology with the core value of caring is essential. Nurse educators must address students’ holistic needs, as their circumstances can influence overall learning development. <b>Objectives:</b> This study aims to ascertain the technological caring competence of nurse educators <b>Methodology:</b> A descriptive design using an adapted tool on technological caring competence for nursing education (TCCNE) <b>Results:</b> A total of 243 Filipino nursing educators participated in this study. Overall, the participants’ perceived level of TCCNE was quite high. This sample representative of nursing educators holds strong perceptions of their TCCNE with the values of being considerate, supportive, and respectful to their students as the highest rated competency. This result implies that the educators keep the essence of what nursing is about as they model the importance of caring even in an academic setting considering that these teachers are using remote instruction. <b>Conclusion:</b> The study opens up a discussion on assessing the TCCNE of nursing education in an academic setting. Thus, its advocacy could start from implementing the research training plan. Further, the nurse educators should strengthen in balancing care with appropriate technology is viewed as a necessary step to maintain the essence of nursing, which is on caring that can be modeled out not just in clinical practice alone, but in nursing education.

<b>Background</b>: Telomere length is a critical biomarker of cellular aging and overall health. While childhood socioeconomic status (SES) indicators such as education and poverty can have long-lasting effects on biological aging, research has shown contradictory results regarding the impact of adulthood SES on future telomere length, particularly in racially and ethnically diverse individuals. This study investigates the effects of baseline adulthood SES indicators such as education and poverty on telomere length nine years later in women, using data from the Future of Families and Child Wellbeing Study (FFCWS). <b>Methods: </b>We analyzed data from the FFCWS, a longitudinal cohort study. The sample included baseline adulthood SES and follow-up telomere length measure of women (n = 2,421) with varying socioeconomic conditions. Telomere length was measured from saliva samples nine years after the baseline measure of adulthood SES. Education, poverty, and marital status at baseline were assessed. Multivariate linear regression models were used to examine the association between adulthood SES indicators at baseline and future telomere length, controlling for potential confounders. <b>Results:</b><b> </b>From the total 2,421 women, 675 were Latino White, 1,158 were non-Latino Black, and 588 were non-Latino White. Our findings indicate that for non-Latino White women poverty at certain level, and childbirth weight, and for non-Latino Black maternal age were predictors of telomere lengths nine years later. <b>Conclusion:</b><b> </b>Poverty at a specific level, maternal age and childbirth weight serve as predictors of telomere lengths nine years later in some women. These findings underscore the importance of socioeconomic factors and early-life influences in understanding telomere dynamics and aging processes among women from varied racial and ethnic backgrounds.

<b>Background</b>: In the landscape of education, the decision-making process that leads students to pursue or reject nursing as a career is a multifaceted phenomenon shaped by a plethora of influences ranging from personal experiences to societal norms. <b>Aim</b>: To explore non-nursing students' insights on nursing education, seeking to shed light on the considerations and challenges that influence their views on nursing education. <b>Materials &#x26; Methods</b>: A qualitative approach using thematic analysis were utilized. Lincoln and Guba's framework for rigor and trustworthiness directed the validation process. Semi-structured interviews based on vetted questionnaires yielded the data<b>. Results</b>: Analysis of interviews with ten (10) non-nursing college students revealed three key themes: 1) initial insights, 2) factors influencing their insights, and 3) difficulty of nursing education. Non-nursing students view nursing education as multifaceted and rigorous, recognizing the profession's complexity but have reservations about the heavy workload, intense clinical demands, and health risks, particularly highlighted by the pandemic, which contributes to their reluctance to choose nursing as a career path. <b>Implications</b>: Addressing perceptions, enhancing curricula, offering mentorship, and providing emotional support, nursing education can be improved, steering more students towards a career in nursing. <b>Conclusion</b>: Non-nursing students respect the complexity of the nursing profession but are deterred by its demands and risks, indicating a need for educational reforms to better convey the role, value, and opportunities within nursing to encourage more students into the field.

Delirium is a major complication most commonly observed in patients with advanced cancer. However, despite its prevalence, the early diagnosis, management, and prevention of this condition have not seen significant progress. Aim of this research is to provide insights into the prevalence of delirium, the optimization of interventions for managing delirium symptoms, their effectiveness and the impact of underlying factors on the reversibility of delirium in advanced cancer patients receiving palliative care. The review involved systematic searches of relevant databases including MEDLINE, CINAHL, ProQuest Nursing and Allied Health, and PsychInfo using refined search terms. Eight publications out of 614 studies originally searched were selected and critically reviewed. Their quality was assessed using Joanna Briggs Institute's Critical Appraisal Tool for Case Series. Data abstraction and content analysis were performed to synthesize the findings. Delirium is prevalent among advanced cancer patients in palliative care, with rates ranging from 10.3% to 24.1%. Pharmacotherapy and non-pharmacological interventions showed effectiveness in reducing delirium symptoms. Delirium was found to be reversible through palliative care interventions, antipsychotic medications, and exercise therapy. Effective delirium management is crucial in improving the quality of life of cancer patients. This review emphasizes the importance of subtype-specific treatments, standardized guidelines, and long-term follow-up studies. Implementing evidence-based individualized approaches to delirium management can optimize treatment efficacy and clinical outcomes in patients as well as improve the quality of care. Tailored interventions, standardized protocols, and further research are hereby recommended.

Background: </b>Over the past decade, there has been a rapid advancement in technology and virtual reality applications, leading to the emergence of the metaverse - a virtual universe where users interact with each other and their surroundings through immersive experiences. In the nursing profession, the metaverse presents unique opportunities to enhance patient care, education, and collaboration. <b>Aim:</b> To analyze and identify the attributes of metaverse in nursing, exploring its dimensions, benefits, challenges, and implications. By examining relevant literature, this study will contribute to a better understanding of the metaverse in nursing. <b>Method/Design:</b> Concept analysis by Walker and Avant (2019). <b>Results:</b> Metaverse in nursing involves three defining attributes: use of advanced technologies, better access to education and healthcare, and collaboration and community building. Antecedents of metaverse in nursing require technological advancements, increased digital literacy, demand for innovative education, globalization of healthcare education <b>Conclusion:</b> Metaverse in Nursing suggests that it is a promising technology that has the potential to enhance nursing practice and improve patient outcomes, but further research is needed to fully explore the impact of its integration.

1) Background: </b>Culture shock is a common experience by internationally educated nurses (IENs) working in foreign countries, characterized by disorientation and discomfort due to distinct norms, values, and rituals. <b>2) Aim</b><b>:</b><b> </b>this study explores culture shock in IENs and explores mitigation techniques to enhance understanding of challenges faced in foreign cultural contexts. <b>3) Method:</b> Using Concept Analysis by Walker and Avant (2019). <b>4</b><b>) Results</b><b>:</b> A total of 20 articles were reviewed. Four major attributes were identified: psychological and emotional impact, communication barriers, acculturation and quality of life, and organizational challenges<b>. 5) Conclusion:</b> This paper explores the challenges faced by nurses from foreign countries due to cultural adjustment and proposes solutions to minimize its effects. It is beneficial for nurses, healthcare organizations, and policymakers, aiming to improve patient care and health outcomes. <b>6) Implication for Practice</b><b>:</b> Addressing culture shock can promote a smooth transition, enhance nurses' experience, and improve their cultural competence. Providing tailored orientation and mentorship programs can help IENs feel supported and empowered, leading to increased job satisfaction, retention rates, and better patient outcomes.

Oncology nurses are more likely to get compassion fatigue (CF) than nurses in other fields because of the emotional stress and poor outlook of cancer patients. Because of this, the care might not be very good, the job might not be very satisfying, and there is a good chance that the patient's pain won't be noticed. <b>Aim.</b> To synthesize empirical evidence on compassion fatigue in order to extract the common, central, and fundamental elements that may improve nursing care. Design. An integrative review <b>Results.</b> Fifteen (15) studies met the eligibility criteria wherein five themes emerged. These are the level of compassion fatigue among oncology nurses, the oncology nurses' perspectives on compassion fatigue, precipitating factors leading to CF with 2 subthemes (work environment and a feeling of lack of support), the influence of compassion fatigue on the personal lives and general well-being of cancer nurses, and the consequences on the quality of oncology nurses' professional lives at work. <b>Conclusion.</b> CF is a significant problem for nurses who work in specialized areas such as cancer units, demonstrated as a basic incapacity to nurture others. The integration of studies provides evidence of clinical practice application which can provide better outcomes and improve nursing care<b>. Implications for Practice.</b> The findings provide understanding into healthcare practice on how to avoid compassion fatigue. Clinical management approaches that can mitigate compassion fatigue and its negative repercussions are presented, as well as the formation of peer support groups that have the ability to ameliorate CF.

<b>Background:</b> Sexuality is considered to be one of the most significant markers of quality of life. This is due to the fact that sexuality is linked to ideas, feelings, behaviors, social integration, and therefore, a person's physical and mental health and well-being but with patients who have gynecologic cancers, there are significant challenges when it comes to matters of sexuality and intimacy. <b>Aim:</b> To find out how gynecological cancer affects women's sexual experiences and how they express sexuality in the context of their sickness <b>Design:</b> A qualitative synthesis, thematic approach <b>Result:</b> Nineteen (19) eligible studies centered with gynecologic cancers on sexual functioning were included with two (2) main themes emerged: (1) Issues with Sexual Experiences and (2) Physical and Emotional Burden. Many individuals were found to have one or more sexual dysfunctions, which commonly caused distress. <b>Conclusion:</b> Changes in the women’s quality of life in the sexual aspect due to their disease takes a toll not just on the physical but in other facets as well. Better knowledge and patient-centered approaches would improve gynecologic cancer patients' capacity to cope in terms of sexual functioning. <b>Implications:</b> Healthcare professionals such as oncology nurses and doctors should better understand ways to address the sexual problems of their patients following the myriad of events following their diagnosis and treatment of their gynecologic cancers.

The rapid spread of COVID 19 outbreak has put a heavy burden on human society and is a great challenge for health care workers. The present study aims to assess the perceptions of nursing personnel regarding challenges in usage of PPE during COVID 19 pandemic and to find out the association between severity of physical symptoms and selected personal variables of nursing personnel. A quantitative approach with descriptive survey research design was used for the study. Web based self-administered questionnaire, rating scale and checklist were developed and distributed among study participants in the “Google forms”. A total of 134 participants were included in the study. Out of the 134 participants, 85(63.4%) nursing personnel were working in the government sector and 49(36.6%) of nursing personnel were working in the private sector. The top five challenges in the usage of PPE ranked based on self-reported data were; 1. difficulty to meet the basic needs such as food and fluids, 2. difficulty to meet elimination needs, 3. Unable to relax, 4. difficulty to meet hygienic needs and 5. disconnected with friends and family during working hours. Analysis of physical symptoms experienced by the nursing personnel showed that 41(30.6%) had mild symptoms, 54(40.3%) had moderate symptoms and 39(29.1%) had severe symptoms experienced owing to PPE usage. The most common physical symptoms reported by nurses were heat stress 124(92.5%), head ache 120(89.6%), exhaustion 117(87.3%) and dryness in throat (86.6%). There were no significant association between physical symptoms of nursing personnel and selected personal variables at 0.05 level of significance.

Hand hygiene is crucial in preventing healthcare-associated infections. In this study, we aimed to quantify the accuracy of subjective evaluation of hand washing through visual inspection and objective evaluation through images. The participants were 24 consenting nursing students, and the study used black light and fluorescent paint to generate sketches and captured images of the unwashed areas, which were processed. Handwashing training was conducted once a week for four consecutive weeks. We collected data in the first and fourth training sessions. We found that the percentage of the unwashed palmar areas was significantly higher in the images than in the sketches (p<0.05). The percentage of the uncleaned area as recognized visually significantly increased for sketches (p=0.01) and decreased for images (p=0.009) in the fourth session. The difference between the percentages of the image and sketch area notably decreased in the fourth session (p=0.002). When we checked the recognition percentage of the unwashed area by dividing the right-hand palmar side into six areas, the fingertips had the highest percentage, and the ball of the thumb had the lowest percentage. The recognition of the unwashed areas was low when comparing the subjective visual assessment with the objective imagery assessment. In addition, the percentage of the unwashed areas decreased with repeated training, indicating a decrease in the difference between the subjective and objective ratings.

<b>Introduction:</b> Health-related quality of life in patients undergoing dialysis decreases over time, not only due to the treatment of the disease but also due to the reduction of physiological, psychological and social well-being. <b>Aim:</b> The aim of this research is to study social support and nursing care that patients with dialysis receive, their levels of fatigue and their quality of life. In addition, the effect of social support and nursing care on the patients'' levels of quality of life is examined. <b>Methodology:</b> A quantitative cross-sectional study was conducted using the questionnaires “Multidimensional Scale of Perceived Social Support”, Fatigue Assessment Scale (FAS), Missoula-VITAS Quality of Life Index and nursing care. The study involved 69 patients on dialysis. <b>Results:</b> Interpersonal relationships were associated with social support (p <0.01). Quality of life was associated with social support (p <0.05). <b>Conclusions:</b> It seems that there is a strong association between social support and quality of life in patients on dialysis.

Student engagement in educational activities is essential for achieving desired learning outcomes. Despite this, little is known about the engagement patterns of nursing students from diverse or disadvantaged backgrounds. A mixed method study was conducted to explore engagement patterns within and outside the classroom but not during clinical placements. Students were asked what engagement means to them and what influences their engagement. Students were also asked how many hours they engaged in each of their undergraduate subjects and the reasons for this. The study was conducted at an Australian education provider. All students (n = 240) enrolled in the Bachelor of Nursing course were invited to participate. Lecture attendance was high at the start of the semester, fluctuated weekly and declined as the semester progressed. Students averaged between 3.5 and 4.4 hours of engagement per subject per week. They defined engagement as actually coming to class and a commitment to learning. Students were engaged by new, interesting content and disengaged by repetitive or complex content and poor tutoring. Most students want to engage but are distracted by intrinsic and extrinsic factors. Research should explore how to best assess students without the concurrent academic workload interfering with their studies.