The Human Side of PBL: Psychological Well-being of Health Sciences Students and Academic Staff: An Integrative Review

The Human Side of PBL: Psychological Well-being of Health Sciences Students and Academic Staff: An Integrative Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The Human Side of PBL: Psychological Well-being of Health Sciences Students and Academic Staff: An Integrative Review Ishmerelda Nonhlanhla Mabena-Segoe, Nkhensani Florence Mabunda This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8357368/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This integrative review examines the psychological wellbeing of health sciences students and academic staff within Problem-Based Learning (PBL) and active learning environments, addressing the human dimension often overlooked in educational research. Methods A comprehensive search of MEDLINE (PubMed), ERIC, PsycINFO, CINAHL, and EBSCO databases was conducted for primary research studies published between January 2010 and December 2024. Inclusion criteria encompassed peer-reviewed articles examining psychological wellbeing, mental health, stress, anxiety, burnout, resilience, or emotional aspects of PBL and related active learning approaches in health sciences education. Whittemore and Knafl's integrative review framework guided the methodology, with thematic analysis used for data synthesis. Results Analysis of 24 studies from 18 countries revealed complex psychological impacts of PBL and active learning on both students and faculty. Students demonstrated enhanced critical thinking, motivation, self-efficacy, and resilience-building, but also experienced significantly higher emotional stress, initial anxiety with new modalities, procrastination-related challenges, and burnout comparable to traditional curricula. Notably, burnout appeared to reflect systemic issues (lack of sleep, unsupportive environments) rather than pedagogy-specific factors. Faculty experiences (n = 2 studies) revealed initial role uncertainty and anxiety, but also psychological respite, professional enrichment, and improved wellbeing through facilitation. Key success factors included appropriate facilitator support, tutorial structure, case authenticity, group harmony, and adequate resources. Implications Active learning implementation must consider psychological dimensions alongside pedagogical outcomes. Findings suggest need for systematic wellbeing support, comprehensive faculty development, curriculum mapping for resilience-building, and institutional policies addressing systemic stressors. This review contributes to Teaching and Learning by highlighting the necessity of human-centered approaches to educational innovation in healthcare sciences. problem-based learning psychological wellbeing health sciences education student mental health faculty stress student anxiety stress Figures Figure 1 Introduction Problem-Based Learning (PBL) has emerged as a dominant pedagogical approach in health sciences education, transforming how medical, nursing, pharmacy, and “allied” health students acquire knowledge and develop clinical reasoning skills (Barrows and Tamblyn, 1980). Originating at McMaster University in the 1960s, PBL shifted the educational paradigm from traditional didactic instruction to student-centered, collaborative learning experiences centred on authentic clinical problems (Wood, 2003). The widespread adoption of PBL across health sciences curricula reflected mounting evidence of its effectiveness in developing critical thinking, self-directed learning, and collaborative skills important for healthcare practice (Koh et al. , 2008; Yew and Goh, 2016). However, this pedagogical transformation demanded significant changes in both student learning approaches and faculty teaching roles, creating new psychological and emotional challenges that warranted careful examination (Dolmans et al. , 2015). Importance of Psychological Wellbeing in Educational Contexts Psychological wellbeing in educational settings covers multiple dimensions including stress management, emotional regulation, self-efficacy, resilience, and overall mental health (Slavin, Schindler and Chibnall, 2014). Research consistently demonstrated that student and faculty wellbeing significantly impacted learning outcomes, retention rates, professional development, and ultimately, patient care quality in health sciences education (Dyrbye, Thomas and Shanafelt, 2006). The demanding nature of health sciences education, combined with the uncertainty and collaborative requirements of PBL, created unique psychological pressures (Frambach et al. , 2012). Students must navigate ambiguous problem scenarios while managing group dynamics and peer evaluation processes. At the same time, staff members (Lecturers) transitioned from information deliverers to learning facilitators, requiring new competencies and emotional labour often without enough institutional support (Steinert, 2005). Rationale for the Integrative Review While extensive literature examines PBL's cognitive and academic outcomes (Norman and Schmidt, 1992; Hmelo-Silver, 2004), limited attention contributed to its psychological and emotional impacts on both learners and educators. This gap represents an important oversight, as the human dimension of educational innovation fundamentally influenced implementation success and sustainability (Maudsley, 1999). An integrative review methodology was particularly appropriate for this inquiry, as it allowed synthesis of diverse research approaches and perspectives to generate comprehensive understanding of PBL's psychological implications (Whittemore and Knafl, 2005). Aim This integrative review aims to synthesize existing evidence regarding psychological wellbeing of health sciences students and academic staff within PBL environments. Research Questions The primary research questions include: How does PBL implementation affect the psychological wellbeing of health sciences students? What psychological challenges and benefits do academic staff experience when facilitating PBL? What factors promote or hinder psychological wellbeing in PBL environments? What support systems and interventions effectively address wellbeing concerns in PBL contexts? Literature Review Introduction Theoretical Framework Problem-Based Learning was characterized by small-group collaborative learning, authentic problem scenarios, student-centered inquiry, and facilitator-guided rather than instructor-led sessions (Barrows and Tamblyn, 1980; Wood, 2003). The typical PBL process involved problem presentation, hypothesis generation, learning issue identification, self-directed study, and knowledge application through group discussion and reflections. This seven-step process, commonly known as the "Maastricht seven-jump" method, had been widely adopted and adapted across health sciences globally (Schmidt, 1983; Dolmans and Schmidt, 2006). The theoretical foundations of PBL are drawn from constructivist learning theories, emphasizing knowledge construction through active engagement with authentic problems (Norman and Schmidt, 1992). Cognitive psychology principles underlying PBL include activation of prior knowledge, elaboration through discussion, contextual learning, and collaborative knowledge construction (Hmelo-Silver, 2004). This pedagogical approach required students to tolerate ambiguity, engage in peer collaboration, self-regulate learning, and develop metacognitive awareness (Yew and Goh, 2016). For the departments/faculty, PBL demanded sophisticated facilitation skills, comfort with uncertainty, and an ability to guide without directing learning processes (Dolmans et al. , 2015). Historical Development and Global Adoption Since its inception at McMaster University in 1969, PBL had spread to medical schools worldwide, with significant adoption in Europe, Asia, and Oceania (Neville, 2008). The approach expanded beyond medical education to nursing, dentistry, pharmacy, and other health professions (Yew and Goh, 2016). However, cultural adaptation had proven necessary, as Western educational assumptions embedded in PBL may conflict with educational traditions emphasizing teacher authority and structured learning (Frambach et al. , 2012). This cultural dimension added complexity to understanding psychological wellbeing within diverse PBL contexts. Psychological Wellbeing Constructs Psychological wellbeing within educational contexts encompassed several key constructs relevant to PBL environments. Understanding these constructions provided a framework for examining the human side of PBL implementation. Stress and Anxiety: Academic stress in health sciences education stemmed from workload demands, performance expectations, and career pressures (Dyrbye, Thomas and Shanafelt, 2006). The transactional model of stress (Lazarus and Folkman, 1984) was particularly relevant to PBL contexts, where students continuously appraise problem-solving demands against their coping resources. PBL introduced additional stressors including group dependency, evaluation uncertainty, and responsibility for peer learning (Moust, Berkel and Schmidt, 2005). State anxiety may increase during PBL sessions due to performance pressure, while trait anxiety influenced adaptation to collaborative learning environments (Cademartori et al. , 2018). Burnout: The Maslach Burnout Inventory framework (Maslach and Leiter, 2016) identified three dimensions: emotional exhaustion, depersonalization (cynicism), and reduced personal accomplishment. Burnout affects both students experiencing chronic academic stress and faculty lecturers managing intensive facilitation demands (Dyrbye et al. , 2017). In PBL contexts, the demands-resources model suggested that facilitation demands (emotional labour, time pressure) must be balanced with resources (institutional support, peer collaboration) to prevent burnout (Bakker and Demerouti, 2007). Self-Efficacy: Bandura, (1997)'s social cognitive theory conceptualized self-efficacy as perceived capability to perform tasks, which influenced both student engagement in collaborative learning and faculty confidence in facilitation roles. Self-efficacy developed through mastery experiences, vicarious learning, social persuasion, and physiological states (Bandura, 1997). In PBL, successful problem-solving experiences enhanced self-efficacy, while repeated struggles without support undermined confidence (Lee et al. , 2023). Resilience: Defined as the capacity to adapt and recover from challenges (Masten, 2001), resilience became important in PBL environments where uncertainty and peer-dependent learning created ongoing psychological demands. Resilience theory suggested that protective factors (social support, problem-solving skills, self-efficacy) buffered the impact of stressors (Luthar, Cicchetti and Becker, 2000). PBL may foster resilience through controlled exposure to challenges within supportive group contexts (Huang et al. , 2022). Theoretical Models of Learning and Wellbeing The relationship between PBL and psychological wellbeing can be understood through several theoretical frameworks. Self-Determination Theory (Deci and Ryan, 2000) suggested that satisfaction of three basic psychological needs like autonomy, competence, and relatedness, promoted wellbeing and optimal functioning. PBL potentially supports autonomy through self-directed learning, competence through problem-solving mastery, and relatedness through collaborative group work. However, when these needs were avoided (e.g., through controlling facilitation, overwhelming challenges, or dysfunctional group dynamics), psychological distress resulted. The Job Demands-Resources model (Bakker and Demerouti, 2007), originally developed for workplace settings, applied to both student learning and faculty facilitation contexts. Job demands (workload, emotional labour, role ambiguity) depleted energy and led to burnout, while job resources (social support, autonomy, feedback) fostered engagement and buffered stress. In PBL environments, the balance between demands and resources determined psychological outcomes for both students and lecturers/ faculty staff. Communities of Practice theory (Wenger, 1999) offered insight into how social learning environments shaped identity and wellbeing. PBL tutorial groups functioned as learning communities where participants negotiated meaning, developed shared practices, and constructed professional identities. The quality of these communities were characterized by mutual engagement, joint enterprise, and shared repertoire, which influenced psychological safety and wellbeing (Moust, Berkel and Schmidt, 2005). Dual Perspective: Students and Academic Staff Understanding PBL's psychological impact required examining both student and staff experiences, as their wellbeing was interconnected within the collaborative learning environment (Azer and Azer, 2015). Student psychological distress impacted group dynamics and learning outcomes, while faculty stress and burnout affected facilitation quality and educational climate (Singaram et al. , 2008). This bidirectional relationship created a complex system where interventions must address the needs of all participants (Steinert, 2005). For students, the transition to PBL represented a significant pedagogical shift requiring adaptation of learning strategies, interpersonal skills, and emotional regulation (White, Gruppen and Fantone, 2013). The student experience encompassed cognitive challenges (problem analysis, knowledge integration), social challenges (group collaboration, peer evaluation), and emotional challenges (uncertainty tolerance, performance anxiety) (Wilson et al. , 2016). For faculty staff, PBL facilitation required professional identity transformation from "sage on the stage" to "guide on the side" (King, 1993). This role transition involved developing new competencies in group facilitation, conflict management, and formative assessment while managing the emotional labour of supporting diverse learners (Choi, 2025). Faculty wellbeing is further influenced by institutional factors including workload recognition, professional development support, and organizational culture (Suwarsi, Ridwan and Fauzan, 2025). Cultural Considerations in PBL and Wellbeing Cultural context significantly influenced both PBL implementation and psychological wellbeing outcomes (Frambach et al. , 2012). Educational approaches emphasizing student autonomy and peer collaboration conflicted with cultural values prioritizing teacher authority, hierarchical relationships, and structured learning (Khoo, 2003). In collectivist cultures, concerns about face-saving, group harmony, and hierarchical relationships created unique psychological pressures within PBL tutorial groups (Azer and Azer, 2015). Understanding these cultural dimensions was important for implementing culturally responsive PBL that supported rather than undermined psychological wellbeing. Methods Introduction This study employed Whittemore and Knafl's integrative review framework, which accommodated diverse methodologies and provided comprehensive understanding of complex phenomena. The five-stage process included problem identification, literature search, data evaluation, data analysis, and presentation of findings. Search Strategy and Databases Systematic research was conducted in MEDLINE (via PubMed), ERIC, and EBSCO databases for articles published between January 2010 and December 2024. Search terms included combinations of "problem-based learning," "PBL," "case-based learning," "CBL," "team-based learning," "TBL," "active learning," "psychological wellbeing," "mental health," "stress," "burnout," "anxiety," "self-efficacy," "resilience," "motivation," "emotional challenges," "health sciences education," "medical education," "nursing education," "pharmacy education," "faculty," and "facilitators." Boolean operators (AND, OR) were used to combine search terms. Reference lists of identified articles were hand-searched for additional relevant studies. Inclusion Criteria Peer-reviewed primary research articles published between January 2010 and December 2024, examining psychological wellbeing, mental health, or emotional aspects of PBL in health sciences education. Studies involving students, faculty, or both; quantitative, qualitative, or mixed methods research. English language publications. Exclusion Criteria Conference abstracts, editorials, or commentary pieces; studies focusing solely on academic outcomes without psychological measures. Non-health sciences educational contexts. Articles examining other active learning approaches without specific PBL focus. Studies were published before 2010 or after December 2024. While the 2010-2024 timeframe was strictly applied to primary research studies included in the review, foundational theoretical works and seminal methodological papers published prior to 2010 (e.g., Self-Determination Theory, Job Demands-Resources Model, Communities of Practice Theory, and foundational PBL literature) are cited in the Literature Review section to provide essential theoretical context and framework for interpreting the findings. This approach is consistent with integrative review methodology, which distinguishes between primary studies under review and theoretical literature used for conceptual framing (Whittemore and Knafl, 2005). Data Extraction and Synthesis Approach Data extraction captured study characteristics, participant demographics, methodology, wellbeing measures, key findings, and implications. Thematic analysis identified patterns across studies, with attention to both positive and negative psychological impacts, support mechanisms, and contextual factors influencing wellbeing outcomes. Quality Assessment The Mixed Methods Appraisal Tool (MMAT) version 2018 and a PRISMA flow diagram were employed to assess the methodological quality of included studies and also provide the flow of information through the different phases of the review. The MMAT is particularly appropriate for integrative reviews as it provides standardized quality criteria for five categories of studies: qualitative research, randomized controlled trials, non-randomized studies, quantitative descriptive studies, and mixed methods studies. Two independent reviewers assessed each study using the MMAT criteria, with disagreements resolved through discussion and consultation with a third reviewer when necessary. The MMAT employs a set of screening questions followed by category-specific quality criteria. Studies were not excluded based on quality scores; rather, quality assessment informed the interpretation and weighting of findings during synthesis. MMAT Criteria Legend S1: Are there clear research questions? S2: Do the collected data allow you to address the research questions? Table 1: The categories of studies and their screening questions according to the MMAT criteria legend. Category 1 (Qualitative): Category 2 (RCT): Category 3 (Quantitative non-randomized): Category 4 (Quantitative Descriptive): Category 5 (Mixed Methods): C1: Is the qualitative approach appropriate? C2: Are data collection methods adequate? C3: Are findings adequately derived from data? C4: Is interpretation sufficiently substantiated? C5: Is there coherence between data sources, collection, analysis and interpretation? C1: Is randomization appropriately performed? C2: Are groups comparable at baseline? C3: Are there complete outcome data? C4: Are outcome assessors blinded? C5: Did participants adhere to assigned intervention? C1: Are participants representative of target population? C2: Are measurements appropriate? C3: Are there complete outcome data? C4: Are confounders accounted for? C5: Is intervention/exposure administered as intended? C1: Is sampling strategy relevant? C2: Is it a sample representative? C3: Are measurements appropriate? C4: Is risk of nonresponse bias low? C5: Is statistical analysis appropriate? C1: Is there adequate rationale for mixed methods? C2: Are components effectively integrated? C3: Are integration outputs adequately interpreted? C4: Are divergences adequately addressed? C5: Do components adhere to quality criteria? Table 1 presents the MMAT 2018 structure used to appraise study quality, starting with two screening questions (S1 and S2) and then applying five category-specific criteria (C1–C5) aligned to each study design type (qualitative, RCT, quantitative This framework provided a consistent way to evaluate methodological rigour across the diverse designs included in the review. Results Introduction The final sample included 24 studies published between 2016 and 2025, spanning multiple health sciences disciplines and geographical contexts across 18 countries. Study designs comprised of 14 quantitative, 6 qualitative, and 4 mixed-methods investigations (Table 3). Participants included undergraduate and graduate students (n=18 studies), faculty members (n=2 studies), and both groups (n=4 studies). All studies met the inclusion criteria of being published between January 2010 and December 2024. Disciplines represented included medicine (n=10), nursing (n=10), pharmacy (n=2), and multi-disciplinary health sciences (n=2). Geographic distribution included studies from Europe (n=7), Asia (n=8), North America (n=5), South America (n=2), Middle East (n=1), and Australia/Oceania (n=1). Figure 1 summarizes the systematic identification, screening, eligibility assessment, and inclusion process used for this integrative review, following PRISMA guidance. Records were sourced from the specified databases within the defined date limits, then screened against the review’s inclusion and exclusion criteria. Full-text articles were assessed for eligibility, with exclusions applied where studies did not meet criteria such as focus on psychological wellbeing outcomes within health sciences PBL/active learning contexts. The PRISMA process culminated in a final included sample of 24 studies, forming the evidence base for synthesis. MMAT Quality Assessment Checklist (Version 2018) results. Note: The MMAT 2018 version discourages calculating an overall score. Instead, detailed presentation of ratings for each criterion is recommended. Ratings: Y = Yes, N = No, CT = Can't tell Study Categories: 1 = Qualitative, 2 = Quantitative RCT, 3 = Quantitative Non-randomized, 4 = Quantitative Descriptive, 5 = Mixed Methods Table 2: The results of the MMAT quality assessment checklist and rating scale of the articles included in the study. Author(s) & Year Study Category Screening Category-Specific Criteria Quality Rating S1 S2 C1 C2 C3 C4 C5 STUDENT-FOCUSED STUDIES (n=44) Sekhar et al. , (2025) 3 Y Y Y Y Y Y Y ***** Hughes et al. , (2021) 1 Y Y Y Y Y Y Y ***** Avraam et al. (2025) 4 Y Y Y Y Y Y Y ***** Kriki et al. , (2025) 3 Y Y Y Y Y Y Y ***** Al-Jehani et al. , (2020) 5 Y Y Y Y Y Y Y ***** Naciri et al. , (2022) 3 Y Y Y Y Y Y Y ***** Ingviya, Fumaneeshoat and Limsomwong, (2025) 3 Y Y Y Y Y Y Y ***** Murad et al. , (2025) 4 Y Y Y Y Y Y Y ***** Reverté-Villarroya et al. , (2021) 5 Y Y Y Y Y Y Y ***** Walsh, (2020) 1 Y Y Y Y Y Y Y ***** Sánchez et al. , (2020) 5 Y Y Y Y Y CT Y **** Wright and Richmond Mynett, (2019) 4 Y Y Y Y Y Y Y ***** Patel et al. , (2022) 1 Y Y Y Y Y Y Y ***** Lien et al. , (2021) 3 Y Y Y Y Y CT Y **** Wu et al. , (2025) 2 Y Y Y Y Y Y Y ***** Nomura et al. , (2023) 4 Y Y Y Y Y Y Y ***** Cantrell, Meyer and Mosack, (2017) 1 Y Y Y Y Y Y Y ***** Kuhn et al. , (2021) 3 Y Y Y Y Y Y Y ***** FACULTY-FOCUSED STUDIES (n=2) Delany et al. , (2025) 4 Y Y Y Y Y Y Y ***** Evans et al. , (2024) 1 Y Y Y Y CT Y Y **** STUDIES EXAMINING BOTH STUDENTS AND FACULTY (n=4) (Hökkä et al. , 2022) 4 Y Y Y Y Y Y Y ***** Kilgour, Grundy and Monrouxe, (2016) 4 Y CT Y CT Y CT Y *** Papan et al. , (2025) 5 Y Y Y Y Y Y Y ***** Rojo et al. , (2025) 1 Y Y Y Y Y Y Y ***** Quality Rating Scale: ***** (100%) All 5 criteria met **** (80%) 4 criteria met *** (60%) 3 criteria met ** (40%) 2 criteria met * (20%) 1 criterion met The quality assessment revealed that the majority of studies (83%, n=20) met at least 80% of the applicable MMAT criteria, indicating generally high methodological quality. Common methodological strengths included clear research questions, appropriate data collection methods, validated instruments for wellbeing assessment, and adequate consideration of researcher influence in qualitative studies. Quantitative studies generally employed appropriate statistical analyses and reported effect sizes. Areas of methodological concern included limited reporting of non-response rates in some survey studies, small sample sizes in qualitative investigations, and incomplete integration of qualitative and quantitative components in some mixed methods studies. Single-institution studies were common, potentially limiting generalizability. Studies with lower quality scores were not excluded but were interpreted with appropriate caution during synthesis. The quality assessment process enhanced confidence in the findings and identified methodological gaps to inform future research recommendations. Table 3: A MMAT representation of the variety of study categories used in the review and the quality range of articles. Study Category Number of Studies MMAT Criteria Applied Quality Range Qualitative Studies 6 Qualitative criteria (5 items) 80-100% Quantitative Descriptive/Cross-sectional 8 Quantitative descriptive criteria (5 items) 80-100% Quantitative Experimental/Quasi-experimental 6 Non-randomized/RCT criteria (5 items) 80-100% Mixed Methods 4 Mixed methods criteria (5 items and component criteria) 60-100% RCT 1 RCT Table 4: Presents a comprehensive summary of the 24 studies included in this integrative review, organized by study focus (students, faculty, or both), methodology, and key findings related to psychological wellbeing. Author(s) and Year Country Discipline Participants Design Wellbeing Measures Key Findings STUDENT-FOCUSED STUDIES (n=18) Ingviya, Fumaneeshoat and Limsomwong, (2025) Thailand Medicine 251 students Quantitative Pre-post surveys Active learning (TBL, FC, experiential) improved knowledge and attitudes but students reported significantly higher emotional stress (p=0.006) and hopelessness (p=0.008). Confidence in end-of-life care did not improve significantly (p=0.238). Kriki et al. , (2025) Greece Nursing (Mental Health) 134 students Quasi-experimental CTASS PBL significantly improved critical thinking in all subscales (p<0.05). Women showed greater improvement, while men had worse performance, suggesting gender effects in PBL education. Sekhar et al. , (2025) Malaysia Medicine (Psychiatry) 32 students Qualitative Focus groups School-based mental health program increased clinical confidence, enhanced resilience through mindfulness and motivational interviewing techniques, and improved stress management through sustained peer support and collaboration. Murad et al. , (2025) Saudi Arabia Nursing (Maternal newborn) 28 students Qualitative Interviews, FGD High-fidelity simulation decreased initial nervousness with repeated practice and instructor support. Students valued simulation for building confidence, though need for improved resources and hospital exposure was highlighted. Pereira et al. , (2024) Brazil Medicine 447 students Quantitative Procrastination scale, LASSI Procrastination associated with higher anxiety, concentration problems, and time management issues (p<0.05). Active methodology (PBL) is associated with higher scores in study aids and time organization compared to traditional learning. Reverté-Villarroya et al. , (2021) Spain, Chile Nursing 1368 students Cross-sectional GHQ-28 Stress from training activities significantly affected GHQ-28 scores. More advanced students showed better mental health than initial years, suggesting nursing education acts as protective factor against mental health disorders despite heavy academic workload. Hughes et al. , (2021) USA Nursing Students (review) Literature review Self-efficacy, emotional intelligence scales Four key resilience factors identified: self-efficacy, optimism, emotional intelligence, and self-stewardship. Educational strategies including reflection, positive reframing, PBL, and mindfulness can cultivate resilience and reduce burnout risk. Walsh, (2020) UK Nursing Students (review) Integrative review Resilience scales Five key teaching methods support resilience development: peer activities, reflective practice, directed study, PBL/enquiry-based learning, and experiential learning. Stress impairs performance and health; resilient qualities can be developed through targeted interventions. Al-Jehani et al. , (2020) Saudi Arabia Medicine 593 students Cross-sectional Modified Copenhagen Burnout Inventory High burnout prevalence found, but there was no significant difference between PBL and traditional curricula. All stressors (lack of sleep, unsupportive staff) significantly associated with high burnout, indicating systemic rather than pedagogical issues. Wright and Richmond Mynett, (2019) UK Medicine Curriculum-level Curriculum evaluation HYMS CARE Criteria Curriculum mapping identified resilience-building activities, strengths, and gaps. Led to new learning objectives and experiences to support student resilience and resourcefulness. Model offers valuable perspective for curriculum improvement. Sánchez et al. , (2020) Colombia Medicine (Physiology) Students (entrants/repeaters) Comparative SISCO scale, Zung scale, salivary cortisol High stress and anxiety levels in all students regardless of teaching method. Cortisol levels increased in entrants. Flipped classroom improved performance only for new students; repeaters scored lower, suggesting differential psychological impacts. Naciri et al. , (2022) Morocco Nursing 20 students Pre-experimental MSLQ Flipped classroom significantly improved motivation scores. Extrinsic goal orientation (p=0.021), control beliefs (p=0.019), and self-efficacy for learning and performance (p=0.016) significantly improved, alongside academic performance (p<0.001). Patel et al. , (2022) UK Medicine Students (review) Scoping review Uncertainty tolerance measures 22 of 24 studies reported positive impact on uncertainty tolerance in at least one domain (cognitive, behavioral, emotional). PBL curricula, medical humanities, simulation, and reflection effective. Some interventions caused negative emotional responses despite positive cognitive/behavioral outcomes. Lien et al. , (2021) Taiwan (multi-country review) Health sciences HCPs and students Network meta-analysis Stigma attitudes/behaviors Interventions combining social contact with PBL workshops most effective for reducing mental illness stigma (SUCRA=77.4%). Education plus contact ranked highest for improving attitudes and behavior intentions toward mental illness. Nomura et al. , (2023) Japan Medicine 112 students Validation study J-MSLQ-PBL Motivation subscales (self-efficacy, task value, goal orientation, test anxiety) validated in Japanese PBL context. Self-efficacy and task value particularly relevant to wellbeing in PBL. Learning strategies subscales showed poor fit, suggesting cultural differences. Cantrell, Meyer and Mosack, (2017) USA Nursing Students (review) Integrative review Stress, anxiety scales Students reported moderate to high stress with HFS but rated experience as valuable. Need for high-quality studies on techniques to decrease negative effects of simulation stress. Acceptance of simulation as learning strategy despite psychological burden. Wu et al. , (2025) China Nursing 56 students RCT Classroom engagement, CTDI, SDL scale FSLSM-based grouping significantly enhanced classroom engagement and critical thinking compared to traditional PBL. Both groups improved in self-directed learning, but experimental group showed greater gains in learning motivation and information quality. Kuhn et al. , (2021) Germany Medicine (Ethics) ~20 students/interns Program evaluation Web-based survey Extracurricular PBL-based ethics program helpful for dealing with moral dilemmas (all respondents agreed). Evidence for support in moral stress situations and strengthening individual resilience. Addresses emotional burden of ethical challenges. FACULTY-FOCUSED STUDIES (n=2) Delany et al. , (2025) Ireland Medicine 10 CBL facilitators Qualitative (IPA) Semi-structured interviews Facilitators expressed enjoyment from closer student interaction and authentic teaching. Initial uncertainty regarding role, anxiety about standardization, and concerns about content expertise. Confidence generally improved with experience facilitating CBL. Evans et al. , (2024) UK Medicine (GP) 8 GP educators Qualitative Semi-structured interviews Clinical debrief facilitation has had transformative impact on personal and professional lives. Themes: psychological 'respite' and wellbeing; professional enrichment; becoming a facilitator as journey; relationships in teaching. Facilitation provided personal enrichment. STUDIES EXAMINING BOTH STUDENTS AND FACULTY (n=4) Rojo et al. , (2025) USA Multi-disciplinary 7 faculty, 7 students Qualitative Thematic analysis Community health fairs as experiential learning promoted skill development and broadened perspectives. Challenges within learning environment included communication barriers, privacy issues, and logistics creating stress for both students and faculty. Papan et al. , (2025) Germany Medicine (Antimicrobial stewardship) 23 students Pilot course evaluation Pre-post self-assessment, IMI Case-based and PBL approach increased competencies and enjoyment (4.6±0.5). Pressure and anxiety levels reported as low (1.8±0.9 and 2.0±1.0). Students moderately satisfied with performance (3.8±1.0). Format is well-received with low psychological burden. Kilgour, Grundy and Monrouxe, (2016) UK (review) Health sciences Students (review) Rapid review Satisfaction measures Despite initial negative emotion and anxiety, perspectives toward small-group active learning are generally positive. Key factors: facilitator role, tutorial structure, individual factors, case authenticity, feedback, group harmony, resource availability. Satisfaction is an important determinant of education quality. (Hökkä et al. , 2022) Finland Nursing and Medicine Students (review) Systematic review Attitudes, knowledge measures Simulations, lectures, films, and humanistic approaches had positive effects on attitudes toward caring for dying. PBL, simulations, and elective courses increased knowledge of palliative care. Game interventions decreased fear of death, eased communication with dying patients/relatives. Note: TBL = Team-Based Learning; FC = Flipped Classroom; CTASS = Critical Thinking Ability in Student Survey scale; FGD = Focus Group Discussions; LASSI = Learning and Study Strategies Inventory; GHQ-28 = General Health Questionnaire-28; MSLQ = Motivated Strategies for Learning Questionnaire; J-MSLQ-PBL = Japanese MSLQ for PBL; CTDI = Critical Thinking Disposition Inventory; SDL = Self-Directed Learning; IPA = Interpretative Phenomenological Analysis; IMI = Intrinsic Motivation Inventory; FSLSM = Felder-Silverman Learning Style Model Table 5: Summary of the findings per theme. CATEGORY STUDENTS ACADEMIC STAFF BOTH GROUPS Positive Wellbeing Factors Enhanced collaboration, peer support, resilience building, self-efficacy development, motivation improvement Professional growth, student interaction, psychological respite, pedagogical innovation Shared learning community, mutual support, co-created strategies Challenges Initial anxiety, uncertainty stress, emotional burden, procrastination, burnout risk, group dysfunction Role ambiguity, facilitation anxiety, moral stress, identity transition challenges Time constraints, resource limitations, environmental stressors Support Needs Clear expectations, stress management training, conflict resolution protocols, mindfulness interventions Facilitation training, peer mentoring, workload recognition, ongoing professional development Institutional commitment, systemic support, adequate resources Psychological Wellbeing of Students in PBL Positive Impacts Students in PBL and active learning environments reported several psychological benefits (Table 4). PBL significantly improved critical thinking abilities across all subscales, with female students showing particularly strong improvement (Kriki et al. , 2025). Enhanced learning strategies and classroom engagement were observed with personalized PBL grouping approaches (Wu et al. , 2025). School-based mental health programs incorporating active learning increased clinical confidence, enhanced resilience through mindfulness and motivational interviewing techniques, and improved stress management through sustained peer support and collaboration (Sekhar et al. , 2025). Motivation and self-efficacy showed improvements with active learning pedagogies. Flipped classroom approaches significantly improved extrinsic goal orientation (p=0.021), control beliefs (p=0.019), and self-efficacy for learning and performance (p=0.016) (Naciri et al. , 2022). Motivation subscales including self-efficacy, task value, and goal orientation were validated as particularly relevant to wellbeing in Japanese PBL contexts (Nomura et al. , 2023). Case-based and PBL approaches increased competencies and enjoyment (4.6±0.5) while maintaining low pressure and anxiety levels (Papan et al. , 2025). Despite initial negative emotions, student perspectives toward small-group active learning were generally positive when facilitator support, tutorial structure, case authenticity, and group harmony were present (Kilgour, Grundy and Monrouxe, 2016). Challenges However, students also experienced significant psychological challenges within active learning environments (Table 4 and Table 5). Active learning approaches, while improving knowledge and attitudes, resulted in significantly higher emotional stress (p=0.006) and hopelessness (p=0.008) in some contexts (Ingviya, Fumaneeshoat and Limsomwong, 2025). High-fidelity simulation decreased initial nervousness only with repeated practice and instructor support (Murad et al. , 2025). Procrastination was associated with higher anxiety, concentration problems, and time management issues (p<0.05), though PBL showed benefits for study aids and time organization compared to traditional learning (Pereira et al. , 2024). Burnout emerged as a significant concern, with high prevalence found across curricula. Importantly, no significant difference in burnout was observed between PBL and traditional curricula, suggesting that stressors such as lack of sleep and unsupportive staff represented systemic rather than pedagogical issues (Al-Jehani et al. , 2020). High stress and anxiety levels affected students regardless of teaching method, with cortisol levels increasing in first-time learners (Sánchez et al. , 2020). Stress from training activities significantly affected mental health scores, though more advanced students showed better mental health than those in initial years, suggesting nursing education may act as a protective factor despite heavy academic workload (Reverté-Villarroya et al. , 2021). Students reported moderate to high stress with simulation experiences, though they rated these as valuable learning opportunities (Cantrell, Meyer and Mosack, 2017). Psychological Wellbeing of Academic Staff and Facilitators Role Transition Challenges Faculty/academic staff members experienced significant psychological adjustment challenges when transitioning to active learning facilitation roles (Table 4 and Table 5). Case-based learning facilitators expressed initial uncertainty regarding their role, anxiety about standardization, and concerns about content expertise, though confidence generally improved with experience (Delany et al. , 2025). The shift from traditional teaching to facilitation represented a journey requiring adaptation and identity reconstruction. Despite challenges, clinical debrief facilitation had transformative impacts on facilitators' personal and professional lives. Key themes included psychological 'respite' and wellbeing enhancement, professional enrichment, the journey of becoming a facilitator, and the importance of relationships in teaching. Facilitation provided personal enrichment and opportunities for reflection that benefited educators' overall wellbeing (Evans et al. , 2024). Facilitator Satisfaction and Professional Growth While facilitation presented challenges, many educators found the experience professionally rewarding. Facilitators expressed enjoyment from closer student interaction and more authentic teaching experiences (Delany et al. , 2025). Clinical debrief facilitation provided psychological respite from clinical demands, offering opportunities for reflection and professional development that enhanced overall wellbeing. Relationships formed through teaching were particularly meaningful, with facilitation creating spaces for professional growth and personal enrichment (Evans et al. , 2024). However, the limited number of faculty-focused studies (n=2) in this review (Table 3 and Table 4) highlights a significant gap in understanding the full spectrum of facilitator experiences with PBL and active learning pedagogies. Future research should examine workload demands, institutional support needs, and strategies for preventing facilitator burnout while maintaining the benefits of these engaging teaching approaches. Professional Development and Support The experience of facilitators improving confidence over time, Delany et al. , (2025) suggests that ongoing support and professional development are essential for successful transitions to active learning facilitation. Initial uncertainty and anxiety regarding role expectations highlight the need for comprehensive preparation programs that address both pedagogical skills and the psychological dimensions of facilitation. The transformative potential of facilitation experiences, Evans et al. , (2024) indicates that when properly supported, active learning facilitation can enhance rather than undermine faculty wellbeing. Professional development initiatives should emphasize the personal and professional growth opportunities inherent in facilitation roles, while providing practical support for managing the initial challenges of role transition. Facilitators valued closer student interaction and authentic teaching, suggesting these aspects should be highlighted in faculty development programs to promote positive attitudes toward active learning pedagogies (Table 4). Comparative Insights and Integrated Findings Studies examining both students and faculty/academic staff members revealed important insights into the systemic nature of wellbeing in active learning environments (Table 4 and Table 5). Community health fairs as experiential learning promoted skill development and broadened perspectives for both groups, though challenges including communication barriers, privacy issues, and logistics created stress for students and faculty alike (Rojo et al. , 2025). This highlights how environmental and organizational factors affect all participants in active learning contexts. The successful integration of active learning approaches with low psychological burden is possible when properly designed. Case-based and PBL courses that balanced challenge with support reported low pressure and anxiety levels alongside high enjoyment and competency development (Papan et al. , 2025). Key factors for positive experiences included appropriate facilitator roles, clear tutorial structure, case authenticity, constructive feedback, group harmony, and adequate resource availability (Kilgour, Grundy and Monrouxe, 2016). Despite initial negative emotions and anxiety, perspectives toward small-group active learning were generally positive when these supportive elements were present. The importance of resilience-building across the curriculum emerged as a cross-cutting theme. Educational interventions incorporating resilience development, including reflection, positive reframing, PBL, mindfulness, peer activities, and experiential learning, can cultivate protective factors and reduce burnout risk for students (Walsh, 2020; Hughes et al. , 2021). Curriculum mapping to identify resilience-building activities, strengths, and gaps can lead to intentional design of learning objectives and experiences supporting student wellbeing (Wright and Richmond Mynett, 2019). Similarly, facilitation experiences offering psychological respite and professional enrichment can support faculty wellbeing (Evans et al. , 2024), demonstrating that active learning pedagogies can benefit all participants when intentionally designed with wellbeing as a priority (Table 5). Discussion The PRISMA flow (Figure 1) demonstrates that, although the initial search yield was substantial across multiple databases, a sizeable proportion of records were removed or excluded during screening, suggesting that psychological wellbeing outcomes in health-sciences PBL remain a relatively narrow and inconsistently indexed evidence area. The steep reduction from screening to inclusion also reflects the deliberate application of the eligibility boundaries (peer-reviewed primary research, English language, health sciences context, and PBL-specific focus), which strengthens topical specificity and interpretability of the final synthesis. The full-text exclusion reasons shown in the flow diagram align with the priori criteria (e.g., studies without psychological measures, non-health sciences educational contexts, and those outside the date limits), which supports transparency and reproducibility of study selection. However, the presence of “reports not retrieved” indicates a potential risk of retrieval bias (i.e., some relevant evidence may not have been accessible), causing a limitation to the study. The reliance on English-language, peer-reviewed literature may also increase publication and language bias, meaning some locally relevant or non-indexed/grey literature evidence could be underrepresented. Overall, the PRISMA workflow (Figure 1) provided a clear audit trail for how the review arrived at the final included evidence base of 24 studies, supporting confidence in the rigor of the selection process. Using MMAT (as outlined in Table 1 with rating scores Table 2) strengthened the interpretive confidence in this review because it enabled design-appropriate appraisal across heterogeneous evidence rather than forcing one-size-fits-all criteria. In line with MMAT guidance, the approach supported transparent, criterion-level judgement (rather than relying on a single overall score), which helps readers understand where evidence is strong versus where caution is warranted. The evidence base included in (Table 2) was generally methodologically strong, with most studies meeting all MMAT screening and category-specific criteria (i.e., receiving ***** ratings). The overall pattern supports this: 83% of studies (n=20) met at least 80% of applicable MMAT criteria, which increases confidence that the synthesis reflects findings from reasonably well-designed research. Where ratings dropped to **** or ***, the main issue was typically “CT” (can’t tell) suggesting unclear or incomplete reporting rather than definitive methodological failure (e.g., some studies had at least one criterion rated CT). Notably, the lowest-rated study (***), with multiple CT judgements, signals that some conclusions should be interpreted cautiously because key methodological details were insufficiently described. Across studies, the most common limitations were non-response reporting gaps, small qualitative samples, and incomplete integration in some mixed-methods papers, alongside frequent single-institution designs that may limit generalizability, so future research should strengthen transparency and multi-site rigor to improve the dependability and transferability of wellbeing findings in PBL contexts. Key Themes and Patterns Several key themes emerged from the synthesis of 24 studies examining psychological wellbeing in PBL and active learning contexts (Table 2 and Table 4). First, the paradox of benefit and burden characterized student experiences. While active learning improved critical thinking (Kriki et al. , 2025), motivation (Naciri et al. , 2022), and resilience (Hughes et al. , 2021; Sekhar et al. , 2025), it simultaneously increased emotional stress and hopelessness in some implementations (Ingviya, Fumaneeshoat and Limsomwong, 2025). Students valued simulation and active learning experiences despite reporting moderate to high stress (Cantrell, Meyer and Mosack, 2017), suggesting psychological challenge may be an accepted cost of valued learning experiences. Second, burnout emerged as a systemic rather than pedagogical issue (Table 4 and Table 5). Critically, no significant difference in burnout was found between PBL and traditional curricula, with stressors such as lack of sleep and unsupportive staff environments affecting students regardless of teaching method (Al-Jehani et al. , 2020; Sánchez et al. , 2020). These findings challenge assumptions that PBL inherently increases student distress, suggesting instead that institutional and environmental factors are primary determinants of psychological well-being. More advanced students showed better mental health than initial-year students, indicating potential protective effects of educational progression despite heavy workload (Reverté-Villarroya et al. , 2021). Third, resilience-building emerged as an intentional curricular goal rather than incidental outcome (Table 4 and Table 5). Educational strategies including reflection, positive reframing, PBL, mindfulness, peer activities, and experiential learning can cultivate protective factors and reduce burnout risk (Walsh, 2020; Hughes et al. , 2021). Curriculum mapping to identify resilience-building activities, strengths, and gaps enables intentional design of learning objectives supporting student wellbeing (Wright and Richmond Mynett, 2019). School-based mental health programs integrating active learning enhanced resilience through sustained peer support and collaboration (Sekhar et al. , 2025). Fourth, faculty experiences reveal both challenges and opportunities (Table 4 and Table 5). Initial role uncertainty and anxiety can transition to psychological respite, professional enrichment, and enhanced wellbeing when proper support is provided (Evans et al. , 2024; Delany et al. , 2025). However, the severe underrepresentation of faculty research (only 2 of 24 studies, as shown in Table 4) reveals a critical gap requiring urgent attention, given facilitator wellbeing's influence on educational quality. The "Human Side" of Active Learning: Emotional and Psychological Dimensions The human side of active learning encompasses the emotional experiences, interpersonal dynamics, and psychological adjustment required for successful implementation. Initial negative emotions and anxiety are common as students adapt to small-group active learning, though perspectives become generally positive when supportive conditions are present (Kilgour, Grundy and Monrouxe, 2016). Key factors influencing emotional experiences include facilitator role, tutorial structure, individual learner characteristics, case authenticity, quality of feedback, group harmony, and resource availability (Table 4). The psychological burden of active learning can be minimized through careful instructional design, as demonstrated by case-based courses maintaining low pressure and anxiety levels while achieving high enjoyment and competency development (Papan et al. , 2025). For faculty/academic staff, facilitation represents both challenges and opportunities for wellbeing (Table 4 and Table 5). Initial role uncertainty and anxiety about standardization are common during the transition to facilitation (Delany et al. , 2025), yet clinical debrief facilitation can have transformative impacts on personal and professional lives. Facilitation provided psychological 'respite' from clinical demands, professional enrichment through closer student interaction, and meaningful relationship-building opportunities (Evans et al. , 2024). This suggests that when properly supported, active learning facilitation enhances rather than undermines faculty wellbeing, offering renewal and professional satisfaction often missing in traditional teaching or clinical roles. Students navigate complex challenges including procrastination associated with anxiety, concentration problems, and time management difficulties (Pereira et al. , 2024). However, active methodologies like PBL show advantages in study aids and time organization compared to traditional approaches. Uncertainty tolerance, a critical competency for healthcare professionals, can be effectively developed through PBL curricula, medical humanities, simulation, and reflection, though some interventions cause negative emotional responses despite positive cognitive and behavioral outcomes (Patel et al. , 2022). This underscores the complexity of psychological responses to active learning and the need for nuanced understanding of the relationship between emotional challenges and professional development. Support Systems and Interventions Effective support systems for active learning wellbeing must address multiple dimensions. For students experiencing initial anxiety with new modalities, repeated practice with instructor support can decrease nervousness and build confidence over time (Murad et al. , 2025). Mindfulness and motivational interviewing techniques enhance resilience and improve stress management through sustained peer support and collaboration (Sekhar et al. , 2025). Pedagogical approaches that improve self-efficacy for learning and performance, control beliefs, and goal orientation (Table 4) contribute to enhanced motivation and wellbeing (Naciri et al. , 2022; Nomura et al. , 2023). Resilience-building should be systematically integrated across curricula through multiple evidence-based strategies. Peer activities, reflective practice, directed study, PBL/enquiry-based learning, and experiential learning all support resilience development (Walsh, 2020). Curriculum mapping can identify existing resilience-building activities, recognize strengths, and address gaps, leading to new learning objectives and experiences that intentionally support student resourcefulness (Wright and Richmond Mynett, 2019). Extracurricular PBL-based programs addressing ethical dilemmas can provide support in moral stress situations and strengthen individual resilience (Table 4), helping students manage the emotional burden of ethical challenges inherent in healthcare practice (Kuhn et al. , 2021). For faculty/academic staff, confidence generally improves with facilitation experience (Delany et al. , 2025), suggesting that ongoing practice combined with peer support enables successful role transitions (Table 4). Facilitator wellbeing is enhanced when facilitation provides psychological respite, professional enrichment, and opportunities for meaningful relationships in teaching (Evans et al. , 2024). Institutions should recognize and promote these positive aspects of facilitation while providing support for initial role uncertainty and anxiety about standardization. Interventions combining multiple approaches show particular promise. Social contact combined with PBL workshops effectively reduces mental illness stigma, with education plus contact ranking highest for improving attitudes and behavior intentions (Lien et al. , 2021). Personalized learning approaches, such as grouping based on learning style models, can significantly enhance classroom engagement and critical thinking compared to traditional PBL while improving learning motivation (Wu et al. , 2025). These findings suggest that tailored, multi-component interventions addressing both content and process dimensions optimize psychological outcomes (Table 5). Implications for Practice Implementation of active learning pedagogies should include explicit attention to psychological wellbeing alongside pedagogical outcomes. Given that burnout appears to reflect systemic rather than pedagogy-specific issues (Al-Jehani et al. , 2020), institutions must address environmental stressors including inadequate sleep opportunities, unsupportive staff attitudes, and resource limitations that affect students regardless of teaching method (Table 4 and Table 5). Active learning implementation offers opportunities to intentionally build resilience and protective factors when designed with wellbeing as a priority (Walsh, 2020; Hughes et al. , 2021). Faculty development programs must recognize the dual nature of facilitation as both challenging and potentially enriching. Initial support should address role uncertainty and anxiety about standardization (Delany et al. , 2025), while highlighting opportunities for psychological respite, professional enrichment, and meaningful relationships that facilitation can provide (Evans et al. , 2024). Programs should emphasize that confidence generally improves with experience and provide ongoing peer support throughout the facilitation journey. Curriculum design should incorporate systematic resilience-building through evidence-based strategies including peer activities, reflection, PBL/enquiry-based learning, experiential learning, and mindfulness (Walsh, 2020; Sekhar et al. , 2025). Curriculum mapping can identify strengths and gaps in resilience-building opportunities (Wright and Richmond Mynett, 2019). Particular attention should be paid to supporting students through initial anxiety when introducing new active learning modalities (Table 5), as repeated practice with instructor support decreases nervousness over time (Murad et al. , 2025). Assessment of active learning should examine both academic outcomes and wellbeing indicators, recognizing that some level of emotional challenge may accompany valuable professional development in areas such as uncertainty tolerance (Patel et al. , 2022). Contribution to Teaching and Learning This integrative review contributes to TL by highlighting the necessity of examining psychological and emotional dimensions of educational innovations. The findings challenge the field to move beyond cognitive and academic measures to include wellbeing indicators in educational research and practice. The review demonstrates the importance of systematic inquiry into the human costs and benefits of pedagogical change, providing evidence for the need to support educational innovations with comprehensive attention to participant wellbeing. This human-centered approach to TL research offers a more complete understanding of educational effectiveness and sustainability. By synthesizing evidence across multiple contexts and populations, this review provides a foundation for future TL researchers that examine the intersection of pedagogy and psychological wellbeing in health sciences education. Recommendations for Educators and Institutions Educators implementing PBL should receive comprehensive training that addresses both pedagogical and psychological aspects of facilitation. This includes understanding group dynamics, recognizing signs of student distress, and developing strategies for maintaining their own wellbeing while supporting student learning. Institutional leaders should recognize PBL implementation as a complex change process requiring sustained support for both students and faculty/academic staff. This includes resource allocation for professional development, mental health support services, and ongoing evaluation of wellbeing outcomes alongside academic measures. Curriculum designers should systematically map resilience-building opportunities throughout programs, identifying strengths and addressing gaps to create intentional learning experiences supporting student wellbeing (Wright and Richmond Mynett, 2019). Evidence-based strategies including peer activities, reflection, PBL/enquiry-based learning, experiential learning, and mindfulness should be integrated across curricula (Walsh, 2020). Programs should address uncertainty tolerance development essential for healthcare professionals through PBL, medical humanities, simulation, and reflection, while acknowledging that productive emotional challenge differs from harmful distress (Patel et al. , 2022). Research and evaluation efforts should routinely include wellbeing measures alongside traditional academic outcomes, providing comprehensive assessment of educational innovation effectiveness. Critically, evaluations should examine systemic factors (sleep opportunities, staff support, resources) affecting wellbeing across all pedagogies, not only active learning-specific variables. Given that burnout appears systemic rather than pedagogy-specific (Al-Jehani et al. , 2020), research must examine institutional environments holistically. Future studies should prioritize faculty experiences, employ longitudinal designs, conduct multi-institutional comparisons, and test targeted wellbeing interventions to build the evidence base for supporting human flourishing in health sciences education. Limitations and Future Research Several limitations should be acknowledged in this integrative review. First, the heterogeneity of wellbeing measures across studies limited the ability to conduct meta-analytic synthesis, requiring reliance on narrative synthesis methods. Studies employed diverse instruments including validated scales (GHQ-28, MSLQ, Copenhagen Burnout Inventory), qualitative approaches (interviews, focus groups), and program evaluations, making quantitative comparison challenges. Second, publication bias may favour studies reporting positive outcomes or significant findings, potentially overlooking neutral or negative wellbeing effects. Third, the severe underrepresentation of faculty-focused research (only 2 of 24 studies) limits conclusions about facilitator experiences. Most studies examined students (n=18), creating an incomplete picture of the bidirectional relationship between student and faculty/academic staff wellbeing in active learning environments. Fourth, while the review spanned 18 countries across six continents, cultural and contextual variations in PBL implementation and wellbeing conceptualization require further examination, there were no South African studies found or included. Fifth, most studies employed cross-sectional designs, with limited longitudinal research preventing full understanding of adaptation processes and long-term wellbeing trajectories. Sixth, many studies were conducted at single institutions, potentially limiting generalizability. Future research should prioritize longitudinal designs examining well-being trajectories throughout active learning experiences, identifying critical periods for intervention and support. The finding that burnout reflects systemic rather than pedagogical issues (Al-Jehani et al. , 2020) demands investigation of institutional and environmental factors affecting wellbeing across teaching modalities. Intervention studies testing specific well-being support strategies, particularly resilience-building interventions, mindfulness programs, and peer support mechanisms, would provide evidence for best practices. Urgent attention is needed to faculty experiences with active learning facilitation. The limited research (n=2) contrasts sharply with extensive student-focused literature, yet faculty wellbeing critically influences educational quality and sustainability. Research should examine facilitator workload, emotional labour, support needs, and factors predicting successful role transitions. Comparative multi-institutional studies examining wellbeing outcomes across different active learning implementations could identify design features that optimize both learning and wellbeing. Finally, economic analyses comparing costs of wellbeing support versus benefits of improved retention, performance, and career satisfaction could inform institutional resource allocation decisions. Conclusion This integrative review reveals that psychological wellbeing represents a critical dimension of active learning implementation in health sciences education that demands systematic attention. Synthesis challenges common assumptions and offers evidence-based insights for educational practice. A key finding is that burnout appears to reflect systemic rather than pedagogy-specific issues. No significant difference in burnout was observed between PBL and traditional curricula, with environmental stressors such as inadequate sleep, unsupportive staff, and resource limitations affecting students regardless of teaching method. This shifts the focus from debating pedagogical approaches to addressing fundamental institutional conditions affecting all students. Also, active learning offers opportunities to intentionally cultivate psychological strengths. PBL and related approaches enhance critical thinking, motivation, self-efficacy, and resilience. When designed with wellbeing as a priority, incorporating appropriate facilitator support, clear structure, case authenticity, feedback, group harmony, and adequate resources, active learning achieves high engagement and competency development with low psychological burden. The challenge lies not in the pedagogy itself but in implementation quality. For faculty/academic staff, facilitation presents both challenges and opportunities. Initial role uncertainty and anxiety can transition to psychological respite, professional enrichment, and enhanced wellbeing when proper support is provided. However, the severe underrepresentation of faculty research (only 2 of 24 studies) reveals a critical gap requiring urgent attention, given facilitator wellbeing's influence on educational quality. For teaching and learning, this review demonstrates the necessity of human-centered approaches to educational research and practice. Future TL researchers should routinely examine psychological and emotional dimensions alongside cognitive and academic outcomes, recognize systemic factors affecting wellbeing across pedagogies, and investigate both students and faculty as interconnected participants in the learning ecosystem. The evidence calls for reconceptualization of educational innovation that positions human wellbeing as central to, not separate from, pedagogical effectiveness. Active learning pedagogies like PBL offer powerful tools for developing the cognitive, professional, and psychological capacities healthcare professionals need. Realizing this potential requires systematic attention to resilience-building, institutional environments supporting all participants, and recognition that some emotional challenge may be inherent in transformative professional education. The question is not whether to implement active learning, but how to implement it in ways that support rather than undermine the wellbeing of those engaged in the educational process. Declarations Author Contribution All authors whose names appear on the submission: IN and NFContributions: IN and NF: concept formationIN: design of the work.IN: analysis and interpretation of data.IN: drafted the work IN and NF: revised it critically for important intellectual content.IN and NF: approved the version to be published.IN: agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Data Availability Data will be available upon request from corresponding author: [email protected] Research Funding Both authors declare no funding for this research project. References Al-Jehani, Y. M. (2020). ‘Burnout Prevalence and Associated Stressors in Medical Students of Traditional and Problem-Based Learning Curricula in a Saudi University.’, Saudi journal of medicine & medical sciences , 8(2), pp. 125–132. 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Problem-based learning: Rationale and description. Medical education , 17 (1), 11–16. Sekhar, S. S. N. (2025). ‘Enhancing medical student training during psychiatry clerkship through a school-based mental health approach: a qualitative study.’, Korean Journal of Medical Education , 37(2), pp. 133–142. Available at: https://doi.org/10.3946/kjme.2025.330 Singaram, V. S., et al. (2008). Perceptions of problem-based learning (PBL) group effectiveness in a socially-culturally diverse medical student population. Education for Health , 21 (2), 116. Slavin, S. J., Schindler, D. L., & Chibnall, J. T. (2014). Medical student mental health 3.0: improving student wellness through curricular changes. Academic Medicine , 89 (4), 573–577. Steinert, Y. (2005). ‘Staff development for clinical teachers.’, Clinical Teacher , 2(2). Suwarsi, S., Ridwan, R., & Fauzan, N. (2025). Evaluating workload impacts on lecturer mental health and productivity in indonesian private universities: A case study from bandung. Multidisciplinary Science Journal , 7 (1), 2025045. Walsh, F. (2020). Loss and resilience in the time of COVID-19: Meaning making, hope, and transcendence. Family process , 59 (3), 898–911. Wenger, E. (1999). Communities of practice: Learning, meaning, and identity . Cambridge University Press. White, C. B., Gruppen, L. D., & Fantone, J. C. (2013). ‘Self-regulated learning in medical education’, Understanding medical education: Evidence, theory and practice , pp. 201–211. Whittemore, R., & Knafl, K. (2005). The integrative review: updated methodology. Journal of advanced nursing , 52 (5), 546–553. Wilson, K. L., et al. (2016). Understanding the early transition needs of diverse commencing university students in a health faculty: informing effective intervention practices. Studies in Higher Education , 41 (6), 1023–1040. Wood, D. F. (2003). Problem based learning. Bmj , 326 (7384), 328–330. Wright, B., & Richmond Mynett, J. (2019). ‘Training medical students to manage difficult circumstances- a curriculum for resilience and resourcefulness?’, BMC medical education , 19(1), p. 280. Available at: https://doi.org/10.1186/s12909-019-1712-x Wu, Y., et al. (2025). Effects of a grouping intervention using the Felder-Silverman learning style model on problem-based learning among nursing students: a randomized controlled trial. Nurse Education Today , 145 , 106489. Yew, E. H. J., & Goh, K. (2016). Problem-based learning: An overview of its process and impact on learning. Health professions education , 2 (2), 75–79. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":114970,"visible":true,"origin":"","legend":"\u003cp\u003ePrisma Flow Diagram adopted from: (Page et al., 2021) and created using automation adopted from (Haddaway et al., 2022)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8357368/v1/fbcbb0af0817613b5bcf9a98.png"},{"id":103177875,"identity":"c9cdae36-66c0-4119-9cd3-a5527b461b9a","added_by":"auto","created_at":"2026-02-22 16:55:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1856456,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8357368/v1/2b2ee41a-81e1-4e9e-96cf-48a2ceeb0180.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Human Side of PBL: Psychological Well-being of Health Sciences Students and Academic Staff: An Integrative Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProblem-Based Learning (PBL) has emerged as a dominant pedagogical approach in health sciences education, transforming how medical, nursing, pharmacy, and “allied” health students acquire knowledge and develop clinical reasoning skills (Barrows and Tamblyn, 1980). Originating at McMaster University in the 1960s, PBL shifted the educational paradigm from traditional didactic instruction to student-centered, collaborative learning experiences centred on authentic clinical problems (Wood, 2003).\u003c/p\u003e\n\u003cp\u003eThe widespread adoption of PBL across health sciences curricula reflected mounting evidence of its effectiveness in developing critical thinking, self-directed learning, and collaborative skills important for healthcare practice (Koh \u003cem\u003eet al.\u003c/em\u003e, 2008; Yew and Goh, 2016). However, this pedagogical transformation demanded significant changes in both student learning approaches and faculty teaching roles, creating new psychological and emotional challenges that warranted careful examination (Dolmans \u003cem\u003eet al.\u003c/em\u003e, 2015).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImportance of Psychological Wellbeing in Educational Contexts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePsychological wellbeing in educational settings covers multiple dimensions including stress management, emotional regulation, self-efficacy, resilience, and overall mental health (Slavin, Schindler and Chibnall, 2014). Research consistently demonstrated that student and faculty wellbeing significantly impacted learning outcomes, retention rates, professional development, and ultimately, patient care quality in health sciences education (Dyrbye, Thomas and Shanafelt, 2006).\u003c/p\u003e\n\u003cp\u003eThe demanding nature of health sciences education, combined with the uncertainty and collaborative requirements of PBL, created unique psychological pressures (Frambach \u003cem\u003eet al.\u003c/em\u003e, 2012). Students must navigate ambiguous problem scenarios while managing group dynamics and peer evaluation processes. At the same time, staff members (Lecturers) transitioned from information deliverers to learning facilitators, requiring new competencies and emotional labour often without enough institutional support (Steinert, 2005).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRationale for the Integrative Review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile extensive literature examines PBL's cognitive and academic outcomes (Norman and Schmidt, 1992; Hmelo-Silver, 2004), limited attention contributed to its psychological and emotional impacts on both learners and educators. This gap represents an important oversight, as the human dimension of educational innovation fundamentally influenced implementation success and sustainability (Maudsley, 1999). An integrative review methodology was particularly appropriate for this inquiry, as it allowed synthesis of diverse research approaches and perspectives to generate comprehensive understanding of PBL's psychological implications (Whittemore and Knafl, 2005).\u003c/p\u003e\n\u003ch2\u003eAim\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis integrative review aims to synthesize existing evidence regarding psychological wellbeing of health sciences students and academic staff within PBL environments.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eResearch Questions\u003c/h2\u003e\n\u003cp\u003eThe primary research questions include:\u003c/p\u003e\n\u003cp\u003eHow does PBL implementation affect the psychological wellbeing of health sciences students?\u003c/p\u003e\n\u003cp\u003eWhat psychological challenges and benefits do academic staff experience when facilitating PBL?\u003c/p\u003e\n\u003cp\u003eWhat\u0026nbsp;\u0026nbsp;factors promote or hinder psychological wellbeing in PBL environments?\u003c/p\u003e\n\u003cp\u003eWhat \u0026nbsp;support systems and interventions effectively address \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;wellbeing concerns in PBL contexts?\u003c/p\u003e"},{"header":"Literature Review","content":"\u003ch2\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/h2\u003e\n\u003ch2\u003eTheoretical Framework\u003c/h2\u003e\n\u003cp\u003eProblem-Based Learning was characterized by small-group collaborative learning, authentic problem scenarios, student-centered inquiry, and facilitator-guided rather than instructor-led sessions (Barrows and Tamblyn, 1980; Wood, 2003). The typical PBL process involved problem presentation, hypothesis generation, learning issue identification, self-directed study, and knowledge application through group discussion and reflections. This seven-step process, commonly known as the \"Maastricht seven-jump\" method, had been widely adopted and adapted across health sciences globally (Schmidt, 1983; Dolmans and Schmidt, 2006).\u003c/p\u003e\n\u003cp\u003eThe theoretical foundations of PBL are drawn from constructivist learning theories, emphasizing knowledge construction through active engagement with authentic problems (Norman and Schmidt, 1992). Cognitive psychology principles underlying PBL include activation of prior knowledge, elaboration through discussion, contextual learning, and collaborative knowledge construction (Hmelo-Silver, 2004). This pedagogical approach required students to tolerate ambiguity, engage in peer collaboration, self-regulate learning, and develop metacognitive awareness (Yew and Goh, 2016). For the departments/faculty, PBL demanded sophisticated facilitation skills, comfort with uncertainty, and an ability to guide without directing learning processes (Dolmans \u003cem\u003eet al.\u003c/em\u003e, 2015).\u003c/p\u003e\n\u003ch2\u003eHistorical Development and Global Adoption\u003c/h2\u003e\n\u003cp\u003eSince its inception at McMaster University in 1969, PBL had spread to medical schools worldwide, with significant adoption in Europe, Asia, and Oceania (Neville, 2008). The approach expanded beyond medical education to nursing, dentistry, pharmacy, and other health professions (Yew and Goh, 2016). However, cultural adaptation had proven necessary, as Western educational assumptions embedded in PBL may conflict with educational traditions emphasizing teacher authority and structured learning (Frambach \u003cem\u003eet al.\u003c/em\u003e, 2012). This cultural dimension added complexity to understanding psychological wellbeing within diverse PBL contexts.\u003c/p\u003e\n\u003ch2\u003ePsychological Wellbeing Constructs\u003c/h2\u003e\n\u003cp\u003ePsychological wellbeing within educational contexts encompassed several key constructs relevant to PBL environments. Understanding these constructions provided a framework for examining the human side of PBL implementation.\u003c/p\u003e\n\u003ch3\u003eStress and Anxiety:\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eAcademic stress in health sciences education stemmed from workload demands, performance expectations, and career pressures (Dyrbye, Thomas and Shanafelt, 2006). The transactional model of stress (Lazarus and Folkman, 1984) was particularly relevant to PBL contexts, where students continuously appraise problem-solving demands against their coping resources. PBL introduced additional stressors including group dependency, evaluation uncertainty, and responsibility for peer learning (Moust, Berkel and Schmidt, 2005). State anxiety may increase during PBL sessions due to performance pressure, while trait anxiety influenced adaptation to collaborative learning environments (Cademartori \u003cem\u003eet al.\u003c/em\u003e, 2018).\u003c/p\u003e\n\u003ch3\u003eBurnout:\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe Maslach Burnout Inventory framework (Maslach and Leiter, 2016) identified three dimensions: emotional exhaustion, depersonalization (cynicism), and reduced personal accomplishment. Burnout affects both students experiencing chronic academic stress and faculty lecturers managing intensive facilitation demands (Dyrbye \u003cem\u003eet al.\u003c/em\u003e, 2017). In PBL contexts, the demands-resources model suggested that facilitation demands (emotional labour, time pressure) must be balanced with resources (institutional support, peer collaboration) to prevent burnout (Bakker and Demerouti, 2007).\u003c/p\u003e\n\u003ch3\u003eSelf-Efficacy:\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eBandura, (1997)'s social cognitive theory conceptualized self-efficacy as perceived capability to perform tasks, which influenced both student engagement in collaborative learning and faculty confidence in facilitation roles. Self-efficacy developed through mastery experiences, vicarious learning, social persuasion, and physiological states (Bandura, 1997). In PBL, successful problem-solving experiences enhanced self-efficacy, while repeated struggles without support undermined confidence (Lee \u003cem\u003eet al.\u003c/em\u003e, 2023).\u003c/p\u003e\n\u003ch3\u003eResilience:\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eDefined as the capacity to adapt and recover from challenges (Masten, 2001), resilience became important in PBL environments where uncertainty and peer-dependent learning created ongoing psychological demands. Resilience theory suggested that protective factors (social support, problem-solving skills, self-efficacy) buffered the impact of stressors (Luthar, Cicchetti and Becker, 2000). PBL may foster resilience through controlled exposure to challenges within supportive group contexts (Huang \u003cem\u003eet al.\u003c/em\u003e, 2022).\u003c/p\u003e\n\u003ch2\u003eTheoretical Models of Learning and Wellbeing\u003c/h2\u003e\n\u003cp\u003eThe relationship between PBL and psychological wellbeing can be understood through several theoretical frameworks. Self-Determination Theory (Deci and Ryan, 2000) suggested that satisfaction of three basic psychological needs like autonomy, competence, and relatedness, promoted wellbeing and optimal functioning. PBL potentially supports autonomy through self-directed learning, competence through problem-solving mastery, and relatedness through collaborative group work. However, when these needs were avoided (e.g., through controlling facilitation, overwhelming challenges, or dysfunctional group dynamics), psychological distress resulted.\u003c/p\u003e\n\u003cp\u003eThe Job Demands-Resources model (Bakker and Demerouti, 2007), originally developed for workplace settings, applied to both student learning and faculty facilitation contexts. Job demands (workload, emotional labour, role ambiguity) depleted energy and led to burnout, while job resources (social support, autonomy, feedback) fostered engagement and buffered stress. In PBL environments, the balance between demands and resources determined psychological outcomes for both students and lecturers/ faculty staff. Communities of Practice theory (Wenger, 1999) offered insight into how social learning environments shaped identity and wellbeing. PBL tutorial groups functioned as learning communities where participants negotiated meaning, developed shared practices, and constructed professional identities. The quality of these communities were characterized by mutual engagement, joint enterprise, and shared repertoire, which influenced psychological safety and wellbeing (Moust, Berkel and Schmidt, 2005).\u003c/p\u003e\n\u003ch2\u003eDual Perspective: Students and Academic Staff\u003c/h2\u003e\n\u003cp\u003eUnderstanding PBL's psychological impact required examining both student and staff experiences, as their wellbeing was interconnected within the collaborative learning environment (Azer and Azer, 2015). Student psychological distress impacted group dynamics and learning outcomes, while faculty stress and burnout affected facilitation quality and educational climate (Singaram \u003cem\u003eet al.\u003c/em\u003e, 2008). \u0026nbsp;This bidirectional relationship created a complex system where interventions must address the needs of all participants (Steinert, 2005).\u003c/p\u003e\n\u003cp\u003eFor students, the transition to PBL represented a significant pedagogical shift requiring adaptation of learning strategies, interpersonal skills, and emotional regulation (White, Gruppen and Fantone, 2013). The student experience encompassed cognitive challenges (problem analysis, knowledge integration), social challenges (group collaboration, peer evaluation), and emotional challenges (uncertainty tolerance, performance anxiety) (Wilson \u003cem\u003eet al.\u003c/em\u003e, 2016).\u003c/p\u003e\n\u003cp\u003eFor faculty staff, PBL facilitation required professional identity transformation from \"sage on the stage\" to \"guide on the side\" (King, 1993). \u0026nbsp;This role transition involved developing new competencies in group facilitation, conflict management, and formative assessment while managing the emotional labour of supporting diverse learners (Choi, 2025). Faculty wellbeing is further influenced by institutional factors including workload recognition, professional development support, and organizational culture (Suwarsi, Ridwan and Fauzan, 2025).\u003c/p\u003e\n\u003ch2\u003eCultural Considerations in PBL and Wellbeing\u003c/h2\u003e\n\u003cp\u003eCultural context significantly influenced both PBL implementation and psychological wellbeing outcomes (Frambach \u003cem\u003eet al.\u003c/em\u003e, 2012). Educational approaches emphasizing student autonomy and peer collaboration conflicted with cultural values prioritizing teacher authority, hierarchical relationships, and structured learning (Khoo, 2003). In collectivist cultures, concerns about face-saving, group harmony, and hierarchical relationships created unique psychological pressures within PBL tutorial groups (Azer and Azer, 2015). Understanding these cultural dimensions was important for implementing culturally responsive PBL that supported rather than undermined psychological wellbeing.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study employed Whittemore and Knafl\u0026apos;s integrative review framework, which accommodated diverse methodologies and provided comprehensive understanding of complex phenomena. The five-stage process included problem identification, literature search, data evaluation, data analysis, and presentation of findings.\u003c/p\u003e\n\u003ch2\u003eSearch Strategy and Databases\u003c/h2\u003e\n\u003cp\u003eSystematic research was conducted in MEDLINE (via PubMed), ERIC, and EBSCO databases for articles published between January 2010 and December 2024. Search terms included combinations of \u0026quot;problem-based learning,\u0026quot; \u0026quot;PBL,\u0026quot; \u0026quot;case-based learning,\u0026quot; \u0026quot;CBL,\u0026quot; \u0026quot;team-based learning,\u0026quot; \u0026quot;TBL,\u0026quot; \u0026quot;active learning,\u0026quot; \u0026quot;psychological wellbeing,\u0026quot; \u0026quot;mental health,\u0026quot; \u0026quot;stress,\u0026quot; \u0026quot;burnout,\u0026quot; \u0026quot;anxiety,\u0026quot; \u0026quot;self-efficacy,\u0026quot; \u0026quot;resilience,\u0026quot; \u0026quot;motivation,\u0026quot; \u0026quot;emotional challenges,\u0026quot; \u0026quot;health sciences education,\u0026quot; \u0026quot;medical education,\u0026quot; \u0026quot;nursing education,\u0026quot; \u0026quot;pharmacy education,\u0026quot; \u0026quot;faculty,\u0026quot; and \u0026quot;facilitators.\u0026quot; Boolean operators (AND, OR) were used to combine search terms. Reference lists of identified articles were hand-searched for additional relevant studies.\u003c/p\u003e\n\u003ch3\u003eInclusion Criteria\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003ePeer-reviewed primary research articles published between January 2010 and December 2024, examining psychological wellbeing, mental health, or emotional aspects of PBL in health sciences education.\u003c/li\u003e\n \u003cli\u003eStudies involving students, faculty, or both; quantitative, qualitative, or mixed methods research.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEnglish language publications.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003eConference abstracts, editorials, or commentary pieces; studies focusing solely on academic outcomes without psychological measures.\u003c/li\u003e\n \u003cli\u003eNon-health sciences educational contexts.\u003c/li\u003e\n \u003cli\u003eArticles examining other active learning approaches without specific PBL focus.\u003c/li\u003e\n \u003cli\u003eStudies were published before 2010 or after December 2024.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWhile the 2010-2024 timeframe was strictly applied to primary research studies included in the review, foundational theoretical works and seminal methodological papers published prior to 2010 (e.g., Self-Determination Theory, Job Demands-Resources Model, Communities of Practice Theory, and foundational PBL literature) are cited in the Literature Review section to provide essential theoretical context and framework for interpreting the findings. This approach is consistent with integrative review methodology, which distinguishes between primary studies under review and theoretical literature used for conceptual framing (Whittemore and Knafl, 2005).\u003c/p\u003e\n\u003ch2\u003eData Extraction and Synthesis Approach\u003c/h2\u003e\n\u003cp\u003eData extraction captured study characteristics, participant demographics, methodology, wellbeing measures, key findings, and implications. Thematic analysis identified patterns across studies, with attention to both positive and negative psychological impacts, support mechanisms, and contextual factors influencing wellbeing outcomes.\u003c/p\u003e\n\u003ch3\u003eQuality Assessment\u003c/h3\u003e\n\u003cp\u003eThe Mixed Methods Appraisal Tool (MMAT) version 2018 \u0026nbsp;and a PRISMA flow diagram were employed to assess the methodological quality of included studies and also provide the flow of information through the different phases of the review. The MMAT is particularly appropriate for integrative reviews as it provides standardized quality criteria for five categories of studies: qualitative research, randomized controlled trials, non-randomized studies, quantitative descriptive studies, and mixed methods studies.\u003c/p\u003e\n\u003cp\u003eTwo independent reviewers assessed each study using the MMAT criteria, with disagreements resolved through discussion and consultation with a third reviewer when necessary. The MMAT employs a set of screening questions followed by category-specific quality criteria. Studies were not excluded based on quality scores; rather, quality assessment informed the interpretation and weighting of findings during synthesis.\u003c/p\u003e\n\u003ch3\u003eMMAT Criteria Legend\u003c/h3\u003e\n\u003cp\u003eS1: Are there clear research questions?\u003c/p\u003e\n\u003cp\u003eS2: Do the collected data allow you to address the research questions?\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1: The categories of studies and their screening questions according to the MMAT criteria legend.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"888\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Qualitative):\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(RCT):\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Quantitative non-randomized):\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory 4\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Quantitative Descriptive):\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory 5\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mixed Methods):\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eC1: Is the qualitative approach appropriate?\u003c/p\u003e\n \u003cp\u003eC2: Are data collection methods adequate?\u003c/p\u003e\n \u003cp\u003eC3: Are findings adequately derived from data?\u003c/p\u003e\n \u003cp\u003eC4: Is interpretation sufficiently substantiated?\u003c/p\u003e\n \u003cp\u003eC5: Is there coherence between data sources, collection, analysis and interpretation?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eC1: Is randomization appropriately performed?\u003c/p\u003e\n \u003cp\u003eC2: Are groups comparable at baseline?\u003c/p\u003e\n \u003cp\u003eC3: Are there complete outcome data?\u003c/p\u003e\n \u003cp\u003eC4: Are outcome assessors blinded?\u003c/p\u003e\n \u003cp\u003eC5: Did participants adhere to assigned intervention?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eC1: Are participants representative of target population?\u003c/p\u003e\n \u003cp\u003eC2: Are measurements appropriate?\u003c/p\u003e\n \u003cp\u003eC3: Are there complete outcome data?\u003c/p\u003e\n \u003cp\u003eC4: Are confounders accounted for?\u003c/p\u003e\n \u003cp\u003eC5: Is intervention/exposure administered as intended?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eC1: Is sampling strategy relevant?\u003c/p\u003e\n \u003cp\u003eC2: Is it a sample representative?\u003c/p\u003e\n \u003cp\u003eC3: Are measurements appropriate?\u003c/p\u003e\n \u003cp\u003eC4: Is risk of nonresponse bias low?\u003c/p\u003e\n \u003cp\u003eC5: Is statistical analysis appropriate?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eC1: Is there adequate rationale for mixed methods?\u003c/p\u003e\n \u003cp\u003eC2: Are components effectively integrated?\u003c/p\u003e\n \u003cp\u003eC3: Are integration outputs adequately interpreted?\u003c/p\u003e\n \u003cp\u003eC4: Are divergences adequately addressed?\u003c/p\u003e\n \u003cp\u003eC5: Do components adhere to quality criteria?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1 presents the MMAT 2018 structure used to appraise study quality, starting with two screening questions (S1 and S2) and then applying five category-specific criteria (C1\u0026ndash;C5) aligned to each study design type (qualitative, RCT, quantitative \u0026nbsp;This framework provided a consistent way to evaluate methodological rigour across the diverse designs included in the review.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe final sample included 24 studies published between 2016 and 2025, spanning multiple health sciences disciplines and geographical contexts across 18 countries. Study designs comprised of 14 quantitative, 6 qualitative, and 4 mixed-methods investigations (Table 3). Participants included undergraduate and graduate students (n=18 studies), faculty members (n=2 studies), and both groups (n=4 studies). All studies met the inclusion criteria of being published between January 2010 and December 2024. Disciplines represented included medicine (n=10), nursing (n=10), pharmacy (n=2), and multi-disciplinary health sciences (n=2). Geographic distribution included studies from Europe (n=7), Asia (n=8), North America (n=5), South America (n=2), Middle East (n=1), and Australia/Oceania (n=1).\u003c/p\u003e\n\u003cp\u003eFigure 1 summarizes the systematic identification, screening, eligibility assessment, and inclusion process used for this integrative review, following PRISMA guidance. Records were sourced from the specified databases within the defined date limits, then screened against the review\u0026rsquo;s inclusion and exclusion criteria. Full-text articles were assessed for eligibility, with exclusions applied where studies did not meet criteria such as focus on psychological wellbeing outcomes within health sciences PBL/active learning contexts. The PRISMA process culminated in a final included sample of 24 studies, forming the evidence base for synthesis.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eMMAT Quality Assessment Checklist (Version 2018) results.\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e The MMAT 2018 version discourages calculating an overall score. Instead, detailed presentation of ratings for each criterion is recommended. Ratings: \u003cstrong\u003eY\u003c/strong\u003e = Yes, \u003cstrong\u003eN\u003c/strong\u003e = No, \u003cstrong\u003eCT\u003c/strong\u003e = Can\u0026apos;t tell\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Categories:\u003c/strong\u003e 1 = Qualitative, 2 = Quantitative RCT, 3 = Quantitative Non-randomized, 4 = Quantitative Descriptive, 5 = Mixed Methods\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2: The results of the MMAT quality assessment checklist and rating scale of the articles included in the study.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"799\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor(s) \u0026amp; Year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScreening\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory-Specific Criteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality Rating\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 799px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSTUDENT-FOCUSED STUDIES (n=44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSekhar \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHughes \u003cem\u003eet al.\u003c/em\u003e, (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAvraam et al. (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKriki \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAl-Jehani \u003cem\u003eet al.\u003c/em\u003e, (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNaciri \u003cem\u003eet al.\u003c/em\u003e, (2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIngviya, Fumaneeshoat and Limsomwong, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMurad \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRevert\u0026eacute;-Villarroya \u003cem\u003eet al.\u003c/em\u003e, (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWalsh, (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eS\u0026aacute;nchez \u003cem\u003eet al.\u003c/em\u003e, (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWright and Richmond Mynett, (2019)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePatel \u003cem\u003eet al.\u003c/em\u003e, (2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLien \u003cem\u003eet al.\u003c/em\u003e, (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWu \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNomura \u003cem\u003eet al.\u003c/em\u003e, (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCantrell, Meyer and Mosack, (2017)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKuhn \u003cem\u003eet al.\u003c/em\u003e, (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 799px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFACULTY-FOCUSED STUDIES (n=2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDelany \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEvans \u003cem\u003eet al.\u003c/em\u003e, (2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 799px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSTUDIES EXAMINING BOTH STUDENTS AND FACULTY (n=4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(H\u0026ouml;kk\u0026auml; \u003cem\u003eet al.\u003c/em\u003e, 2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKilgour, Grundy and Monrouxe, (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePapan \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRojo \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eQuality Rating Scale:\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e*****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eAll 5 criteria met\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e(80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e4 criteria met\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e(60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3 criteria met\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e(40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2 criteria met\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1 criterion met\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe quality assessment revealed that the majority of studies (83%, n=20) met at least 80% of the applicable MMAT criteria, indicating generally high methodological quality. Common methodological strengths included clear research questions, appropriate data collection methods, validated instruments for wellbeing assessment, and adequate consideration of researcher influence in qualitative studies. Quantitative studies generally employed appropriate statistical analyses and reported effect sizes. Areas of methodological concern included limited reporting of non-response rates in some survey studies, small sample sizes in qualitative investigations, and incomplete integration of qualitative and quantitative components in some mixed methods studies. Single-institution studies were common, potentially limiting generalizability. Studies with lower quality scores were not excluded but were interpreted with appropriate caution during synthesis. The quality assessment process enhanced confidence in the findings and identified methodological gaps to inform future research recommendations.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;3: A MMAT representation of the variety of study categories used in the review and the quality range of articles.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"793\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMMAT Criteria Applied\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eQualitative Studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eQualitative criteria (5 items)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e80-100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eQuantitative Descriptive/Cross-sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eQuantitative descriptive criteria (5 items)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e80-100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eQuantitative Experimental/Quasi-experimental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eNon-randomized/RCT criteria (5 items)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e80-100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eMixed Methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eMixed methods criteria (5 items and component criteria)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e60-100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4: \u0026nbsp;Presents a comprehensive summary of the 24 studies included in this integrative review, organized by study focus (students, faculty, or both), methodology, and key findings related to psychological wellbeing.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"894\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor(s) and \u0026nbsp;Year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiscipline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWellbeing Measures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey Findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 894px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSTUDENT-FOCUSED STUDIES (n=18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eIngviya, Fumaneeshoat and Limsomwong, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eThailand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e251 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eQuantitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003ePre-post surveys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eActive learning (TBL, FC, experiential) improved knowledge and attitudes but students reported significantly higher emotional stress (p=0.006) and hopelessness (p=0.008). Confidence in end-of-life care did not improve significantly (p=0.238).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eKriki \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eGreece\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNursing (Mental Health)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e134 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eQuasi-experimental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eCTASS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePBL significantly improved critical thinking in all subscales (p\u0026lt;0.05). Women showed greater improvement, while men had worse performance, suggesting gender effects in PBL education.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eSekhar \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMalaysia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine (Psychiatry)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e32 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eQualitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eFocus groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSchool-based mental health program increased clinical confidence, enhanced resilience through mindfulness and motivational interviewing techniques, and improved stress management through sustained peer support and collaboration.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMurad \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSaudi Arabia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNursing (Maternal newborn)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e28 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eQualitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eInterviews, FGD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eHigh-fidelity simulation decreased initial nervousness with repeated practice and instructor support. Students valued simulation for building confidence, though need for improved resources and hospital exposure was highlighted.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePereira \u003cem\u003eet al.\u003c/em\u003e, (2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eBrazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e447 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eQuantitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eProcrastination scale, LASSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eProcrastination associated with higher anxiety, concentration problems, and time management issues (p\u0026lt;0.05). Active methodology (PBL) is associated with higher scores in study aids and time organization compared to traditional learning.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eRevert\u0026eacute;-Villarroya \u003cem\u003eet al.\u003c/em\u003e, (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSpain, Chile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1368 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eCross-sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eGHQ-28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eStress from training activities significantly affected GHQ-28 scores. More advanced students showed better mental health than initial years, suggesting nursing education acts as protective factor against mental health disorders despite heavy academic workload.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eHughes \u003cem\u003eet al.\u003c/em\u003e, (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eStudents (review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eLiterature review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eSelf-efficacy, emotional intelligence scales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFour key resilience factors identified: self-efficacy, optimism, emotional intelligence, and self-stewardship. Educational strategies including reflection, positive reframing, PBL, and mindfulness can cultivate resilience and reduce burnout risk.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eWalsh, (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eUK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eStudents (review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eIntegrative review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eResilience scales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFive key teaching methods support resilience development: peer activities, reflective practice, directed study, PBL/enquiry-based learning, and experiential learning. Stress impairs performance and health; resilient qualities can be developed through targeted interventions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eAl-Jehani \u003cem\u003eet al.\u003c/em\u003e, (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSaudi Arabia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e593 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eCross-sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eModified Copenhagen Burnout Inventory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eHigh burnout prevalence found, but there was no significant difference between PBL and traditional curricula. All stressors (lack of sleep, unsupportive staff) significantly associated with high burnout, indicating systemic rather than pedagogical issues.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eWright and Richmond Mynett, (2019)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eUK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eCurriculum-level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eCurriculum evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eHYMS CARE Criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eCurriculum mapping identified resilience-building activities, strengths, and gaps. Led to new learning objectives and experiences to support student resilience and resourcefulness. Model offers valuable perspective for curriculum improvement.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eS\u0026aacute;nchez \u003cem\u003eet al.\u003c/em\u003e, (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eColombia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine (Physiology)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eStudents (entrants/repeaters)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eComparative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eSISCO scale, Zung scale, salivary cortisol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eHigh stress and anxiety levels in all students regardless of teaching method. Cortisol levels increased in entrants. Flipped classroom improved performance only for new students; repeaters scored lower, suggesting differential psychological impacts.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eNaciri \u003cem\u003eet al.\u003c/em\u003e, (2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMorocco\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e20 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePre-experimental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eMSLQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFlipped classroom significantly improved motivation scores. Extrinsic goal orientation (p=0.021), control beliefs (p=0.019), and self-efficacy for learning and performance (p=0.016) significantly improved, alongside academic performance (p\u0026lt;0.001).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePatel \u003cem\u003eet al.\u003c/em\u003e, (2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eUK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eStudents (review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eScoping review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eUncertainty tolerance measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e22 of 24 studies reported positive impact on uncertainty tolerance in at least one domain (cognitive, behavioral, emotional). PBL curricula, medical humanities, simulation, and reflection effective. Some interventions caused negative emotional responses despite positive cognitive/behavioral outcomes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eLien \u003cem\u003eet al.\u003c/em\u003e, (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eTaiwan (multi-country review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eHealth sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eHCPs and students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eNetwork meta-analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eStigma attitudes/behaviors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eInterventions combining social contact with PBL workshops most effective for reducing mental illness stigma (SUCRA=77.4%). Education plus contact ranked highest for improving attitudes and behavior intentions toward mental illness.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eNomura \u003cem\u003eet al.\u003c/em\u003e, (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eJapan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e112 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eValidation study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eJ-MSLQ-PBL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eMotivation subscales (self-efficacy, task value, goal orientation, test anxiety) validated in Japanese PBL context. Self-efficacy and task value particularly relevant to wellbeing in PBL. Learning strategies subscales showed poor fit, suggesting cultural differences.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eCantrell, Meyer and Mosack, (2017)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eStudents (review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eIntegrative review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eStress, anxiety scales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eStudents reported moderate to high stress with HFS but rated experience as valuable. Need for high-quality studies on techniques to decrease negative effects of simulation stress. Acceptance of simulation as learning strategy despite psychological burden.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eWu \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e56 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eClassroom engagement, CTDI, SDL scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFSLSM-based grouping significantly enhanced classroom engagement and critical thinking compared to traditional PBL. Both groups improved in self-directed learning, but experimental group showed greater gains in learning motivation and information quality.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eKuhn \u003cem\u003eet al.\u003c/em\u003e, (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eGermany\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine (Ethics)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e~20 students/interns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eProgram evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eWeb-based survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eExtracurricular PBL-based ethics program helpful for dealing with moral dilemmas (all respondents agreed). Evidence for support in moral stress situations and strengthening individual resilience. Addresses emotional burden of ethical challenges.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 894px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFACULTY-FOCUSED STUDIES (n=2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eDelany \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eIreland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e10 CBL facilitators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eQualitative (IPA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eSemi-structured interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFacilitators expressed enjoyment from closer student interaction and authentic teaching. Initial uncertainty regarding role, anxiety about standardization, and concerns about content expertise. Confidence generally improved with experience facilitating CBL.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eEvans \u003cem\u003eet al.\u003c/em\u003e, (2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eUK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine (GP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e8 GP educators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eQualitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eSemi-structured interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eClinical debrief facilitation has had transformative impact on personal and professional lives. Themes: psychological \u0026apos;respite\u0026apos; and wellbeing; professional enrichment; becoming a facilitator as journey; relationships in teaching. Facilitation provided personal enrichment.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 894px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSTUDIES EXAMINING BOTH STUDENTS AND FACULTY (n=4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eRojo \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMulti-disciplinary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e7 faculty, 7 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eQualitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eThematic analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eCommunity health fairs as experiential learning promoted skill development and broadened perspectives. Challenges within learning environment included communication barriers, privacy issues, and logistics creating stress for both students and faculty.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePapan \u003cem\u003eet al.\u003c/em\u003e, (2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eGermany\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine (Antimicrobial stewardship)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e23 students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePilot course evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003ePre-post self-assessment, IMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eCase-based and PBL approach increased competencies and enjoyment (4.6\u0026plusmn;0.5). Pressure and anxiety levels reported as low (1.8\u0026plusmn;0.9 and 2.0\u0026plusmn;1.0). Students moderately satisfied with performance (3.8\u0026plusmn;1.0). Format is well-received with low psychological burden.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eKilgour, Grundy and Monrouxe, (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eUK (review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eHealth sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eStudents (review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eRapid review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eSatisfaction measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eDespite initial negative emotion and anxiety, perspectives toward small-group active learning are generally positive. Key factors: facilitator role, tutorial structure, individual factors, case authenticity, feedback, group harmony, resource availability. Satisfaction is an important determinant of education quality.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(H\u0026ouml;kk\u0026auml; \u003cem\u003eet al.\u003c/em\u003e, 2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eFinland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNursing and Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eStudents (review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eSystematic review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAttitudes, knowledge measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSimulations, lectures, films, and humanistic approaches had positive effects on attitudes toward caring for dying. PBL, simulations, and elective courses increased knowledge of palliative care. Game interventions decreased fear of death, eased communication with dying patients/relatives.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e TBL = Team-Based Learning; FC = Flipped Classroom; CTASS = Critical Thinking Ability in Student Survey scale; FGD = Focus Group Discussions; LASSI = Learning and Study Strategies Inventory; GHQ-28 = General Health Questionnaire-28; MSLQ = Motivated Strategies for Learning Questionnaire; J-MSLQ-PBL = Japanese MSLQ for PBL; CTDI = Critical Thinking Disposition Inventory; SDL = Self-Directed Learning; IPA = Interpretative Phenomenological Analysis; IMI = Intrinsic Motivation Inventory; FSLSM = Felder-Silverman Learning Style Model\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;5: Summary of the findings per theme.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCATEGORY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSTUDENTS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACADEMIC STAFF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBOTH GROUPS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePositive\u0026nbsp;Wellbeing\u0026nbsp;Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eEnhanced collaboration, peer support, resilience building, self-efficacy\u0026nbsp;development,\u0026nbsp;motivation improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eProfessional\u0026nbsp;growth,\u0026nbsp;student interaction, psychological respite, pedagogical innovation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eShared learning community,\u0026nbsp;mutual support,\u0026nbsp;co-created strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eChallenges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eInitial\u0026nbsp;anxiety,\u0026nbsp;uncertainty\u0026nbsp;stress, emotional burden, procrastination, burnout risk, group dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRole ambiguity, facilitation anxiety,\u0026nbsp;moral\u0026nbsp;stress,\u0026nbsp;identity transition challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTime constraints, resource limitations, environmental\u0026nbsp;stressors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSupport Needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eClear expectations, stress management training, conflict resolution\u0026nbsp;protocols,\u0026nbsp;mindfulness interventions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eFacilitation training, peer mentoring, workload recognition, ongoing professional\u0026nbsp;development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eInstitutional\u0026nbsp;commitment, systemic support, adequate resources\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePsychological Wellbeing of Students in PBL\u003c/h2\u003e\n\u003ch3\u003ePositive Impacts\u003c/h3\u003e\n\u003cp\u003eStudents in PBL and active learning environments reported several psychological benefits (Table 4). PBL significantly improved critical thinking abilities across all subscales, with female students showing particularly strong improvement (Kriki \u003cem\u003eet al.\u003c/em\u003e, 2025). Enhanced learning strategies and classroom engagement were observed with personalized PBL grouping approaches (Wu \u003cem\u003eet al.\u003c/em\u003e, 2025). School-based mental health programs incorporating active learning increased clinical confidence, enhanced resilience through mindfulness and motivational interviewing techniques, and improved stress management through sustained peer support and collaboration (Sekhar \u003cem\u003eet al.\u003c/em\u003e, 2025).\u003c/p\u003e\n\u003cp\u003eMotivation and self-efficacy showed improvements with active learning pedagogies. Flipped classroom approaches significantly improved extrinsic goal orientation (p=0.021), control beliefs (p=0.019), and self-efficacy for learning and performance (p=0.016) (Naciri \u003cem\u003eet al.\u003c/em\u003e, 2022). Motivation subscales including self-efficacy, task value, and goal orientation were validated as particularly relevant to wellbeing in Japanese PBL contexts (Nomura \u003cem\u003eet al.\u003c/em\u003e, 2023). Case-based and PBL approaches increased competencies and enjoyment (4.6\u0026plusmn;0.5) while maintaining low pressure and anxiety levels (Papan \u003cem\u003eet al.\u003c/em\u003e, 2025). Despite initial negative emotions, student perspectives toward small-group active learning were generally positive when facilitator support, tutorial structure, case authenticity, and group harmony were present (Kilgour, Grundy and Monrouxe, 2016).\u003c/p\u003e\n\u003ch3\u003eChallenges\u003c/h3\u003e\n\u003cp\u003eHowever, students also experienced significant psychological challenges within active learning environments (Table 4 and Table 5). Active learning approaches, while improving knowledge and attitudes, resulted in significantly higher emotional stress (p=0.006) and hopelessness (p=0.008) in some contexts (Ingviya, Fumaneeshoat and Limsomwong, 2025). High-fidelity simulation decreased initial nervousness only with repeated practice and instructor support (Murad \u003cem\u003eet al.\u003c/em\u003e, 2025). Procrastination was associated with higher anxiety, concentration problems, and time management issues (p\u0026lt;0.05), though PBL showed benefits for study aids and time organization compared to traditional learning (Pereira \u003cem\u003eet al.\u003c/em\u003e, 2024).\u003c/p\u003e\n\u003cp\u003eBurnout emerged as a significant concern, with high prevalence found across curricula. Importantly, no significant difference in burnout was observed between PBL and traditional curricula, suggesting that stressors such as lack of sleep and unsupportive staff represented systemic rather than pedagogical issues (Al-Jehani \u003cem\u003eet al.\u003c/em\u003e, 2020). High stress and anxiety levels affected students regardless of teaching method, with cortisol levels increasing in first-time learners (S\u0026aacute;nchez \u003cem\u003eet al.\u003c/em\u003e, 2020). Stress from training activities significantly affected mental health scores, though more advanced students showed better mental health than those in initial years, suggesting nursing education may act as a protective factor despite heavy academic workload (Revert\u0026eacute;-Villarroya \u003cem\u003eet al.\u003c/em\u003e, 2021). Students reported moderate to high stress with simulation experiences, though they rated these as valuable learning opportunities (Cantrell, Meyer and Mosack, 2017).\u003c/p\u003e\n\u003ch2\u003ePsychological Wellbeing of Academic Staff and Facilitators\u003c/h2\u003e\n\u003ch3\u003eRole Transition Challenges\u003c/h3\u003e\n\u003cp\u003eFaculty/academic staff members experienced significant psychological adjustment challenges when transitioning to active learning facilitation roles (Table 4 and Table 5). Case-based learning facilitators expressed initial uncertainty regarding their role, anxiety about standardization, and concerns about content expertise, though confidence generally improved with experience (Delany \u003cem\u003eet al.\u003c/em\u003e, 2025). The shift from traditional teaching to facilitation represented a journey requiring adaptation and identity reconstruction.\u003c/p\u003e\n\u003cp\u003eDespite challenges, clinical debrief facilitation had transformative impacts on facilitators\u0026apos; personal and professional lives. Key themes included psychological \u0026apos;respite\u0026apos; and wellbeing enhancement, professional enrichment, the journey of becoming a facilitator, and the importance of relationships in teaching. Facilitation provided personal enrichment and opportunities for reflection that benefited educators\u0026apos; overall wellbeing (Evans \u003cem\u003eet al.\u003c/em\u003e, 2024).\u003c/p\u003e\n\u003ch2\u003eFacilitator Satisfaction and Professional Growth\u003c/h2\u003e\n\u003cp\u003eWhile facilitation presented challenges, many educators found the experience professionally rewarding. Facilitators expressed enjoyment from closer student interaction and more authentic teaching experiences (Delany \u003cem\u003eet al.\u003c/em\u003e, 2025). Clinical debrief facilitation provided psychological respite from clinical demands, offering opportunities for reflection and professional development that enhanced overall wellbeing. Relationships formed through teaching were particularly meaningful, with facilitation creating spaces for professional growth and personal enrichment (Evans \u003cem\u003eet al.\u003c/em\u003e, 2024).\u003c/p\u003e\n\u003cp\u003eHowever, the limited number of faculty-focused studies (n=2) in this review (Table 3 and Table 4) highlights a significant gap in understanding the full spectrum of facilitator experiences with PBL and active learning pedagogies. Future research should examine workload demands, institutional support needs, and strategies for preventing facilitator burnout while maintaining the benefits of these engaging teaching approaches.\u003c/p\u003e\n\u003ch2\u003eProfessional Development and Support\u003c/h2\u003e\n\u003cp\u003eThe experience of facilitators improving confidence over time, Delany \u003cem\u003eet al.\u003c/em\u003e, (2025) suggests that ongoing support and professional development are essential for successful transitions to active learning facilitation. Initial uncertainty and anxiety regarding role expectations highlight the need for comprehensive preparation programs that address both pedagogical skills and the psychological dimensions of facilitation.\u003c/p\u003e\n\u003cp\u003eThe transformative potential of facilitation experiences, Evans \u003cem\u003eet al.\u003c/em\u003e, (2024) indicates that when properly supported, active learning facilitation can enhance rather than undermine faculty wellbeing. Professional development initiatives should emphasize the personal and professional growth opportunities inherent in facilitation roles, while providing practical support for managing the initial challenges of role transition. Facilitators valued closer student interaction and authentic teaching, suggesting these aspects should be highlighted in faculty development programs to promote positive attitudes toward active learning pedagogies (Table 4).\u003c/p\u003e\n\u003ch2\u003eComparative Insights and Integrated Findings\u003c/h2\u003e\n\u003cp\u003eStudies examining both students and faculty/academic staff members revealed important insights into the systemic nature of wellbeing in active \u0026nbsp;learning environments (Table 4 and Table 5). Community health fairs as experiential learning promoted skill development and broadened perspectives \u0026nbsp; for both groups, though challenges including communication barriers, privacy issues, and logistics created stress for students \u0026nbsp;and faculty alike (Rojo \u003cem\u003eet al.\u003c/em\u003e, 2025). This highlights how environmental and organizational factors affect all participants \u0026nbsp; in active learning contexts.\u003c/p\u003e\n\u003cp\u003eThe successful integration of active learning approaches with low psychological burden is possible when properly designed. \u0026nbsp;Case-based and PBL courses that balanced challenge with support reported low pressure and anxiety levels alongside high \u0026nbsp;enjoyment and competency development (Papan \u003cem\u003eet al.\u003c/em\u003e, 2025). Key factors for positive experiences included appropriate \u0026nbsp;facilitator roles, clear tutorial structure, case authenticity, constructive feedback, group harmony, and adequate resource \u0026nbsp; availability (Kilgour, Grundy and Monrouxe, 2016). Despite initial negative emotions and anxiety, perspectives toward small-group active \u0026nbsp; learning were generally positive when these supportive elements were present.\u003c/p\u003e\n\u003cp\u003eThe importance of resilience-building across the curriculum emerged as a cross-cutting theme. Educational interventions \u0026nbsp;incorporating resilience development, including reflection, positive reframing, PBL, mindfulness, peer activities, and \u0026nbsp;experiential learning, can cultivate protective factors and reduce burnout risk for students (Walsh, 2020; Hughes \u003cem\u003eet al.\u003c/em\u003e, 2021). \u0026nbsp; Curriculum mapping to identify resilience-building activities, strengths, and gaps can lead to intentional design of learning \u0026nbsp;objectives and experiences supporting student wellbeing (Wright and Richmond Mynett, 2019). Similarly, facilitation experiences offering \u0026nbsp;psychological respite and professional enrichment can support faculty wellbeing (Evans \u003cem\u003eet al.\u003c/em\u003e, 2024), demonstrating that active \u0026nbsp;learning pedagogies can benefit all participants when intentionally designed with wellbeing as a priority (Table 5).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe PRISMA flow (Figure 1) demonstrates that, although the initial search yield was substantial across multiple databases, a sizeable proportion of records were removed or excluded during screening, suggesting that psychological wellbeing outcomes in health-sciences PBL remain a relatively narrow and inconsistently indexed evidence area. \u0026nbsp;The steep reduction from screening to inclusion also reflects the deliberate application of the eligibility boundaries (peer-reviewed primary research, English language, health sciences context, and PBL-specific focus), which strengthens topical specificity and interpretability of the final synthesis. The full-text exclusion reasons shown in the flow diagram align with the priori criteria (e.g., studies without psychological measures, non-health sciences educational contexts, and those outside the date limits), which supports transparency and reproducibility of study selection. However, the presence of “reports not retrieved” indicates a potential risk of retrieval bias (i.e., some relevant evidence may not have been accessible), causing a limitation to the study. The reliance on English-language, peer-reviewed literature may also increase publication and language bias, meaning some locally relevant or non-indexed/grey literature evidence could be underrepresented. \u0026nbsp;Overall, the PRISMA workflow (Figure 1) provided a clear audit trail for how the review arrived at the final included evidence base of 24 studies, supporting confidence in the rigor of the selection process.\u003c/p\u003e\n\u003cp\u003eUsing MMAT (as outlined in Table 1 with rating scores Table 2) strengthened the interpretive confidence in this review because it enabled design-appropriate appraisal across heterogeneous evidence rather than forcing one-size-fits-all criteria. In line with MMAT guidance, the approach supported transparent, criterion-level judgement (rather than relying on a single overall score), which helps readers understand where evidence is strong versus where caution is warranted.\u003c/p\u003e\n\u003cp\u003eThe evidence base included in (Table 2) was generally methodologically strong, with most studies meeting all MMAT screening and category-specific criteria (i.e., receiving ***** ratings). The overall pattern supports this: 83% of studies (n=20) met at least 80% of applicable MMAT criteria, which increases confidence that the synthesis reflects findings from reasonably well-designed research. \u0026nbsp;Where ratings dropped to **** or ***, the main issue was typically “CT” (can’t tell) suggesting unclear or incomplete reporting rather than definitive methodological failure (e.g., some studies had at least one criterion rated CT). \u0026nbsp; Notably, the lowest-rated study (***), with multiple CT judgements, signals that some conclusions should be interpreted cautiously because key methodological details were insufficiently described. \u0026nbsp;Across studies, the most common limitations were non-response reporting gaps, small qualitative samples, and incomplete integration in some mixed-methods papers, alongside frequent single-institution designs that may limit generalizability, so future research should strengthen transparency and multi-site rigor to improve the dependability and transferability of wellbeing findings in PBL contexts.\u003c/p\u003e\n\u003ch2\u003eKey Themes and Patterns\u003c/h2\u003e\n\u003cp\u003eSeveral key themes emerged from the synthesis of 24 studies examining psychological wellbeing in PBL and active learning contexts (Table 2 and Table 4). First, the paradox of benefit and burden characterized student experiences. While active learning improved critical thinking (Kriki \u003cem\u003eet al.\u003c/em\u003e, 2025), motivation (Naciri \u003cem\u003eet al.\u003c/em\u003e, 2022), and resilience (Hughes \u003cem\u003eet al.\u003c/em\u003e, 2021; Sekhar \u003cem\u003eet al.\u003c/em\u003e, 2025), it simultaneously increased emotional stress and hopelessness in some implementations (Ingviya, Fumaneeshoat and Limsomwong, 2025). Students valued simulation and active learning experiences despite reporting moderate to high stress (Cantrell, Meyer and Mosack, 2017), suggesting psychological challenge may be an accepted cost of valued learning experiences.\u003c/p\u003e\n\u003cp\u003eSecond, burnout emerged as a systemic rather than pedagogical issue (Table 4 and Table 5). Critically, no significant difference in burnout was found between PBL and traditional curricula, with stressors such as lack of sleep and unsupportive staff environments affecting students regardless of teaching method (Al-Jehani \u003cem\u003eet al.\u003c/em\u003e, 2020; Sánchez \u003cem\u003eet al.\u003c/em\u003e, 2020). These findings challenge assumptions that PBL inherently increases student distress, suggesting instead that institutional and environmental factors are primary determinants of psychological well-being. More advanced students showed better mental health than initial-year students, indicating potential protective effects of educational progression despite heavy workload (Reverté-Villarroya \u003cem\u003eet al.\u003c/em\u003e, 2021).\u003c/p\u003e\n\u003cp\u003eThird, resilience-building emerged as an intentional curricular goal rather than incidental outcome (Table 4 and Table 5). Educational strategies including reflection, positive reframing, PBL, mindfulness, peer activities, and experiential learning can cultivate protective factors and reduce burnout risk (Walsh, 2020; Hughes \u003cem\u003eet al.\u003c/em\u003e, 2021). Curriculum mapping to identify resilience-building activities, strengths, and gaps enables intentional design of learning objectives supporting student wellbeing (Wright and Richmond Mynett, 2019). School-based mental health programs integrating active learning enhanced resilience through sustained peer support and collaboration (Sekhar \u003cem\u003eet al.\u003c/em\u003e, 2025).\u003c/p\u003e\n\u003cp\u003eFourth, faculty experiences reveal both challenges and opportunities (Table 4 and Table 5). Initial role uncertainty and anxiety can transition to psychological respite, professional enrichment, and enhanced wellbeing when proper support is provided (Evans \u003cem\u003eet al.\u003c/em\u003e, 2024; Delany \u003cem\u003eet al.\u003c/em\u003e, 2025). However, the severe underrepresentation of faculty research (only 2 of 24 studies, as shown in Table 4) reveals a critical gap requiring urgent attention, given facilitator wellbeing's influence on educational quality.\u003c/p\u003e\n\u003ch2\u003eThe \"Human Side\" of Active Learning:\u0026nbsp;\u003c/h2\u003e\n\u003ch3\u003eEmotional and Psychological Dimensions\u003c/h3\u003e\n\u003cp\u003eThe human side of active learning encompasses the emotional experiences, interpersonal dynamics, and psychological adjustment required for successful implementation. Initial negative emotions and anxiety are common as students adapt to small-group active learning, though perspectives become generally positive when supportive conditions are present (Kilgour, Grundy and Monrouxe, 2016). Key factors influencing emotional experiences include facilitator role, tutorial structure, individual learner characteristics, case authenticity, quality of feedback, group harmony, and resource availability (Table 4). The psychological burden of active learning can be minimized through careful instructional design, as demonstrated by case-based courses maintaining low pressure and anxiety levels while achieving high enjoyment and competency development (Papan \u003cem\u003eet al.\u003c/em\u003e, 2025).\u003c/p\u003e\n\u003cp\u003eFor faculty/academic staff, facilitation represents both challenges and opportunities for wellbeing (Table 4 and Table 5). Initial role uncertainty and anxiety about standardization are common during the transition to facilitation (Delany \u003cem\u003eet al.\u003c/em\u003e, 2025), yet clinical debrief facilitation can have transformative impacts on personal and professional lives. Facilitation provided psychological 'respite' from clinical demands, professional enrichment through closer student interaction, and meaningful relationship-building opportunities (Evans \u003cem\u003eet al.\u003c/em\u003e, 2024). This suggests that when properly supported, active learning facilitation enhances rather than undermines faculty wellbeing, offering renewal and professional satisfaction often missing in traditional teaching or clinical roles.\u003c/p\u003e\n\u003cp\u003eStudents navigate complex challenges including procrastination associated with anxiety, concentration problems, and time management difficulties (Pereira \u003cem\u003eet al.\u003c/em\u003e, 2024). However, active methodologies like PBL show advantages in study aids and time organization compared to traditional approaches. Uncertainty tolerance, a critical competency for healthcare professionals, can be effectively developed through PBL curricula, medical humanities, simulation, and reflection, though some interventions cause negative emotional responses despite positive cognitive and behavioral outcomes (Patel \u003cem\u003eet al.\u003c/em\u003e, 2022). This underscores the complexity of psychological responses to active learning and the need for nuanced understanding of the relationship between emotional challenges and professional development.\u003c/p\u003e\n\u003ch2\u003eSupport Systems and Interventions\u003c/h2\u003e\n\u003cp\u003eEffective support systems for active learning wellbeing must address multiple dimensions. For students experiencing initial anxiety with new modalities, repeated practice with instructor support can decrease nervousness and build confidence over time (Murad \u003cem\u003eet al.\u003c/em\u003e, 2025). Mindfulness and motivational interviewing techniques enhance resilience and improve stress management through sustained peer support and collaboration (Sekhar \u003cem\u003eet al.\u003c/em\u003e, 2025). Pedagogical approaches that improve self-efficacy for learning and performance, control beliefs, and goal orientation (Table 4) contribute to enhanced motivation and wellbeing (Naciri \u003cem\u003eet al.\u003c/em\u003e, 2022; Nomura \u003cem\u003eet al.\u003c/em\u003e, 2023).\u003c/p\u003e\n\u003cp\u003eResilience-building should be systematically integrated across curricula through multiple evidence-based strategies. Peer activities, reflective practice, directed study, PBL/enquiry-based learning, and experiential learning all support resilience development (Walsh, 2020). Curriculum mapping can identify existing resilience-building activities, recognize strengths, and address gaps, leading to new learning objectives and experiences that intentionally support student resourcefulness (Wright and Richmond Mynett, 2019). Extracurricular PBL-based programs addressing ethical dilemmas can provide support in moral stress situations and strengthen individual resilience (Table 4), helping students manage the emotional burden of ethical challenges inherent in healthcare practice (Kuhn \u003cem\u003eet al.\u003c/em\u003e, 2021).\u003c/p\u003e\n\u003cp\u003eFor faculty/academic staff, confidence generally improves with facilitation experience (Delany \u003cem\u003eet al.\u003c/em\u003e, 2025), suggesting that ongoing practice combined with peer support enables successful role transitions (Table 4). Facilitator wellbeing is enhanced when facilitation provides psychological respite, professional enrichment, and opportunities for meaningful relationships in teaching (Evans \u003cem\u003eet al.\u003c/em\u003e, 2024). Institutions should recognize and promote these positive aspects of facilitation while providing support for initial role uncertainty and anxiety about standardization.\u003c/p\u003e\n\u003cp\u003eInterventions combining multiple approaches show particular promise. Social contact combined with PBL workshops effectively reduces mental illness stigma, with education plus contact ranking highest for improving attitudes and behavior intentions (Lien \u003cem\u003eet al.\u003c/em\u003e, 2021). Personalized learning approaches, such as grouping based on learning style models, can significantly enhance classroom engagement and critical thinking compared to traditional PBL while improving learning motivation (Wu \u003cem\u003eet al.\u003c/em\u003e, 2025). These findings suggest that tailored, multi-component interventions addressing both content and process dimensions optimize psychological outcomes (Table 5).\u003c/p\u003e\n\u003ch2\u003eImplications for Practice\u003c/h2\u003e\n\u003cp\u003eImplementation of active learning pedagogies should include explicit attention to psychological wellbeing alongside pedagogical outcomes. Given that burnout appears to reflect systemic rather than pedagogy-specific issues (Al-Jehani \u003cem\u003eet al.\u003c/em\u003e, 2020), institutions must address \u0026nbsp;environmental stressors including inadequate sleep opportunities, unsupportive staff attitudes, and resource limitations that affect students \u0026nbsp;regardless of teaching method (Table 4 and Table 5). Active learning implementation offers opportunities to intentionally build resilience and protective factors \u0026nbsp;when designed with wellbeing as a priority (Walsh, 2020; Hughes \u003cem\u003eet al.\u003c/em\u003e, 2021).\u003c/p\u003e\n\u003cp\u003eFaculty development programs must recognize the dual nature of facilitation as both challenging and potentially enriching. Initial support \u0026nbsp;should address role uncertainty and anxiety about standardization (Delany \u003cem\u003eet al.\u003c/em\u003e, 2025), while highlighting opportunities for psychological \u0026nbsp;respite, professional enrichment, and meaningful relationships that facilitation can provide (Evans \u003cem\u003eet al.\u003c/em\u003e, 2024). Programs should emphasize \u0026nbsp;that confidence generally improves with experience and provide ongoing peer support throughout the facilitation journey.\u003c/p\u003e\n\u003cp\u003eCurriculum design should incorporate systematic resilience-building through evidence-based strategies including peer activities, reflection, \u0026nbsp; PBL/enquiry-based learning, experiential learning, and mindfulness (Walsh, 2020; Sekhar \u003cem\u003eet al.\u003c/em\u003e, 2025). Curriculum mapping can identify \u0026nbsp;strengths and gaps in resilience-building opportunities (Wright and Richmond Mynett, 2019). Particular attention should be paid to supporting students \u0026nbsp;through initial anxiety when introducing new active learning modalities (Table 5), as repeated practice with instructor support decreases nervousness \u0026nbsp;over time (Murad \u003cem\u003eet al.\u003c/em\u003e, 2025). Assessment of active learning should examine both academic outcomes and wellbeing indicators, recognizing that \u0026nbsp;some level of emotional challenge may accompany valuable professional development in areas such as uncertainty tolerance (Patel \u003cem\u003eet al.\u003c/em\u003e, 2022).\u003c/p\u003e\n\u003ch2\u003eContribution to Teaching and Learning\u003c/h2\u003e\n\u003cp\u003eThis integrative review contributes to TL by highlighting the necessity of examining psychological and emotional dimensions of educational innovations. The findings challenge the field to move beyond cognitive and academic measures to include wellbeing indicators in educational research and practice.\u003c/p\u003e\n\u003cp\u003eThe review demonstrates the importance of systematic inquiry into the human costs and benefits of pedagogical change, providing evidence for the need to support educational innovations with comprehensive attention to participant wellbeing. This human-centered approach to TL research offers a more complete understanding of educational effectiveness and sustainability. By synthesizing evidence across multiple contexts and populations, this review provides a foundation for future TL researchers that examine the intersection of pedagogy and psychological wellbeing in health sciences education.\u003c/p\u003e\n\u003ch2\u003eRecommendations for Educators and Institutions\u003c/h2\u003e\n\u003cp\u003eEducators implementing PBL should receive comprehensive training that addresses both pedagogical and psychological aspects of facilitation. This includes understanding group dynamics, recognizing signs of student distress, and developing strategies for maintaining their own wellbeing while supporting student learning.\u003c/p\u003e\n\u003cp\u003eInstitutional leaders should recognize PBL implementation as a complex change process requiring sustained support for both students and faculty/academic staff. This includes resource allocation for professional development, mental health support services, and ongoing evaluation of wellbeing outcomes alongside academic measures.\u003c/p\u003e\n\u003cp\u003eCurriculum designers should systematically map resilience-building opportunities throughout programs, identifying strengths \u0026nbsp;and addressing gaps to create intentional learning experiences supporting student wellbeing (Wright and Richmond Mynett, 2019). Evidence-based \u0026nbsp;strategies including peer activities, reflection, PBL/enquiry-based learning, experiential learning, and mindfulness should be \u0026nbsp;integrated across curricula (Walsh, 2020). Programs should address uncertainty tolerance development \u0026nbsp;essential for healthcare \u0026nbsp;professionals through PBL, medical humanities, simulation, and reflection, while acknowledging that productive emotional challenge \u0026nbsp;differs from harmful distress (Patel \u003cem\u003eet al.\u003c/em\u003e, 2022).\u003c/p\u003e\n\u003cp\u003eResearch and evaluation efforts should routinely include wellbeing measures alongside traditional academic outcomes, providing comprehensive assessment of educational innovation effectiveness. Critically, evaluations should examine \u0026nbsp; systemic factors (sleep opportunities, staff support, resources) affecting wellbeing across all pedagogies, not only active \u0026nbsp;learning-specific variables. Given that burnout appears systemic rather than pedagogy-specific (Al-Jehani \u003cem\u003eet al.\u003c/em\u003e, 2020), \u0026nbsp; research must examine institutional environments holistically. Future studies should prioritize faculty experiences, employ \u0026nbsp;longitudinal designs, conduct multi-institutional comparisons, and test targeted wellbeing interventions to build the evidence \u0026nbsp;base for supporting human flourishing in health sciences education.\u003c/p\u003e\n\u003ch2\u003eLimitations and Future Research\u003c/h2\u003e\n\u003cp\u003eSeveral limitations should be acknowledged in this integrative review. First, the heterogeneity of wellbeing measures across studies limited the ability to conduct meta-analytic synthesis, requiring reliance on narrative synthesis methods. Studies employed diverse instruments including validated scales (GHQ-28, MSLQ, Copenhagen Burnout Inventory), qualitative approaches (interviews, focus groups), and program evaluations, making quantitative comparison challenges.\u003c/p\u003e\n\u003cp\u003eSecond, publication bias may favour studies reporting positive outcomes or significant findings, potentially overlooking neutral or negative wellbeing effects.\u003c/p\u003e\n\u003cp\u003eThird, the severe underrepresentation of faculty-focused research (only 2 of 24 studies) limits conclusions about facilitator experiences. Most studies examined students (n=18), creating an incomplete picture of the bidirectional relationship between student and faculty/academic staff wellbeing in active learning environments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFourth, while the review spanned 18 countries across six continents, cultural and contextual variations in PBL implementation and wellbeing conceptualization require further examination, there were no South African studies found or included.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFifth, most studies employed cross-sectional designs, with limited longitudinal research preventing full understanding of adaptation processes and long-term wellbeing trajectories.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSixth, many studies were conducted at single institutions, potentially limiting generalizability.\u003c/p\u003e\n\u003cp\u003eFuture research should prioritize longitudinal designs examining well-being trajectories throughout active learning experiences, identifying critical periods for intervention and support. The finding that burnout reflects systemic rather than pedagogical issues (Al-Jehani \u003cem\u003eet al.\u003c/em\u003e, 2020) demands investigation of institutional and environmental factors affecting wellbeing across teaching modalities. Intervention studies testing specific well-being support strategies, particularly resilience-building interventions, mindfulness programs, and peer support mechanisms, would provide evidence for best practices.\u003c/p\u003e\n\u003cp\u003eUrgent attention is needed to faculty experiences with active learning facilitation. The limited research (n=2) contrasts sharply with extensive student-focused literature, yet faculty wellbeing critically influences educational quality and sustainability. Research should examine facilitator workload, emotional labour, support needs, and factors predicting successful role transitions. Comparative multi-institutional studies examining wellbeing outcomes across different active learning implementations could identify design features that optimize both learning and wellbeing. Finally, economic analyses comparing costs of wellbeing support versus benefits of improved retention, performance, and career satisfaction could inform institutional resource allocation decisions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis integrative review reveals that psychological wellbeing represents a critical dimension of active learning implementation in health sciences education that demands systematic attention. Synthesis challenges common assumptions and offers evidence-based insights for educational practice.\u003c/p\u003e\n\u003cp\u003eA key finding is that burnout appears to reflect systemic rather than pedagogy-specific issues. No significant difference in burnout was observed between PBL and traditional curricula, with environmental stressors such as inadequate sleep, unsupportive staff, and resource limitations affecting students regardless of teaching method. This shifts the focus from debating pedagogical approaches to addressing fundamental institutional conditions affecting all students. Also, active learning offers opportunities to intentionally cultivate psychological strengths. PBL and related approaches enhance critical thinking, motivation, self-efficacy, and resilience. When designed with wellbeing as a priority, incorporating appropriate facilitator support, clear structure, case authenticity, feedback, group harmony, and adequate resources, active learning achieves high engagement and competency development with low psychological burden. The challenge lies not in the pedagogy itself but in implementation quality.\u003c/p\u003e\n\u003cp\u003eFor faculty/academic staff, facilitation presents both challenges and opportunities. Initial role uncertainty and anxiety can transition to psychological respite, professional enrichment, and enhanced wellbeing \u0026nbsp;when proper support is provided. However, the severe underrepresentation of faculty research (only 2 of 24 studies) reveals a critical gap requiring urgent attention, given facilitator wellbeing's influence on educational quality.\u003c/p\u003e\n\u003cp\u003eFor teaching and learning, this review demonstrates the necessity of human-centered approaches to educational research and practice. Future TL researchers should routinely examine psychological and emotional dimensions alongside cognitive and academic outcomes, recognize systemic factors affecting wellbeing across pedagogies, and investigate both students and faculty as interconnected participants in the learning ecosystem.\u003c/p\u003e\n\u003cp\u003eThe evidence calls for reconceptualization of educational innovation that positions human wellbeing as central to, not separate from, pedagogical effectiveness. Active learning pedagogies like PBL offer powerful tools for developing the cognitive, professional, and psychological capacities healthcare professionals need. Realizing this potential requires systematic attention to resilience-building, institutional environments supporting all participants, and recognition that some emotional challenge may be inherent in transformative professional education. The question is not whether to implement active learning, but how to implement it in ways that support rather than undermine the wellbeing of those engaged in the educational process.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors whose names appear on the submission: IN and NFContributions: IN and NF: concept formationIN: design of the work.IN: analysis and interpretation of data.IN: drafted the work IN and NF: revised it critically for important intellectual content.IN and NF: approved the version to be published.IN: agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData will be available upon request from corresponding author:\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003ch2\u003eResearch Funding\u003c/h2\u003e\n\u003cp\u003eBoth authors declare no funding for this research project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Jehani, Y. 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Problem-based learning: An overview of its process and impact on learning. \u003cem\u003eHealth professions education\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e(2), 75\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"problem-based learning, psychological wellbeing, health sciences education, student mental health, faculty stress, student anxiety, stress","lastPublishedDoi":"10.21203/rs.3.rs-8357368/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8357368/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis integrative review examines the psychological wellbeing of health sciences students and academic staff within Problem-Based Learning (PBL) and active learning environments, addressing the human dimension often overlooked in educational research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive search of MEDLINE (PubMed), ERIC, PsycINFO, CINAHL, and EBSCO databases was conducted for primary research studies published between January 2010 and December 2024. Inclusion criteria encompassed peer-reviewed articles examining psychological wellbeing, mental health, stress, anxiety, burnout, resilience, or emotional aspects of PBL and related active learning approaches in health sciences education. Whittemore and Knafl's integrative review framework guided the methodology, with thematic analysis used for data synthesis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of 24 studies from 18 countries revealed complex psychological impacts of PBL and active learning on both students and faculty. Students demonstrated enhanced critical thinking, motivation, self-efficacy, and resilience-building, but also experienced significantly higher emotional stress, initial anxiety with new modalities, procrastination-related challenges, and burnout comparable to traditional curricula. Notably, burnout appeared to reflect systemic issues (lack of sleep, unsupportive environments) rather than pedagogy-specific factors. Faculty experiences (n = 2 studies) revealed initial role uncertainty and anxiety, but also psychological respite, professional enrichment, and improved wellbeing through facilitation. Key success factors included appropriate facilitator support, tutorial structure, case authenticity, group harmony, and adequate resources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eActive learning implementation must consider psychological dimensions alongside pedagogical outcomes. Findings suggest need for systematic wellbeing support, comprehensive faculty development, curriculum mapping for resilience-building, and institutional policies addressing systemic stressors. This review contributes to Teaching and Learning by highlighting the necessity of human-centered approaches to educational innovation in healthcare sciences.\u003c/p\u003e","manuscriptTitle":"The Human Side of PBL: Psychological Well-being of Health Sciences Students and Academic Staff: An Integrative Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 00:52:47","doi":"10.21203/rs.3.rs-8357368/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9f203e4c-33ef-453e-8ffa-1e762e075370","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-22T16:54:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-30 00:52:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8357368","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8357368","identity":"rs-8357368","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}